The article by Mr. Barbo is very helpful and informative for those groups contemplating methods of developing new revenue-sharing opportunities in a setting of collaborative activity or strategic alliances with parties who have common goals. Evolution can be a challenging and sometimes contentious issue. An analogy to hospital-clinical practice environment can be drawn from a recent review1 and book entitled The Cooperative Gene by Mark Ridley.2 In the book, the author explores concepts of genetic turmoil that occur in all organisms. The work focuses on a concept that has troubled Darwinian theorists, namely the recognition that natural selection should favor those individuals or organisms that are best able to survive and reproduce. One would think the concept of natural selection would suggest that nice guys finish last and that we would no longer see them or their progeny in existence — but this is not quite so when examined carefully. To play off the analogy further, I would suggest that the dance of relationships between private medical groups and the hospital can be viewed as undergoing evolutionary development. The milieu is one of constant tension between “selfish” and “cooperative” genes and the endpoints are continuously evolving macrocosms that are, in my opinion, better off with the cooperation and progress that occur as a consequence. As with all histories and categorizations of evolution, one needs to make sure that each generation is told the stories of the past. However, the future is framed by those hundreds of successful interactions that build to new experiences, new opportunities and successes. In the environmental milieu we label clinical practice there exists numerous environmental microcosms — the office, the health system, the hospital, etc. — and within each of these domains are yet smaller microcosms of activity — the emergency room, the cath lab, the examination room, the operating room, etc. The question becomes one of interplay and rationale for organizational designs. Is it purposeful design or fortuitous adventure or financial striving that drives the structure, and to what end? The past decade has seen some interesting attempts at bringing various constituencies into symbiotic working relationships (gain-sharing; heart hospitals; physician practice management companies; a host of joint ventures; etc.). What lies in store as one looks to the future? Not being a political scientist, it may be wise not to venture beyond our present. Historically, there has been much more than strategic alliances, legal constructs or financial arrangements that have served as the glue for our professional encounters and the place of those encounters. Perhaps these new and innovative constructs should not be looked upon in absentia from the totality of our work and for whom we ultimately labor, namely our patients. We can’t be naive about the forces that loom ever larger in our clinical practice and business lives, but we also should understand that slowly evolving and eroding borders between the various micro- and macrocosms come with responsibility, accountability and potentially new challenges, as well as evolution. The future will belong to those practices and organizations that successfully navigate the boundaries of cooperation. “It should be known that war is universal, that strife is justice, and all things come into existence by strife and necessity.” Heraclitus (c. 540-480 B.C.)
1. Silver LM, ‚ÄúThe Reproducers,‚Äù New York Times, 8 July 2001. 2. Mark Ridley, ‚ÄúThe Cooperative Gene ‚Äî How Mendel‚Äôs Demon Explains the Evolution of Complex Beings,‚Äù New York: The Free Press, 2001.