Working with family members in your practice poses unique challenges

Practical guideposts will help you avoid the most common difficulties.

Issue: June 10, 2012

ByJohn B. Pinto

Any problem, big or small, within a family
always seems to start with bad communication.
— Emma Thompson

Home is the place where boys and girls
first learn how to limit their wishes, abide by
rules, and consider the rights and needs of others.
— Sidonie Gruenberg

The first half of our lives is spoiled by our parents,
and the last half by our children.
— Jennifer James

John B. Pinto

Although no official study has been done, an unofficial check of my files indicates that in approximately 10% of all ophthalmic practices, family members are working with each other. Or perhaps it only seems that way because a disproportionate number of family-based practices have problems that need outside intercession.

Family-based practices come in four basic flavors:

Wives or husbands who help their physician-spouses launch a practice and then stay on, sometimes longer than originally intended.
Brothers and sisters who practice with each other (as physician-partners, or with one sibling as the physician and one as the administrator).
Children of physician-owners who come home to practice medicine or be an office worker with one or both parents.
Siblings and children of lay office workers who are conveniently tapped as a labor pool.

Most of the time, hiring or partnering with family members is a long-contemplated event. You know when your wife is in her residency that you will help her launch a practice. You know that your daughter will be coming in to run the practice after she completes her MBA. But even when you plan well in advance to work with a family member, special problems will crop up that would not be the case when hiring a stranger.

Here are a few guideposts to help you avoid or extract yourself from the most common difficulties.

Abundant meetings, disclosure and communication are the key to harmony in a family business

The need for communication rises materially in family businesses of every type. In some rare cases, this great communication has been present from the outset. More often, teaching family members how to communicate more effectively is at the core of turning around discordant relationships within the practice setting. Go overboard in being transparent with data, meeting minutes, policies and the basis for making decisions.

Get your story straight for non-family members

Job candidates, and particularly doctor and administrator candidates, can be justifiably leery of joining your cozy family practice. Consider the following:

Will the non-family member be treated as an equal, or will the founder’s son, daughter or spouse effectively be an untouchable?
In the case of a partner-track associate physician joining a solo practice in which the founder’s spouse is the administrator, be clear about whether the new doctor will eventually have veto power over who will be the practice’s administrator and how this control will be exercised without undue hurt feelings.

The past can be prelude

Sibling rivalries can be enduring. I am often called on to help resolve intra-family business rivalries. When I take the history from every involved family member within a practice, it is amazing to learn how the current discord has its roots in earlier family dynamics. Struggles for control and leadership, or a parent’s affections, can resonate through the years.

Do not hire anyone you are not willing to fire

If you are the physician who is hiring a family member, this is easy to say — and even to discuss and agree to at the outset. The theory is sensible. But execution is tough. Make sure you really mean it before you make the hire. Remember: The average tenure for a new worker, even a doctor, entering your practice is about 4 years, even if some stay for decades. When staff leave you and your practice, it is usually for the better for both parties. Do not block the exit.

The business comes first, people second

This may sound a bit cold, but think of it this way: Your practice is a professional workshop as well as an economic engine supporting many other families besides your own. This engine can be harmed, sometimes mortally, when you make the wrong hiring decision. When you begin to suspect you have made the wrong hiring decision, do not focus solely on the hurt feelings of the family member you may need to pull out of the company. Think also — and, I would assert, primarily — about the interests of the wider company.

Arrange a trial hire if possible

If you are on the fence about having a family member join your practice, try to arrange a readily reversible period of trial employment. Be sure to listen carefully to your staff when they tell you, “We love your [sister, aunt, wife, daughter], but please don’t let her work here full time.”

Consider stopping short of formal employment

The most common familial addition to a practice is still the wife as office manager. If this is causing difficulties, ask yourself if it would be better for your practice, and your personal relationship with your spouse, to have your wife take on a more limited role. I have seen numerous cases in which a spouse who was ill-suited to be the in-office administrator did a splendid job once they shifted to working outside the clinic as a bookkeeper or marketing coordinator.

Get outside help

Chances are, if you presently work in a family-based practice, you have already been using your attorney, accountant and various other advisors as referees. This is very healthy and can stave off the after-hours frictions that can understandably still smolder when the ophthalmologist has to override a spouse or child working in the office. If you are a physician whose spouse runs the office, urge your spouse to seek external validation before they spring a potentially unpleasant but necessary change on staff.

Familial practice problems can crop up suddenly

Here is a common scenario. Two ophthalmologists are equal partners. One surgeon’s child goes to medical school. You know what is coming next. … There is a new partner-to-be knocking on the door, full of a sense of entitlement. In principle, the admission of a new partner-track associate should not be colored by family connections. In the real world, wise ophthalmologists whose children commence a path to become an eye surgeon will start “what if” discussions early on with their present colleagues.

Demonstrate your neutrality

Unless you are working in the smallest mom-and-pop practice setting, you must avoid both the appearance and reality of favoritism. Do not let your newly minted doctor-daughter pull rank on your peer partners. Tell her, “Every doctor here had to pay their dues. I love you, but you’re going to have to wait your turn like everyone else.” Be sure to explain to younger family members joining you in practice that they will have to do twice as much work, twice as well as others, to get half the credit.

Do not be afraid to make your practice different

Although equality is the norm in most group practices, it does not have to be in your setting. If you are the “Papa Doc” and want your son and daughter to take over for you one day, there is nothing wrong with hiring every other provider on terms spelling out that they will be durable associates with no control over operations. The key is disclosure of the special conditions and boundaries from the outset and their consistent application.

For more information:

John B. Pinto is president of J. Pinto & Associates Inc., an ophthalmic practice management consulting firm established in 1979. 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; Legal Issues in Ophthalmology: A Review for Surgeons and Administrators; and Leadership: A Practical Guide for Physicians, Administrators and Teams. He can be reached at 619-223-2233; email: pintoinc@aol.com; website: www.pintoinc.com.

Keys to working with family

by Craig N. Piso, PhD

Couples unite without expecting to be divorced. So, too, are family members in a shared practice often unaware of the pitfalls that threaten both their future bonds and the practice itself.

Craig N. Piso

Psychologists and other health care providers invite sanctions for ethics violations when they enter into “dual relationships” (eg, hiring a patient) because of the risks that are inherent in multiple close ties. A problem in one aspect of the relationship might adversely affect the other aspect, thus such complications are to be avoided. Hiring family members into the practice is parallel to this, in that multiplexed relationships can be damaging. A key risk factor is the staff’s perception of preferential treatment, managerial unfairness, and the loss of morale or trust that follows when there is not a level playing field at work. Remember that staff perceptions become their reality.

On the other hand, there can be a valid reason for permitting family involvement in a practice, including both economic and relational advantages. Managed well, hiring a competent and trustworthy family member creates a win for the practice.

In view of both the risks and the rewards of working with family in a practice, here are some keys to preserving both relational and practice integrity:

1. Just as “good fences make good neighbors,” establish and maintain appropriate boundaries with clear expectations regarding roles, limits and consequences for any good or poor performance.

2. Maintain a level playing field by demonstrating objectivity and fair treatment toward staff across the board.

3. Maintain an effective “firewall” by keeping family issues at home when at work and keeping work issues at the practice when at home.

4. Continually ask whether the arrangement is a win-win, not only for you and your loved one, but also for those who are intermeshed with family in the practice.

5. Muster the courage to do the right thing for your practice, independent of any one person, including a loved one. As Jim Collins has said, “When you know you need to make a people change, act.”

For more information:

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 can be reached at 570-239-3114; email: cpiso@pisoandassociates.com; website: www.pisoandassociates.com.