A Health System Arranged Marriage: When the Engagement Comes After the Union

Editor’s Note: Real Talk is a recurring Cardiovascular Business feature, with stories reflecting uncomfortable, look-the-other-way realities. It is told from an anonymous perspective to encourage honesty and objectivity, without sugarcoating. If you have a story, experience or lesson to share, email kbdavid@cardiovascularbusiness.com.

Mergers are a lot like arranged marriages in that there’s little or no opportunity for the parties to build relationships before their union is finalized. Building a united team requires much more than a mandate from leadership. 

“Seriously!” said Dr. D, a 30-year veteran of our academic cardiology practice. “They can’t keep doing this!”

“Doing what?” I asked, though, given his tone, I wasn’t sure I really wanted to know.

“It’s this new group,” Dr. D exclaimed. “They operate on patients they aren’t capable of managing, and then I get the dump at 3 AM. I’m tired of wiping their %^$es and cleaning up their mess.”  

Our medical center had just acquired a community cardiology practice as part of a recent merger—an arranged marriage by our health system and theirs. Neither practice wanted the union, and now both the academic and community providers were suffering the challenges of the forced relationship.  

“Just because they join our system doesn’t mean they can do complex procedures. They aren’t as skilled as us. You know that!” Dr. D said, pointing his finger at me. “You’ve got to get this under control!”

We were at one of the most heated practice meetings I’d witnessed. The academic physicians seemed to agree there should be more control over who was performing which procedures—and they should be the ones deciding. The vast majority believed the system’s new community physicians weren’t qualified to perform structural heart procedures, going so far as to refer to their new colleagues as “unskilled dabblers, at best.” And I was left with relaying the message.  

Fast-forward one week, across town at the community practice faculty meeting…

“These academic docs think they’re so special. Not one of them could do what we do. They would never survive if they had to eat what they kill. I generate the amount of revenue in one day in the community that they do in a week.”

Dr. E, who was the managing partner of the community practice prior to the merger, was venting. 

“And now they are whining about the acuity of the patients we’re treating? At least we actually go see our patients after we operate on them. Could you imagine them trying to do what we do in this environment, without all the residents and fellows around them? They would be lost!”

I decided not even to bring up that the academic group expected the community practice cardiologists to step away from structural cases. I was starting to worry that the two groups were never going to be able to work together.  

The problem

Talk about conflicting directives and competing priorities! Who was I, the administrator, to tell either group they were wrong—and just who was wrong? On the one hand, the community physicians had been providing complex care before the merger. They were (and still are) credentialed, trained and nationally boarded to do so. In fact, they’d been trained by an academic group to perform these cases.  

On the other hand, our academic medical center’s principle has always been that, as the tertiary care center, we should have the market cornered on complex care. Spreading such care to less advanced facilities went against all previous strategic plans and marketing.

And then there was the directive from my academic service line dyad partner to both protect the specialists who provided the majority of the high-end care and collaborate with clinicians across the newly defined network. No matter what, we had to ensure patients received the highest service, experience and quality. 

The biggest conundrum of all: The stakeholders best qualified to sort through the conflict were directly involved, posturing and in full-defensive mode.  

A solution

When I reconsidered the situation, I realized that the conflict wasn't really about what was best for patients. I was on the sidelines of an old-fashioned turf war. And, if it kept up, we all were going to lose. I needed to de-escalate the situation, and quickly.

Thankfully, my dyad academic service line physician partner was a senior leader with a niche in his field that didn’t cross over either of the warring groups. Although he was sympathetic to his academic partners, his leadership role came with institutional pressure to make the merger work. He and I sat down together to strategize. 

Our first task was getting the teams to meet together in a nonthreatening manner. We hosted an introductory dinner where we deliberately steered the conversation away from detailed shop talk—you can’t avoid it completely with a group of physicians, but we made it clear the evening wasn’t to discuss the current conflict. To be honest, it was a little stiff, but by the end of the evening, progress was being made. The physicians were learning about one another and beginning (barely) to build relationships. 

Next, we began holding meetings with representatives from both groups. Over a fairly short period, trust began to grow. It became evident that the majority of the community group didn’t even want to do every procedure they had in the scope of their license. For the two community physicians who were genuinely interested in the more complex cases, we struck a deal. They could see these patients, but the procedures would be performed at the tertiary academic facility, not the community hospital. And they couldn’t dabble in complex procedures. They needed to become active members of the structural heart team and accountable for following the established care pathways.

Once the tensions were defused, the other community partners were thrilled to be doing the work they loved. They hadn’t really wanted to manage the “redo of a redo” or the once-in-a-career kind of case, but they didn’t like being marginalized. Who does? They wanted to know they had a place and added value. As the team coalesced, it became clear that the community partners could make important contributions. They continued generating high volume and taking excellent care of the patients they enjoyed, and now they had an excellent place to offload the more time-consuming and less rewarding (to them) cases. Meanwhile, the academic physicians came to understand that the community group not only worked hard but also brought tremendous throughput and downstream complex cases to the team.


In the early stages of a merger, while the attorneys are working out the details, nearly everyone else is kept in the dark. Then, the minute the blindfolds come off, the clock starts ticking on implementation. In our case, we had three months to create a blended group. The key to transforming our uncomfortable arranged union into a united, single-system partnership was a three-part engagement strategy: 

  1. Belonging: Instilling a sense of community by nurturing relationships and valuing individual contributions
  2. Alignment: Defining expectations and responsibilities to create goal alignment
  3. Trust: Creating a climate of trust by promoting open communication and alternate win strategies

On the surface, it looked like our problem was about privileging, but that was the least of it. We needed to focus on ensuring that everyone felt valued and appreciated for their skills and contributions. Eventually, after a bumpy ride, the “us” and “them” in our story became “we.” It didn’t happen until the academic and community practices built a community with a shared sense of belonging. But once this occurred, we were able to align our goals and create a real partnership.