Emergency, Inc.;

 

An odd-looking trophy adorns the desk of Stanley R. Gold, M.D., founder and president of American Emergicenter Inc., a chain of publicly owned walk-in medical clinics in Orange County, Calif. The statuette, a gift from a former staff member, is a crude rendering of McDonald's famous golden arches. But twisting upward between the arches is a serpent clearly borrowed from the caduceus, the ancient symbol of the medical profession. Another doctor might find such mockery offensive; Gold sees it as apt and even amusing.

"It used to bother me when they called these centers 'McMedicine," says Gold, a 52-year-old emergency physician who also serves as president of the Dallas-based National Association for Ambulatory Care, a four-year-old umbrella organization for walk-in clinics. "Not any more. I think it's accurate. Just like the fast-food chains, we're offering a service that's efficient, accessible, and economical. And I'd be delighted if we became as successful financially as McDonald's."

It is not as whimsical a notion as one might think. The American health care system is in the throes of a revolution, and founders of such clinics as Gold's are among the shock troops. A decade ago, few people took seriously the concept of walkin medical centers, unaffiliated with any hospital, that stayed open 14 to 18 hours a day to serve patients with routine health problems as well as non-life-threatening medical emergencies. Today, there are some 3,000 so-called freestanding emergency clinics (FECs) across the country, a number expected to double by the end of the decade.

But to an observer familiar with the troubled history of American Emergicenter and some of the other FEC chains, the snake in Gold's sculpture has a double meaning. It also stands for the hidden perils of this new kind of medical entrepreneurship, especially for physicians who are innocent of business experience. "This type of health care delivery is the wave of the future," says Neal F. Bermas, formerly the national director of health care planning and productivity services for Arthur Young & Co. and now president of the forprofit operating company of Forbes Health Systems. "But there's a second wave -- a wave of concern. There have already been a number of failures in the field, and it's too early to decipher the trends."

Perhaps the most severe challenge faced by walk-in clinics is developing management talent. Although medicine is a lucrative profession -- according to the American Medical Association, U.S. physicians in patient care earn an average of $106,300 a year -- doctors haven't traditionally needed many business skills. The doctor-entrepreneurs who are starting walk-in clinics must, by contrast, know about financing, multisite management, marketing, personnel, billing, and all the other aspects of running a successful business.

Most don't -- and like Stanley Gold, they are learning the old-fashioned way. They are making a lot of mistakes.

If heredity were destiny, Stanley Gold would have turned out to be the opposite of a medical entrepreneur: a traditional physician, perhaps in a teaching hospital. That is what his father, a professor of clinical pharmacology at Cornell University's Medical College, was. His mother was chairman of the physiology department at Hunter College. It was a background, says Gold, of "intellectual snobbery." He resisted the family medical tradition at first, ending up with a degree in electrical engineering from Columbia University. Eventually, pushed by his father, Gold got his M.D. from New York University's School of Medicine.

Gold trained in internal medicine and surgery, but had trouble deciding what to do with the training. "I did a lot of surgery," he says, "but I wasn't turned on intellectually." By this time, the Vietnam War was heating up. In 1967, to avoid being drafted into the Army, Gold joined the Navy and shipped out to the Marine Corps base in Camp Pendleton, Calif.

What seemed at first like dismal luck soon revealed itself to be serendipity. "The only sick calls were malingerers," Gold recalls. "I felt like I was on perpetual vacation." To fill up the time, he began moonlighting -- "and even daylighting" -- in local emergency rooms.

In the past, emergency medicine had been regarded as a subspecialty of every medical service, part of the regular rotation for hospital staff. But in the 1960s, the passage of Medicare and Medicaid legislation created a class of consumers who used hospital emergency rooms as their primary source of health care. As a result (and for a variety of other reasons), hospitals began staffing emergency departments with fulltime physicians. And Stanley Gold, at last, discovered a specialty he found challenging. "I was interested in critical care," he says. "I'd discovered that most doctors were affraid to deal with matters of life and death. I wasn't."

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