Physicians must deal effectively with difficult employees

One of the quickest ways for a medical practice to fail involves not dealing with a problematic employee. Such an individual can cause larger difficulties for the employer, including poor morale, conflict among co-workers and patient care issues.

Russell Kohl, M.D., FAAFP, a family physician in Vinita, Oklahoma, and speaker of the Congress of Delegates of the American Academy of Family Physicians, says the first step is to shift perception of the person as a problem employee to an employee with problems.

“Presumably, they were a ‘good employee’ at some point, but who has changed,” he says. “Separating the person from the actions and focusing on correcting those actions will let you determine whether this is a situation that can be corrected or needs to be a termination.”

Jordan Grumet, M.D., an internal medicine doctor who has worked in and owned several practices, says it is important to determine whether an employee is a danger to self, co-workers or patients.

“I had a patient tech show up drunk to the office and the first step was to remove the employee from the office and assure that they could receive the appropriate care and follow-up,” he says. “I also had a nurse who was using the EMR (electronic medical record) to look up personal information on a family friend without permission. Her access was immediately denied until the situation could be investigated, the proper people notified and HIPAA (Health Insurance Portability and Accountability Act of 1996) paperwork filed.”

Steve Furr, M.D., FAAFP, a family physician in Jackson, Alabama, and a member of the board of directors of the American Academy of Family Physicians, notes that careful consideration should begin with hiring practices. “There’s a shortage of workers now, so you might end up hiring someone just because you’re desperate, but the headache that can potentially cause is not going to (be) worth it,” he says. “You’re better off taking your time and getting the right person, because the wrong person could cause a whole lot of grief.” It is important to do proper background checks, get recommendations and ensure you are not hiring someone who will be a problem.

Speak the Truth

Discussing problems with a challenging employee is not easy, but such conversations must occur to avoid further problems. The tone and substance of the conversation are critical to a smooth resolution. Conversations with the employee should reflect the importance of the issue, the goal of resolving it and the need for the employee’s commitment to participate in good faith in the process.

“The practice must take into consideration whether the employee’s conduct is disrupting the practice, impacting patient care or otherwise intolerable,” says Michelle L. Greenberg, a partner in Frier Levitt’s health care litigation department. “Conversations should include a clear recitation of the issue, how and why that issue doesn’t comport with the successful operation of the practice, and a pathway to rectify those issues, if possible, including any performance improvement plan.”

Still, this should not be a spontaneous discussion. Kohl recommends preparing by making notes about specific concerns and their impacts.

“After you’ve shared these with the employee, give them an opportunity to respond while you seriously listen to their comments,” he says. “Ask them what they think might resolve the concerns you’ve raised and consider whether those might be interventions you’d entertain.” The goal of the discussion should be to improve or correct behavior, not just to exert authority over an employee.

During his career, Grumet said, he has found doctors must protect themselves, the practice, employees and patients while systematically assessing the problem and damage. “In nonthreatening situations, employees should be given direct feedback, a plan for improvement and clear statements of which actions will lead to termination and how quickly,” he says.

Those conversations should include what the employee is doing wrong, why their action or lack of action mattered, what harm or potential harm has occurred and an expected timeline to improvement and the actions that will be taken if a change in behavior does not occur.

“You must address the things that need to happen for them to stay an employee,” Furr says. “This gives them a chance to change their behavior.”

For instance, Furr once had a staff member who spoke loudly and often said inappropriate things to patients. “She was a good, hard worker, but unfortunately, your voice tends to travel in the office, and sometimes patients would hear things,” he says. “It happened multiple times, and we gave her multiple chances to improve, and had to finally say, ‘If it happens one more time, we have to release you,’ and it did happen again.”

Getting Employees Back on Track

An employee’s being problematic does not necessarily mean they need to go or that their actions cannot be changed. Sometimes, it is simply a matter of recognizing the issue.

“Just because you see a problem doesn’t mean that everyone does,” Kohl says. “Frequently, simply identifying the problem and how the actions are impacting patients or fellow staff can be all that is required for the employee to self-correct.”

For example, Kohl had a situation with a “formerly really high-performing LPN” who had begun to make small, careless errors and seemed to have a gradual shift away from her normal optimism and energy.

“In discussion of the errors it became clear that she was bored with the standard duties she had performed so well,” he says. “After identifying that she was interested in expanding her knowledge and skills, I increased the amount of active teaching I did with her and provided financial support for her to attend an evening LPN-to-RN program. Her attitude improved almost immediately, and she began to seek out additional opportunities in the office to enhance her abilities or to educate patients and staff.”

Most employees who want to improve can do so with appropriate encouragement, training and proper corrective plans, Grumet says. An employee with good intentions usually can be rehabilitated.

If things do not work out, Furr notes that sometimes the job might not be a good fit, but that does not mean the employee could not prosper elsewhere in the practice. For instance, a person might not be good on the phone with patients but may be great in the back office dealing with employees. He moved one employee around to three different positions and she eventually found her niche and became an asset to the practice.

When It Is Time to Go

Employees who are dangerous or specifically act in a way to harm the practice, its patients or the doctors should be fired quickly, in the opinion of most physicians.

“Employees who act unlawfully or steal should also be let go immediately,” Grumet says, noting his practice had a biller who was downgrading bills and working against the practice, so evidence was collected, and she was fired.

Additionally, those who do not adhere to their correction plan or show no effort in correcting their behavior should be removed from their job sooner rather than later.

A piece of advice Kohl received when he opened his first practice was: “The employees are all working to save you time so that you can focus on the physician-level work. Once their actions start taking away from your time to care for patients, you need to ask yourself why they’re still an employee.”

“As physicians, and particularly family physicians, we want to be fixers,” he says. “However, that isn’t always our role with employees. There’s always an ability to be supportive and even nurturing within the workplace, but ultimately we are there to care for our patients. If we can’t effectively do that because of an individual employee’s situation, and the situation can’t be resolved, it’s time for them to go.”

The first time Kohl had to let someone go came when he noticed an increase in insurance denials within the billing. In following up, he discovered that the insurance verification tracking numbers were not in the proper format for the company denying the claims and that the cases seemed associated with new patients presenting for pain diagnoses.

“Ultimately, I discovered that the employee who verified insurance was recording false verification numbers inside our system for people who didn’t have insurance and were seeking narcotic prescriptions,” Kohl says. “She was terminated immediately, escorted out of the office in the middle of the day, and the local police and state bureau of narcotics received reports about her behavior.”

Avoiding Legal Issues

As with any employer, risk of legal issues is always a consideration in determining the best course of action. “Since it is not always possible to avoid a lawsuit, the employer should make sure to take action that will allow for a strong defense,” Greenberg says. “We work to identify potential future issues by including provisions in agreements, where possible, to have a clear exit strategy for these types of issues. We also work with our client when they foresee the issue arising and work to strategize the best action to avoid litigation and/or be able to mount a strong defense.”

Kohl notes you should never try to explain yourself and your rationale, and if someone has made the decision to terminate an employee, they need to follow that formal notification and termination process.

“Too often, physicians try to soften the blow or make it easier with consoling statements or explanations that generally only serve to create confusion and anger in the terminated employee,” he says. “You can be compassionate but formal at the same time. They just lost their livelihood, so comments like ‘I know you’ll land on your feet’ only serve to make the physician feel better, not to help the now-former employee’s state of mind.”