The physicians of Heritage Medical Group have spent many long hours in the last two years bringing our 10 practices together into a single multispecialty group. This move was a response to opportunity, not adversity; each of our practices was successful and well-respected in its own right. But we realized that in today's medical environment, we could do more and have more influence in our health care market if we were united. Our size has allowed us to negotiate from a position of strength with local health care plans and to have more influence on their policies and payment structures. We've also developed ancillary services — including a lab, a diagnostic radiology center and a comprehensive breast care center — which we couldn't have developed alone.

Creating a strong multispecialty group is a process full of challenges. But for us, one of the most significant related not to finances, governance or income but to ourselves. That challenge was creating groupthink. By this, I don't mean the pejorative definition you'll find in the dictionary, which focuses on self-deception and forced agreement. By groupthink, I mean an environment of cooperation in which every member of the group holds the vision, mission and values of the group above self-interest. In a nutshell, the rule is that the good of the group outweighs the interest of any individual.

Groupthink isn't merely a part of the group-formation process. Unless it becomes a permanent fixture of the group's life, the group will have little chance for success, regardless of the technical ability of the physicians involved. Without a sense of shared purpose, a group is simply a complicated and unmanageable collection of doctors who have been accustomed to achieving success on their own. This is a recipe for certain failure.

To define and operationalize groupthink, our steering committee developed a code — a set of rules that each physician would agree to follow to help ensure the group's success. The idea was to leave no misunderstanding in group members' minds about what we meant by this concept and how important we felt it was.

Getting the members of the group to buy into our groupthink code is a work in progress. We discuss issues related to groupthink at every meeting of the membership and at every board meeting. We believe it's important to remind ourselves of what we're trying to accomplish as a group and where we need to be in our thinking. It's only by reviewing these principles with everyone that they will become second nature, just as we once learned the rules for success in private or small-group practice.

So what does groupthink mean to us? Here is our code — Heritage Medical Group's 10 Commandments of Groupthink:

1. Place no other business allegiances or obligations ahead of your commitment to the group. Remember that other affiliations, particularly those with insurance companies or hospitals, may be false gods.

It's imperative to commit to a group and not play the field by belonging to myriad organizations. Spreading your loyalty dilutes your influence and effective power in bargaining (particularly with insurance companies) for your patients' interests and for your own.

It's equally important that the group you commit to be owned, governed and operated by physicians. This is the only way to ensure that the mission and goals of all participants will be aligned. In other group models, the interests of the doctors and the other players inevitably seem to come into conflict. For example, there are certainly times when the interests of physicians and insurance companies don't match. The physician-hospital model also offers fertile ground for conflict, no matter what the hospital promises in the formative stages. Remember that in the current environment, a hospital is a cost center, not a profit center. We can't exist without hospitals, but our relationships with them should be business contracts, not partnerships.

2. Do not speak badly of the group or any of its members in the presence of others because they will use this information to divide the group.

We must realize that in any community, certain forces (those currently holding power) will be threatened by physicians' attempts to organize, and those forces may try to disrupt the new group. Don't hand them a weakness they can exploit by making problems within the group public. This doesn't mean that members of a group must always agree. Honest, vigorous discussion and disagreement among group members is healthy — in private. Careless public criticism leads to rumors, which can be surprisingly damaging and difficult to correct.

3. Be decisive without being hasty, and base your decisions on the group's mission and vision.

There is no decision that must be made immediately. Take the time to consider your group's vision and mission so that your decisions reflect them. Don't be afraid to ask for expert help, but be sure that you have thought of all the questions you want answered when you do so. Then look at the facts, discuss the issues, and make an informed and considered choice.

By the same token, there is also no decision that should be delayed endlessly. Don't use analysis as an excuse to procrastinate. Too often, physician groups facing difficult issues simply discuss them to death without taking real action. This avoids the problem but harms the group.

4. Honor and respect the officers and board members of your group. They work hard to make the group succeed.

Committed leadership is one of the linchpins of a successful physician group. But leading a group is often a thankless job that demands a significant commitment of time and great attention to detail. Don't take this work for granted.

Emotional support from group members can go a long way, but you should also consider compensating group leaders financially. Their work has tremendous value; don't devalue it by expecting them to volunteer their talents.

In addition, remember to recognize and thank the families of group leaders. They also make a tremendous sacrifice for the success of the group.

5. Remember that you have an obligationto the groupto behave professionally and ethically at all times.

The members of a group should have a common set of professional values, a common philosophy of care and common expectations about patient service. Then they must live up to them, not just because of their individual professional responsibility but because of their responsibility to the success of the group. It only takes an isolated professional or ethical impropriety to tarnish the reputation of everyone in the group.

6. Take your commitment to the group seriously.

By joining a group, each physician makes a commitment to work for the advancement of the group. That commitment parallels the commitment one makes in a marriage. Certainly, as time goes on, each group member will face decisions about other practice options. But exercising those options is not a step to be taken lightly. Members need to think about the effect their actions would have on the others in the group to whom they made a commitment rather than merely acting out of self-interest.

7. Put your best effort into your work so that you carry your fair share of the load rather than profiting from the work of others.

Each member of the group needs to avoid the “company money” syndrome and the lure of no longer being responsible for making ends meet. We've all known physicians whose productivity declined when their practices were acquired by a hospital or other third party. Some doctors in situations like this simply lose the incentive to work hard.

But being part of a physician-owned, -governed and -operated group is different. The underlying economics of running a successful practice don't change when that practice becomes part of a group. The need to work hard and smart doesn't change. Allowing members of the group to dodge accountability for remaining productive undermines the group's stability.

8. Don't expect to get everything you want, and be prepared to support the group's decisions.

Group members can and should differ over issues, and groups often need vigorous discussion before settling on a course of action. No single member will get his or her way on every issue (if an individual needs to get his or her way, then both that person and the group would be better served if the person stayed outside it). But once a decision is made, it's time to put aside individual differences and support the decision.

9. Work to better the entire group, not to advance yourself or your specialty.

We've all seen examples of the division between primary care physicians and other specialists. We've witnessed arrogance on both sides and a sense of entitlement from the more affluent among us. In a multispecialty group, these attitudes must become extinct.

Each physician and each specialty brings to the group unique characteristics that help make the group strong. By the same token, the individuals in the group profit from being able to do things together that can't be done alone. As the adage says, “The strength of the pack is in the wolf, and the strength of the wolf is in the pack.”

As the group is strengthened, so is each member. Economically, the purpose of the group isn't to lower the income of the higher earners in order to raise the income of the lower earners. The purpose is to bring up the earnings of everyone.

10. Always show respect to other members of the group, and never seek to show them up.

Working with your colleagues in the group shouldn't be like rounds in medical school, where people sometimes seemed more interested in showing what we didn't know than in helping us learn. Showmanship, personal pride and ego have no place in a group's proper functioning, and these traits are particularly inappropriate for the group's leaders. If members are intimidated and don't contribute their ideas, it's the group that ultimately loses. Each member has his or her own expertise; the challenge is to identify it, match it up with work the group needs to accomplish and get that member involved. A little humility goes a long way in encouraging everyone to work toward the group's best interest.

Think of yourself third

The members of our group are committed to these commandments because we believe following them will make our group stronger. We fully expect to make mistakes, to have differences and to disagree. But we also expect to succeed in this undertaking — to stay together and accomplish the goals we decide are in the best interest of the group.

Too many organizations get sidetracked by petty and personal agendas that serve no purpose in the operation of the group. By creating a culture of groupthink, and by focusing on how members can achieve more together than they can individually, the group's leaders can help members avoid these traps. Doctors in groups need to adopt a mind-set like that of Gale Sayers in his book, I Am Third. Our groups come first, our practice sites and personnel come second, and our own needs and pride come third.