In a recent KevinMD podcast, palliative physician Kirsten Engel and writer Medha Tripathi described a patient they called Mr. L. He was dying in the hospital. He could not speak for himself, no family visited, and he had never named a health care proxy. A court-appointed guardian held the authority to decide.
The team believed comfort measures and hospice would serve him best. In his case, decisions of that weight required the court. The legal process moved more slowly than his decline, and he died before those measures were in place. As Dr. Engel put it, hospital decisions move in hours to days, and court decisions typically take weeks. Mr. L died in the gap between two clocks.
It is easy to read that story as a problem for patients with no one beside them. Most physicians reading this have family, colleagues, and advisers. But Mr. L’s crisis was not simply an absence of people. It was an absence of legally recognized authority. For a physician with a spouse, partners, and employees, the same gap is harder to see, because it can sit in financial accounts and practice operations.
The Tuesday stroke
Consider a hypothetical fifty-four-year-old gastroenterologist who is the managing partner and majority owner of a four-physician practice. On Tuesday morning, she has a stroke. She survives, but she cannot reliably communicate, read, or make decisions.
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Her husband is at the bedside. For medical decisions, he may have authority under the state’s default surrogate law, though its scope depends on the jurisdiction. Her finances are another matter. Her IRA is individually owned. Her brokerage account is titled in her name alone. She never signed a financial power of attorney.
On Wednesday, her partners begin absorbing her patients. Procedures are reassigned, follow-up appointments are postponed, and staff field calls from patients who expected to see her. The clinical team can redistribute the work. But the administrator discovers that several business decisions still require her authorization.
By Thursday, payroll is ready and the funds are available. Fourteen employees have worked their shifts. But the managing partner is the only officer authorized to approve its release, and the payroll platform reflects that restriction. No alternate officer was ever designated. She is still in the hospital.
The practice is not short of money. It is short of authority.
Her partners know how to care for her patients. Her administrator knows how to run the business. Her husband knows what she would want. None of that establishes who is legally authorized to act.
Family is not authority
Having assets, having family, and having legal authority are three different things. Marriage does not automatically grant authority over another person’s financial accounts. Neither does a will, which governs property after death and was never designed to manage a living person’s incapacity.
A durable financial power of attorney, signed while the person still has capacity, can authorize a trusted agent to act. Without appropriate authority, a family may need a court to appoint a conservator or guardian of the estate, depending on state law. That can mean petitions, hearings, bonds, and judicial oversight. The same mismatch returns. Bills run on a calendar. Courts run on a docket.
In medicine, identifying the decision-maker is part of the consent process. At home and in the practice, the same question is too often left unanswered.
The practice has its own clock
For an employed physician, incapacity may primarily disrupt household finances. For a practice owner, it can also disrupt the enterprise within days.
Three questions expose the vulnerability. Who can authorize payroll? Who can execute contracts and financial instructions on the practice’s behalf? Who has the legal authority to keep the enterprise operating for the next ninety days?
A personal power of attorney does not necessarily answer them. An agent may have authority to exercise the physician’s ownership rights without having authority to manage the practice itself. Day-to-day operating authority may instead depend on the entity’s governing documents, management appointments, banking resolutions, and applicable law.
In many multi-physician practices, those arrangements already provide continuity. Where authority is concentrated in one person, incapacity can expose a weakness that years of profitability concealed. A practice can be clinically capable, financially solvent, and operationally paralyzed.
Your practice may be able to function without your clinical labor for a few weeks. Can it make decisions without your signature?
Run the drill
In an earlier essay here, I suggested physicians test their succession plans rather than assume they work. Incapacity deserves the same discipline:
- Medical authority: Who makes decisions if I cannot, and have I formally designated that person rather than relying on my state’s default rules?
- Financial authority: Who can act on my accounts, and does my durable power of attorney grant the powers those accounts require? Retirement accounts deserve particular attention; a generic form may be insufficient.
- Practice authority: Who can operate the practice for ninety days, and do its governing documents and banking arrangements support that authority?
Then verify the answers. Ask the relevant institutions what documentation they require, and resolve foreseeable obstacles now. Review the practice’s authority arrangements with counsel. Confirm that the people you designated understand their responsibilities and know where the documents are kept. A plan that has never been tested is still an assumption.
Mr. L had no one formally designated to speak for him. A physician’s family and colleagues may know who should act. The governing documents and institutions may tell a different story.
Knowing who should act is not the same as giving them the authority to act.
Who signs on the day you cannot?
Mike Chando is the founder of Chando Global Group, a Charlotte-based capital architecture firm serving physicians, practice owners, and executives, and editor of The Capital Architect, a private briefing on how capital is structured and how it quietly comes apart.
Most physicians build their financial lives one competent decision at a time: a retirement plan chosen by an employer, a practice interest governed by a partnership agreement, a certified public accountant here, an attorney there, someone managing the portfolio. Each professional may be highly capable within a particular discipline. The problem is that no one necessarily owns the seams between them, and the seams are where structural failures tend to surface: tax exposure embedded inside retirement assets, a buy-sell agreement without sufficient liquidity behind it, or an estate plan that no longer reflects the family or balance sheet it was designed to protect.
His work is architectural rather than transactional. The central question is not simply what a physician owns, but how the pieces interact, how much control the family retains, and what happens to the structure when the person holding it together is no longer there.
Physicians can pressure-test their own structure with the three-minute Capital Architecture Diagnostic. Essays and prior issues of The Capital Architect are available in the journal archive.
He lives in Charlotte, North Carolina.
