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Addressing the ‘you’ve got to go, doctor’ elephant in the room
Many factors play into the choice to remove a physician from a practice.
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“The FBI Academy teaches new agents that the best predictor of future behavior is past behavior.” – Ronald Kessler
In boating circles, they say the best 2 days in a sailor’s life are when he buys a boat and when he gets rid of it. This might not be too far off the mark in ophthalmology. Adding a new doctor is always cause for celebration. But about half of the time so, too, is the removal of the same provider for one reason or another.
Here are the seven deadly sins most commonly observed in American ophthalmic practices, and in Canada, Chile, England, Singapore, Germany — actually, everywhere I have seen eye surgeons at work.
1. Poor hands. Standards vary from practice to practice. But in most settings, peer review, even though not formal, is a pretty ruthlessly effective way to weed out doctors who should not make partner. In the most effective settings, standards are kept high and reinforced with internal agreement on care pathways and operative protocols. Peer review is made more formal with doctor-by-doctor outcomes studies and periodic monitoring.
2. Poor judgement. This is actually more common — and more troubling — than poor clinical and surgical skills. It is much easier to improve the surgical skills of an undertrained young doctor than to revise poor judgement, given the deep roots of the latter.
3. Misalignment with the mission or values of other owners. Few boards are 100% in alignment, and healthy disagreements are always welcome. But when the board votes on a course of action, everyone — even the strongest dissenter — has to get in line.
4. Conflict generation. Very few practices have multiple doctors who generate conflict. Instead, like an infection, there is a nidus: one surgeon who is in conflict with multiple people in the practice. In consulting with clients, while we have ways to objectify the source and strength of the conflict, we are usually pointing out a fact that everyone already knows, “We’re miserable here because Dr. Jones can’t help himself.” If you have a Dr. Jones in your practice and are not yet certain about the depth of the problem, you can conduct patient satisfaction studies and staff morale polling.
5. Conflict avoidance. When administrators gather to discuss their frustrations, high on the list is the doctor who is unable or unwilling to safely and appropriately confront others. This can be the managing partner who does not want to confront a colleague about late arrivals. Or the head of a quality assurance task force who is not able to confront a surgeon about her excess complication rate. This is rarely a problem worthy of expulsion but is often the basis for removing an MD from a leadership position.
6. Low productivity. By the end of his second year in practice, the typical full-time general ophthalmologist in private practice will be hitting $750,000+ in revenue. While the number is higher or lower depending on the subspecialty — and your board may be more lenient about its productivity expectations — you should still develop and stick to production levels needed to make partner and stay a partner.
7. Questionable ethics. Poor ethics, like the old saying about pornography, is hard to define, but everyone knows what crosses over the line when they are looking at it. Common examples are excessive testing or treatment rates, withholding poor outcomes from patients, or failing to report practice quality gaps to the board. If your practice has experienced ethical struggles in the past or is on the verge of an ethical dilemma today, as described below, it is up to the managing partner to be proactive in mustering up the board’s response.
Dealing with doctors who may have to go
Prevention is much less expensive than treatment: Very few practices undertake sufficient vetting to improve the odds of a hiring success. In personnel management circles, this is called, “hiring hard so you can manage easily.” Often-missed vetting includes:
- Going to a candidate’s current place of work, watching him see clinic patients, watching him in surgery and asking his staff for their “impressions of Dr. Smith.”
- Conducting a working interview in which you see patients together and compare findings.
- Asking for and interviewing a deeper set of references. Do not talk to just a young candidate’s department chair; talk to the chief resident and the RN who runs the OR.
- Having 15 or more hours of face time with a candidate; some of this can be video.
- Spending time with the candidate’s significant other. If your candidate has a spouse or committed partner, he or she is already holding down a job with a kind of “boss.” If “Bill” has lived happily with his doctor-wife “Sarah” for several years, maybe you can as well.
- Evaluating the “teamability” of a candidate before the hire. This can be as simple as checking a candidate’s background (military service, participation with team sports or fraternity/sorority life) and asking references for examples of how your applicant was a team player.
Formal performance and behavioral standards: An increasing number of practices are publishing a “code of conduct” for all providers to follow. This code covers everything from relatively victimless offenses such as not keeping up with dictation to the harm that can come from romancing multiple office staff. This document spells out progressive discipline steps that will be taken in the event of continuing misbehavior or failure to carry out a corrective action plan. (Some of you reading this, particularly in small practices, may find such formality overkill or beneath the dignity of the profession. But experience is now showing — especially in larger practices — the utility of such board-imposed standards in bringing everyone’s professional deportment up a notch.)
Managing partner and administrator vigilance: Parking meters are always combined with parking enforcement officers so there is a tangible consequence for not feeding the meter. In the same way, a practice’s code of conduct is toothless unless someone is the “cop.” That someone, in the vast majority of practices, has to be the managing partner and administrator, teamed up like parents to keep the kids in line for their own good.
Not avoiding early, difficult discussions: Most ophthalmologists are naturally conflict-avoidant. This makes for pleasant, tractable students in medical school but can lead to the buildup of unspoken issues, which are ultimately very damaging to practice performance and enjoyment of your professional life. The managing partner must be the CCRO — the chief conflict resolution officer — finding, unveiling and dampening conflicts.
Determining the financial impact of removing a provider: Do not let economics alone hold you back from needed action. As it turns out, the most expulsion-worthy doctors are often the most financially productive, too. Intense, high-volume surgeons can carry this intensity, volumetric grasping and perfectionistic behavior over to their relationships with partners, staff and patients. Statistically, more retinologists and uber-volume cataract surgeons are put on corrective action plans than their mild-mannered colleagues. As a result, boards often dawdle on termination action for fear of their own near-term financial hit. In advance of any provider termination, it is important to run the numbers and be aware of the financial consequences (and have a plan for dealing with these), but to not procrastinate action needed to save the practice from longer-term damage.
- For more information:
- John B. Pinto is president of J. Pinto & Associates Inc., an ophthalmic practice management consulting firm established in 1979. John 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, Cashflow: The Practical Art of Earning More From Your Ophthalmology Practice, The Efficient Ophthalmologist, The Women of Ophthalmology, Legal Issues in Ophthalmology, Ophthalmic Leadership: A Practical Guide for Physicians, Administrators and Teams and a new book, Simple: The Inner Game of Ophthalmic Practice Success. He can be reached at 619-223-2233; email: pintoinc@aol.com; website: www.pintoinc.com.