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Dear Boss,
I recently took over as an ED chairman in a facility that has eight other docs. I’ve been here about six months and I like and respect most of the other emergency physicians. However, there is one doc who complains frequently, is much slower and less productive than everyone else and I’m afraid he could undermine the work I’m trying to do. I’m thinking I might need to fire him but that seems aggressive for a new chairman.
Any thoughts?
Signed,
Feeling alone

Dear Alone,
As you are quickly learning, a good ED staff can make your life easy, but one bad apple can ruin the batch. With that in mind, you need to be able to answer the following questions. Can you coach and educate Dr. Underachiever (UA) to bring his performance to average or above average? What are the implications if you fire him, both from your hospital administrator’s perspective and the rest of the group’s perspective? If he stays and doesn’t improve, what is his impact on the department’s performance and morale? Finally, how short staffed will you be if he leaves and how will your group handle picking up the additional shifts?

Generally speaking, it’s more efficient to try and improve your physician’s attitude and productivity than to recruit a new doc and get them up to speed. Recruiting and credentialing can take months. Plus, you are a manager, and managers get their staffs to function at peak performance. This is what you do best.

That said, since you’ve put termination on the table, step one is to let your hospital administration know about your assessment and plan—to coach, remediate and possibly to terminate. You wouldn’t want to get to the termination part only to find out that this physician was the hospital CEO’s husband’s cousin or was a major benefactor to the hospital. In addition, keeping your administrator in the loop would allow for you to get buy-in from your bosses while continuing with your plan. Finally, document, document, document!  Every attempt to counsel or remediate your physician must be documented. Most importantly, the physician needs to know what the purpose of this counseling is and what the outcomes will be for continued poor performance.  If these things aren’t done, he’ll get a paycheck without working another hour for you once he files his wrongful termination suit.

Let’s say Dr. UA stays and doesn’t improve. Perhaps he continues to under perform and your docs no longer want to carry him so they slow down as well. Maybe they even become a little toxic to keep up with his complaining. Just imagine how those scenarios can impact your ED’s performance and patient and staff satisfaction. And that’s before taking into the account the negative impact he can have on the morale of the nursing staff. Perhaps your “good” docs no longer want to work with him. Eventually, they may even want to leave your department. Then what?

Don’t allow one doctor to ruin your department. It’s important as a new chairman to start strong and begin breeding success. And that might mean picking the low hanging fruit. Sure, being short staffed can have its problems, but your staff will likely be thrilled that the low performer is gone. Plus, it will give you the opportunity to get the right person on the team, someone who shares your vision. I know a former chairman who used to say, “you’re never overstaffed, just underfired.” Maybe you should start looking for that new hire now so that you’re a little overstaffed. Then, when you cut the dead wood and do the appropriate firing, you can keep your department moving forward.

Lastly, I wouldn’t be concerned about this appearing “too aggressive” for a new chairman. If that is your mindset, you need to change it fast.  Your new title carries with it responsibility, accountability and authority to fix the problems in that department.  If the hospital CEO doesn’t see you tackle tough issues to improve that department, you’ll be the one looking for the new job.

Mike Silverman, MD, is chairman of emergency medicine at Harbor Hospital in Baltimore and on the faculty at the TeamHealth Leadership Academy
 

Comments   

# Gibson General Hospital ER Medical DirectorThomas H. Nelson, MD 2008-10-06 20:33
By continuing to show Dr. UA his opportunities for improvement individually and thru peer review, he will improve or quit, and save you the grief of having to actually try to fire him. Make sure you stay strictly professional and document the counseling.
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# Yes, and ...Tom Scaletta, MD FAAEM 2008-10-15 21:44
Three facets of emergency physician excellence are quality of care, patient/staff satisfaction and productivity. While I think quality and satisfaction are non-negotiable in top-tier ED, I am OK accepting a reasonable continuum regarding productivity. However, this only works when a meaningful productivity incentive is used.

Consider an ED that pays and average of $160 per hour with an average patients per physician per hour of 2. Essentially, this means each case can be paid at $80. Then, doc seeing 1.5 patients-per-ho ur makes $120/h and a doc seeing 2.5 patients-per-ho ur makes $200/h.

Actually, to prevent any cherry picking, I prefer linking the hourly rate linearly to charges billed per hour worked ... again, with quality and satisfaction being non-negotiable. Now, a motivated and capable EP is happy working alongside Dr. UA. And, Dr. UA drifts to St. Elsewhere.

Finally, to retain the best and brightest docs and to maximally satisfy the community, medical staff, and administrators, professional revenue must be fully returned to the docs after fair business expenses are deducted.
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