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Dear Boss,
I was recently asked to resign from a job I had been at for years. My director told me he had been giving me hints for months that I needed to find a new job but I guess I didn’t pick up on it. What did I miss?
Signed,
Blindsided

After successfully managing college, medical school, and residency, it’s difficult to imagine that a physician can be fired, yet it occurs regularly. It’s not in our DNA to fail, and being fired or being asked to resign (which is the much preferred option) can point out faults that we may not recognize within ourselves. However, there are typically many steps between a doctor making a mistake and being fired. Staff physicians would benefit from understanding some of the HR techniques employed by medical directors when they see a physician heading down the wrong path.

Why people get fired:


First, unless behaviors are extreme, such as being violent or screaming and cursing at patients or nurses, no one gets fired for a one time occurrence.

Typically, I’m looking for patterns of behavior over a period of time or a failure to achieve in one of three categories—performance metrics, such as productivity and patient satisfaction; personality and relationships (with medical staff, nursing, management or anyone else); and patient care/quality.

While you can be average in any of these categories, very poor performance in any of them can lead to you looking for a new job. Even the most productive person in the group who is regarded as the best clinician, can find themselves sending out CVs if they can’t play nicely with others.

There are no magic numbers when it comes to letting people go. It’s very unusual for me to draw a line in the sand and say that any physician who doesn’t meet productivity marks or has more than X core measure misses will be terminated. If you’re too slow to work in that particular ED, you tend to know it and you look for other jobs before I tell you to. The same can be said of quality issues. There is no secret number of issues that forces you out the door, but most docs recognize that multiple lawsuits, complaints, or high profile bad outcomes, will lead to conversations that will encourage looking for a new job.

The disruptive physician has such an impact on healthcare—affecting patient satisfaction and adverse outcomes and increasing the cost of care—that The Joint Commission released an official stance on the topic.  In the end, probably the most common reason that people rotate out of a job is their individual failure to maintain relationships. They may have anger management issues and explode from time to time in the nursing station (i.e. the disruptive physician), or they may just be rude to patients or difficult for staff to get along with. Whatever the case, time and time again I’ve seen good docs looking for new jobs because of how they communicate or interact with the hospital community and/or patients.

How Directors Respond to Problems:

Mild concern
Mild offenses range from forgetting to call the house officer for an admission to admitting a patient to the wrong attending (a hospitalist instead of private attending) and may only warrant a reminder email. Sometimes I’ll send a memo to our group or discuss it at a staff meeting as anyone can make this mistake once or twice. Admittedly, it’s a bit passive aggressive, but it’s not uncommon for me to get an email back from the offender apologizing. If I don’t think the individual recognizes the problem as their own, I’ll usually make mention of it casually in the ED. If there is a potential quality issue or an isolated case or patient satisfaction survey to review, I may ask to speak to the provider privately during a shift. Keep in mind that it’s rare to have an important meeting that may be sensitive and time consuming while someone is working clinically. If the question or discussion is fairly benign, I may even do it in the clinical area. If it is more sensitive, I may ask them to meet me in my office. Mild offenses, and therefore mild stress on your part, can usually be discussed quickly and be kept informal (not documented in your file).

Moderate concern
There are some red flags that indicate that an offense is more serious, in which case the response needs to match. This may come after a doc repeatedly forgets to do something, is at the bottom on a performance graph, or has had a particularly negative interaction with a nurse, physician, or patient. The first warning sign for the doc is how they’re approached about the meeting. While I may tell the individual I want to meet with them, typically the request is also by email, thus formalizing the process and starting a paper trail. While I meet with docs regularly to review routine performance evaluations, any individual meeting request outside of your normal routine should let you know that something potentially serious has come up. I typically meet with people in my office who had a risk management issue, but if you get to the meeting after receiving an email invite and it’s not about a case, your warning lights should be flashing.

Honestly, medical directors don’t like having these conversations, and we might not be direct about the purpose, but be alert to any reference about updating your CV or looking for other work. Even if it’s discussed as a positive for you, it would behoove you to begin examining your performance.

There are three other things that should trigger moderate concern for your job, though none should be viewed as sure signs that you’re about to get fired. The first has to do with quality. I’ve seen this with EKG interpretation and airway management where providers are told they have deficiencies and need to obtain CME in a particular area. This is not the time to find CME in Hawaii and go to the beach. Next is if your medical director has you sign details of a conversation. It may be as simple as saying you’re aware that your productivity is significantly below average and that you will take steps A,B and C to improve them. It might also have to do with a behavior that you demonstrated, such as screaming “the patient’s going to die if we don’t get them to the ICU now” while you’re in the nursing station. (Don’t laugh, happens more than you would think and in many areas of the hospital, not just the ED). This is our way of making sure you acknowledge the problem and this will be placed in your file. Finally, is if you’re put on a performance improvement plan (PIP) or corrective action plan. These should be the scariest to the provider as a failure to achieve what’s laid out in the plan can lead to termination, and I usually view these as a last step prior to terminating someone. Our goal in using these techniques – while creating a paper trail so we can fire you if we need to – is really to give you the opportunity to see exactly where the problems are and find ways to improve.

Significant concern
There are many scenarios where you should view your job as being immediately at risk. For starters, any meeting after being on a PIP, particularly if you have not improved is a “Danger, Will Robinson” moment. If you think you can do the same thing after being told to stop, and having that behavior documented, you should start looking for a new job. You should also be concerned if you’re asked to meet with the medical director. Complaints that reach the level of the chief medical or nursing officer can escalate pretty quickly up to the hospital president, who may ask that a provider be dismissed.

You really need to remember whose house it is, and while this may apply in many situations, it’s not ours.  If the CEO wants someone removed from the schedule, the chairman has two choices: remove the doc or look for new work themselves and risk losing the contract for the group.  Therefore, any meeting that contains just about anyone in addition to your medical director, particularly the CMO or someone from HR, is cause for concern. Although few contracts that I’ve seen promise due promise, it’s certainly nice to believe that all physicians are entitled to due process and that no one would lose their job without a step wise disciplinary process (the PIP). 

Personally, I know that when I’m called by my boss while on vacation, something big is happening. Likewise, providers should recognize that if I’m calling them when they’re on vacation, something big is happening. Another red flag is when a medical director tells you it’s not your metrics, it’s your personality. Many years ago, I worked with a great doc, but you never knew when he was going to lose his mind. It occurred regularly, a couple of times a year, but wasn’t predictable. Ultimately, he needed to find a new job because the chairman couldn’t afford to let the potential of his explosive behavior impact something down the road. (This fell under the lose the doc or lose the contract category).  Bottom line, personalities tend not to change so medical directors need to eliminate potential issues after a pattern of negative behavior emerges.

What to do after the big meeting
If you do get pulled into an obvious red flag, you’re-about-to-get-canned meeting, be sure to resign. Every license and hospital application asks if you’ve been fired from a job, so there is a difference between resigning and getting fired. Several years ago I recruited someone I thought was a great doc but instead he went to work for one of my competitors. When he called me a couple years later to ask for a job, I was thrilled, until we met and he admitted that he had been fired. I wasn’t able to get him credentialed and couldn’t offer him a job.

Finally, understand that medicine is a business, and in business, people get terminated routinely. EDs, like all of healthcare, are under tremendous pressure to achieve, and there is little room for an under-performer or a disruptive physician. It’s the responsibility of the director to clearly communicate when a provider’s job is on the line, and it’s the doc’s job to read the red flags and be ready to move on when necessary.

Michael Silverman, MD, is a member of Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center.

 

Comments   

# Hueydoc 2011-11-18 18:11
How about when your job puts your license at risk ?
Administrators who push understaffing, remove essential services, remove " expensive " medications from the pixis, etc....and yet their only response to problems from these decisions is to blame the ER staff.
Things go both ways, yet it's far easier to get rid off ER staff than it is to get rid of an incompetent Administrator.
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