How to address top issues administrators have with their doctors

A practice management consultant, a psychologist and a practice administrator offer strategies for addressing doctor-driven challenges.

John B. Pinto

Craig N. Piso

There was this ophthalmologist … and when he was good, he was very good indeed. But when he was bad, he was horrid.

(With apologies to Henry Wadsworth Longfellow)

The setup

The three of us — a consultant, a psychologist and a practice administrator — had the privilege of co-presenting for the first time as a team at Hawaiian Eye 2011 on the subject of practice development. This topic was generic enough to give us license to cover just about anything we wanted up to the last minute and to go with the mood and requests of the audience.

Candace S. Simerson

And so we did.

In the midst of the day’s upbeat presentation to about 150 administrator attendees, we asked workshop participants to write down and turn in a short answer to a difficult, highly charged practice development question: “What are some things that the doctors in your practice do that hold back the growth and development of your organization?”

Their responses, which you will read below, will come as no surprise to those who are practice veterans but may shock readers who live a more cloistered life. In part 1, we share a roughly rank-order abstract of the brave comments generously shared by 58 of our Hawaiian Eye participants during “Organizational Development Day,” which Candy and Craig co-chaired. Part 2 is a generalized discussion of what you might consider doing if your practice is held back by some of the same issues discussed in part 1. Part 3 is Candy’s closing remarks on how important it is to face up to the challenge of vanquishing these doctor-driven challenges.

Part 1: Doctor behaviors that hold practices back from greatness

1. A lack of teamwork. This was the most common catch-all criticism and ranged from not responding to emails or following agreed rules to the point of being boldly dishonest. Examples shared included doctors saying yes in the board room or to the administrator and then undermining that agreement on the clinic floor. Some doctors were described to be changing policies without telling others. A central theme expressed was concern about an all-too-common double standard: doctors (especially owners) not personally demonstrating the kind of work habits and team-building behaviors that are expected of lay staff. Arriving late to clinic. Hoarding charts. Giving certain staff the cold shoulder while lavishing undue praise on favorites. One respondent wrote: “Our doctor discounts obviously valuable staff members while inflating the value of others who don’t deserve his praise.”

2. Poorly developed communication skills. Providers were cited for jumping to conclusions without listening to all sides, finishing other peoples’ sentences for them, butting heads with management rather than communicating more productively, and especially a hesitancy to confront or engage in difficult conversations.

3. Being rude, condescending and belittling with staff. Some providers were described as seeming to derive pleasure in finding fault with others and meting out criticism that is out of all proportion with the scope of a given problem. One participant wrote, “We are so afraid of what he’s going to say next that we go out of our way to not talk to this doctor at all.” Another wrote, “Our doctor is very kind and appropriate with patients, but is rude and inconsiderate with staff members. Sometimes such behavior can be consistent, but it’s more often unpredictable and presents as frequent mood swings. Blaming and fault finding. Arrogance.”

4. Unreasonable expectations. An example cited was a variety of perfectionistic behaviors: a disconnect between demanding high performance from the team, while not being willing to release the resources needed to staff up to the levels required to function effectively.

5. Overt anger management issues. This is always a serious problem but particularly adverse when it takes place in front of patients.

6. Being inconsistent and indecisive from day to day. “My doctor has an inability to plan ahead and think about the future.” Eye care is typically provided in 5-minute increments from room to room, so it is not unusual for doctors to be lost in the now rather than thinking a year down the track and anticipating future needs.

7. Old-fashioned selfishness. Not considering the needs of others; a “me first” approach to all practice decisions.

8. Excess controlling behavior. “One of our doctors is a control freak.” Being a know-it-all. Negative reactions to new ideas unless they came from the offending provider.

9. Passive-aggressive behaviors. Pot-stirring. “If a crisis isn’t brewing, our doctor will create one.”

10. Being suspicious, to the point of paranoia. Trust is a vital component of working groups if they are to function effectively, and trust has to be built from the top of the organization.

11. Disengagement with and disinterest in staff and their lives. This issue is one of degrees. Too much or too little engagement with support staff can be problematic. A “Goldilocks” approach is indicated, which requires judgment, sensitivity and limit setting.

12. Defensiveness (an inability to accept constructive feedback or coaching).

13. Lazy work habits on the part of young doctors. Some time ago the term “precocious sweatophobia” was coined by one of us to describe the habits of providers who were curiously less workaholic than the previous generation. When a young provider with commendable work-life balance replaces a retiring high-volume senior doctor, this can create headaches for administration and financial collapse for the practice.

14. An “ADHD-like” distractibility. Respondents described this in a lot of ways: “An inability to stay on task … a poor sense of time … procrastination … poor time management … thinking in distracted, roundabout terms out loud rather than forming his thoughts privately and then directing staff or patients clearly … asks for management to research something and then ignores the findings as though he’s forgotten he ever asked for the help … tells multiple staffers to do the same task … gives conflicting orders to two different staff members.”

15. Overt discourtesy to patients. For example, answering personal cell phone calls in the exam room, arriving late for clinic and blowing off reasonable patient questions.

16. Being overcommitted. Taking on too many projects at once.

17. Paperwork gaps. Attendants wrote: “Coding ‘any old way’ instead of what’s correct … holding onto charts … not finishing chart entries at the time of an individual exam, but instead pushing all of the notes and dictation to the end of the day … multi-week delays with dictation.”

18. An unrecognized need to retire. “Our surgeon’s skill is getting shaky and he’s getting forgetful … hard to tell him this, though.”

Part 2: Personal responsibility and problematic physician behavior

Ophthalmologists need to be picky, perfectionistic and detail-oriented. They are trained to be alarmed by small, even microscopic, problems. In daily practice, however, this advanced skill set is over-generalized and misapplied to staff, marking others as “the problem” and stirring staff resentment by demanding perfection. Tensions are created when a physician is closed-minded, rude or disrespectful, overly controlling, and especially if he is imposing a double standard. Such problems sometimes stem from a provider’s blind spot within the domain of personal responsibility (ie, the provider is looking in the wrong direction, applying the wrong lens, and choosing the wrong focus — external rather than internal).

Ophthalmologists wield powerful influence within their practices, and this power bears a potentially burdensome responsibility. Physicians are imbued by society, patients and staff with superhuman powers, leaving providers feeling inherently burdened with the lion’s share of responsibility because power and responsibility go hand in hand.

This can set the stage for dysfunctional interactions between doctors, patients and staff, resulting in many of the issues outlined above. Tension-producing interactions follow when any physician seeks to take charge without accepting commensurate responsibility. (And is it any wonder that in the current financial and legal environment, any provider is loathe to take on more responsibility?)

Jim Collins, who wrote the classic text Good to Great, asserts that a key component of great leadership is demonstrated through “the window and the mirror” — looking unselfishly through the window to give full credit to staff when things are going well and looking courageously in the mirror to take responsibility when things go poorly. In a more recent text, How the Mighty Fall, he described the first three stages of business failure, which are applicable, perhaps, to problematic physician behavior:

1.Hubris born of success

2.Undisciplined pursuit of “more”

3.Denial of risk and peril

Accordingly, here are three self-diagnostic questions each physician should ask and answer. These same questions can be used by practice administrators to coach their physician leaders:

1. Am I a servant leader, humbly striving to serve a mission greater than myself, or do I impress others as being primarily concerned about my own welfare and prosperity (eg, using my position of authority in ways that demean, frustrate or hurt others)?

2. Do I demonstrate a democratic leadership style in which others feel empowered, valued and appreciated, and encouraged to find and express their voice, or do I show more of a dictatorial approach (eg, unilateral decision-making, double-standard behavior, controlling others without holding myself equally or more accountable)?

3. When I become frustrated, anxious, irritable and tired, do I take responsibility for my reactions to others, graciously trying to become part of the solution, or do I blame others (eg, expecting others to change or adjust to improve my moods and feeling states)?

Frequent self-assessment with these questions will provide an ongoing barometer of the degree to which your power and responsibility are in sync. Remember: Real power in leadership comes from your ability to generate loyal followership. Accordingly, the physician who does the best job of controlling himself in an authentically responsible fashion is most effective at influencing change in both people and circumstances.

Part 3: Practice leaders start with themselves to address problem behaviors

Dealing with conflicts arising from behavioral issues is an ongoing challenge for administrators. When these situations occur, each party (doctors and managers alike) is certain that the conflict is entirely someone else’s fault. Generally speaking, even in the toughest issues described above, all involved parties have contributed to creating the issue. As a result, it is impossible to reach a successful resolution unless everyone is willing to step back and take a role in contributing to the needed solutions.

In order to get past the point of self-deception, someone (generally the administrator or managing partner) must proactively accept the reality of the problem, take ownership, and then take positive steps with all involved parties. This obliges setting aside time, building a foundation of trust, engaging in honest conversations and listening actively.

It is much easier for an administrator to ignore behavioral issues than deal with them. The provider exhibiting any of the adverse behaviors described above is likely your boss. Unfortunately these behavioral problems rarely resolve without intervention; they get worse and become more disruptive over time. It takes courage to lead, to be proactive, and especially to expose yourself to potential censure or termination by a physician you are trying to redirect.

As a leader, you may be able to positively influence the behavior of others, but you can absolutely control your own feelings and behaviors. When inappropriate behavioral issues first surface, do not wait for the provider who has acted out to spontaneously change. The provider involved may not be aware that their behavior is unacceptable. If your practice is saddled with a provider who was not sufficiently screened or oriented when they were hired, take the time to review expectations and goals, set boundaries and roles, and outline rules and consequences. Then, with progressive discipline, hold your providers accountable.

• John B. Pinto is president of J. Pinto & Associates Inc., an ophthalmic practice management consulting firm established in 1979. Mr. Pinto is the country’s most published author on ophthalmology management topics. He is the author of John Pinto’s Little Green Book of Ophthalmology; Turnaround: 21 Weeks to Ophthalmic Practice Survival and Permanent Improvement; Cash Flow: The Practical Art of Earning More From Your Ophthalmology Practice; The Efficient Ophthalmologist: How to See More Patients, Provide Better Care and Prosper in an Era of Falling Fees; The Women of Ophthalmology; and his new book, Legal Issues in Ophthalmology: A Review for Surgeons and Administrators. He can be reached at 619-223-2233; email: pintoinc@aol.com; website: www.pintoinc.com.
• Craig N. Piso, PhD, is president of Piso and Associates, LLC, an organizational development and psychological services consulting firm based in Northeastern Pennsylvania. A consultant/psychologist with 30 years of corporate executive and clinical practice experience, Craig is the author of a new book, Dream of Life … Live Your Dream – A Manual of Skills for Living for Today’s Young Adults. He can be reached at 570-239-3114; email: cpiso@pisoandassociates.com; website: www.pisoandassociates.com.
• Candace S. Simerson is president and COO of Minnesota Eye Consultants, P.A., a large, nationally recognized ophthalmology practice with multiple locations. The practice focuses on providing subspecialty services in cornea, glaucoma and oculoplastics. She can be reached at 952-567-6100; email: cssimerson@mneye.com.