Trusting your gut when supervising staff

One of my first practices was as an employed physician in a hospital-owned group. I was offered this position by a colleague I met while I was in residency training. She thought I would be the "perfect replacement" as she moved out of the area. I eagerly accepted the position and moved in to take care of her patients while continuing to use her previous staff.

It was a rocky start. I was 6 months pregnant, with another child at home. I needed to support my husband, myself, and my children and was anxious to make this work for the long haul. So I jumped in and began to care for these patients the best I could.

It soon became obvious that this arrangement was different than I had planned. Many patients were taking chronic narcotics and benzodiazepines. Every encounter became a dizzying field of what prescription they would receive and how we would handle this medication, or what they might be willing to take instead. It was very stressful, to say the least. Still, I believed it would be worthwhile because my partners were supportive. I thought that if I embraced the opportunity, it would work.

Jane was well known to the practice, having worked there for years with an excellent record. Still, I was uncomfortable. I blamed myself for this judgment. I heard that she had a difficult life with an alcoholic husband and was the primary support for her family. I needed to be more open-minded, I told myself. After all, she knew these patients best, and it was probably a good thing for the practice to ease the transition as I got to know the patients.

Time passed, and I settled into a routine. Many patients had already changed to other doctors before I came to the practice, and some did not agree to medication changes and wanted medications I was not willing to prescribe, so there was attrition. It was a slow-growing practice in a neighborhood that was older and not growing, so it was a struggle to believe this was going to work out after all.

One evening when I got home from work, I found a phone message from one of my patients-I was on call. The patient was looking for a prescription for amoxicillin that she said I wrote for her "strep throat." When I called her back, she said the pharmacy had called to tell her that they did have the antibiotic. That's funny, I thought. I didn't recall phoning in a prescription for this patient at work. Maybe my medical assistant, Jane, spoke with one of my colleagues.

The next day I reviewed the patient's chart. No note about an antibiotic, sore throat, or anything else. I asked Jane about it, who mumbled something like "I'm not sure, uh...I don't remember." It seemed curious. I questioned my partners, but no one admitted to discussing the issue. I called the pharmacy and asked about the prescription. A quick investigation led to a prescription called in by Jane without my authorization or any other physician approval. I went to the pharmacy to obtain documentation of the event.

I felt this was grounds for termination. Others I discussed it with said, "It was only amoxicillin." I felt strongly that this action was illegal and immoral and endangered my patient-Jane was practicing without a license! Administration said it would be difficult to terminate her because she had an "impeccable record" with years of good reviews

Finally, it was agreed she would be fired. For some reason, I felt horrible. Even though I believed it was likely she had committed more than this offense, I felt guilty for ruining her record and causing her to lose her job. I worried about her life, and I wondered whether I had done the right thing.

Months later, our clinic was broken into. The housekeeping staff was there and able to identify the perpetrator. It was Jane.