Monday, October 08, 2007

Firing doctors

Several years ago, before taking this job, I was asked to turn around a relatively small clinical trials data processing company. I had to lay off a number of people who were not critical to the company's success, and one of these included a doctor who had been hired to expand the business into a certain area that we determined was no longer appropriate. This was not a case of incompetence or lack of energy or enthusiasm. He was great guy with terrific credentials, but we just could not afford his particular expertise in that troubled little company.

Recently, we had a chance to meet, and he confessed to me that my decision to lay him off had caused him to have a real crisis of confidence. He had never been fired before and, as he put it, his view of himself as a person and the job he did was one and inseparable. Here, I had torn them apart, and it took him a while to remember and feel that he was still as adept and valuable a physician as he had been before he was fired. Indeed, he was able to thank me, years later, for teaching him the important lesson that a particular job does not define who he is.

I replied to him that I thought that his initial reaction explained to me why doctor-managers often find it difficult to fire other doctors. They too quickly internalize how it would feel to themselves to be fired, and they project this onto others. They conclude that they cannot devalue the professional abilities of a fellow physician by terminating his or her employment. They have difficulty separating the business imperative from the degradation of one's self esteem.

(When I talk about safety and quality improvement in public forums, I often refer to an aspect of this problem. If you are a doctor, you have to assume that you are a good doctor and that you are taking good care of your patients. How could you live with yourself otherwise? You have devoted your life to this calling, and you have spent years and years in training, and you often live a lifestyle that is very demanding in service to your patients. And yet, we need doctors to understand that they are often part of systemic flaws in patient treatment that leads to death or injury. Admitting that makes them no less able as physicians. Quite the contrary.)

In the business world, personnel decisions have to be made for the greater good of the organization -- sometimes to save the jobs of hundreds of other workers. Good managers do their best to help employees who are not working out in a particular position by mentoring, training, or offering other support. But every now and then someone has to be fired. Notwithstanding that business imperative, doctor-managers are often overly influenced by physicians' view of themselves. I have seen dozens of cases in which this leads to leaving physicians in positions when the good of the organization demands otherwise.

Oddly enough, many of us in other professions seem more comfortable at being fired. In fact, we sometimes too easily tend to blame the boss for our own flaws. In any event, we often move right on to the next job, scarcely looking back. Maybe, too, that is why we are more adept at firing people. We understand that a termination notice is not necessarily a statement about a person's inherent worth. More often that not, it is just business.

I don't want you to read this and think that I am a person who enjoys firing people. Those who have worked with me know otherwise. They also know, however, that when the time comes to terminate someone's employment -- whether a physician or otherwise -- for the good of the majority in the organization, I do not hesitate.

19 comments:

Anonymous said...

Hmmm...methinks this post may be sending a message to someone in your organization? What is a "doctor-manager" - you mean a chief of department? Or a doctor who holds a position in a private company? I am trying to decide what your point is. That doctors take firing harder than anyone else? I think that is contradicted by the literature on the general loss of self esteem, anger, etc. experienced by most any firee.

Anonymous said...

If you care to share, what prompted you to write this particular entry at this particular time?

Paul Levy said...

Anon 2;31,

It was the conversation that I referenced in the second paragraph. That and nothing more.

Anon 1:07,

And, no, I am not sending a message to anyone about getting fired. I don't use this forum for that purpose.

And my point is the one I stated, that physician-managers often, from my observation, have trouble firing their physician colleagues. By physician-managers, I mean those doctors who are in high administrative positions.

Anonymous said...

A physician's "calling" is no different than the "calling" that anyone else feels about their chosen profession. You choose a field that you are drawn to. Physician's are no better than the rest of us and if they are not putting their patient's first, they need to go. This is part of the safety problem. Some think they have more worth than the patient that they're treating and some administrators are afraid to let them go.

Paul Levy said...

I truly have not met many doctors who think they are worth more than their patients. I have, though, certainly seen cases where administrators are afraid to let them go when it is time.

But, in our hospital, and many other academic medical centers, the CEO actually does not have personal authority to fire a physician for his or her problems in delivering care. With the exception of a few physicians who report to me in an administrative capacity, our physicians are not employees of the hospital. They are members of a self-governing faculty practice. When there are performance or disciplinary problems related to patient care, they are subject to review by their peers. Check this posting for more on that topic: http://runningahospital.blogspot.com/2006/10/errors-improvement-and-discipline_19.html.

Actually -- and this may seem strange to some of you -- if the CEO fires a doctor out of his or her administrative role, he or she still has the option of remaining on the medical staff as a member of the faculty.

Barry Carol said...

I think the bigger challenge is appropriately disciplining the comparatively small number of less competent doctors who account for a disproportionate share of malpractice. Ideally, the worst of them should be removed from practicing medicine altogether.

At the very least, as a patient, I would like to know how many times a doctor has been successfully sued, how that compares to other doctors within his or her specialty, and how large were the payouts – 5, 6, or 7 figures? Even a general measure of payouts (both number and size) such as in line with peers, better than peers, or worse than peers and the number of actions that define each band would be helpful. A little transparency can go a long way toward informing both patients and referring doctors.

Paul Levy said...

I don't know much about that, in terms of what is public. Perhaps it is available at the state Board of Registration in Medicine.

I'm guessing the numbers will be so small, though, as to make statistically valid comparisons difficult.

Rob said...

Paul: I built what I thought was a pretty solid career in IT, having worked my way up from worker-bee tech to Director of IT.

When a $400,000,000 ad agency is bought out by a much larger company, guess what happens? I had to lay off most of my employees, then, I myself was let go. The CEO was very apologetic.

Try to find another Director of IT job in a failing economy. It took me two years to find ANYTHING, because the field was flooded with younger, cheaper help. I'd have taken the pay cut, but people wrote me off because I was too experienced.

Imagine that. Imagine the way it made me feel. Old. Outdated. Ugly. Fat. Pointless. On and on and on. It ripped me up.

It rips everyone up. But yeah, now that I've literally rebuilt my career from scratch, starting at the level I'd begun - a store technician - and going upward, I do have a better perspective of my own worth.

Also. I don't trust anyone in power. There is no loyalty. There is only selfish greed. No one has earned my trust yet. I'm still willing, but a lot wiser to the lies.

It's the betrayal, you see. You think you're good, and maybe you are, but no one cares. They care only for the money.

Pity. But that's what we've been taught to do for the last 50 years - money makes the decisions. It's not ME laying you off...

So maybe we need to rethink the "value" of people as more than the work we appear to get out of them.

Paul Levy said...

Well, it IS sometimes about money. But sometimes, it is about having the organization succeeed when someone is standing in the way of that.

In the nonprofit world, the goal is not to make money for some set of investors. It is to have a financially solvent organization to carry out the mission.

John Norris said...

There is also the difference between "fired" and being "layed off". The former implies a transgression, and is pejorative. The latter, lacks the implication of personal responsibility for the action.

Your points are well taken. It still hurts to be asked to leave.

Anonymous said...

To Barry Carol---everything you ask for is on the Mass Board of Registration's website: www.massmedboard.org ---click on "Physician Profiles."

It also reveals any hospital discipline or BORM discipline, which is often more telling than the malpractice history.

Happy surfing!

bev M.D. said...

Barry;

There is an entity called the National Practitioners Data Bank, which compiles information on physicians having had malpractice suits; but it is officially for the use of privileging agencies such as hospitals only. There is some pressure from consumer groups to make it public. Here is its link:

http://www.npdb-hipdb.hrsa.gov/

You can also google it to see some of the info regarding making it public.

And Paul; I don't think physician managers have any more trouble firing their colleagues than other professionals in a practice together. It is difficult for one professional to fire another because of the assumption of competence (however inaccurate that assumption may be).

YogiBear_ said...

Hatchet jobs are best carried out impersonally, only by uninvolved proffesional managers. Physicians are so overcome by Guilt and a sense of betrayal that they almost always start defending anything to do with their collegues. Firing a redundent collegue would probably be extremely painful.

Firing or Lay-off...
Rob & John Norris above have really said it all.

Only the 'Victim' can understand.

I am not sure that the Physician (who you laid-off from the Pharmacieutical firm many years ago and) who met you recently could afford to be completely honest to reveal to you his innermost feelings because you are now in a even more superior position with respect to effecting the poor guy's career-image !

Patient Dave said...

Ya wanna talk about rebuilding from scratch? In the past 18 months I found that I wanted to move back home to New England (go Sox! was among the reasons), and did so. Another factor was that the job was not working out. In the absence of a chance at a big payout someday, I just wanted to get home.

An hour after we closed on the new house, I got a call from the guy I THOUGHT was giving me a job, saying he gave it to someone else. It was the only job in the Boston area that was a fit for my skills (product management in graphic arts). paying two mortgages, prop tax, etc, and me suddenly without income. (My wife works part time.) Soooo, time to create a new career, at age 56.

Plus, this was just as the housing bust started. We finally sold that house in Sept - 17 months on the market, and the market had collapsed so much that we had to pay off $23k of negative equity in order to get out from under.

That was July '06. I started a great new career (writing) in Sept. Then in January I found out I had Stage IV, Grade 4 kidney cancer, with median survival time of 5.5 months.

MAN was I worried about how I'd justify my existence (as a pretty new employee) to my company as I went through the arduous treatment.

But happily my company (a firm of just 25 people, six years old) stuck with me. So although I'm very aware of the heartlessness of some employers, it's an exaggeration to say there's no such thing as loyalty anymore.

And today the cancer seems to be hiding somewhere, not manifest in my daily life. BIDMC apparently has the best kidney cancer care in the northeast, according to the listserv that I joined (on ACOR.org).

But that was one harrowing experience, one which could easily have led to bankruptcy. (The other house had just gone into foreclosure when the buyer showed up.) So that company loyalty made all the difference in our lives.

I yearn for the day when we as a society will revert to valuing people more than valuing equity. (Thom Hartmann's book "Unequal Protection: The Rise of Corporate Dominance and the Theft of Human Rights" is excellent on that point.) Laws can be created that ban just about anything we want, but we'll have to get off our butts and do something about it.

Anonymous said...

Regarding Rob's comment, with the view from the top, how does a willing approach to firing jibe with maintaining employee loyalty? On a broader level (and this could be a very interesting post or posts), what does the BI do to maintain employee loyalty to some degree? Probably the employees you view as the best for your institution are also the most desirable to other institutions and therefore the most likely to leave. How, as a manager, do you balance these competing goals?

SFG said...

Actually -- and this may seem strange to some of you -- if the CEO fires a doctor out of his or her administrative role, he or she still has the option of remaining on the medical staff as a member of the faculty.
Sure, why not? There are plenty of physicians who are great doctors but lousy managers. It's probably comparable to a project manager who gets demoted to programmer or something like that.

Not that I doubt the docs have it a little easier...I also wonder if, for whatever reason, medicine has a more of an esprit de corps than many other fields and they tend to watch each other's backs more than other fields.

Paul Levy said...

Anon 8:22,

Interesting term "a willing approach to firing". I don't think I would have used that, but I think I get your point. I don't see competing goals.

Firing is a last resort, as a disciplinary matter, and should follow a real effort to help someone succeed. Firing undertaken not for discipline, but for larger business reasons, should be accompanied by an effort to either find the person another job in the same organization or to help him or her find another one.

You maintain loyalty by treating people well and giving them a chance to develop personally and professionally and work in a good environment. Sometimes really good people leave for better opportunities. I personally do my best to encourage that -- and even provide excellent references -- even where I know we will miss them.

Anonymous said...

A physician who is asked to leave a managment position because it is no longer relevant to the business or he/she is just not an adept manger may continue to be an excellent patient care provider. The real delimma for firing a physician for cause that distinguishes it from firing an IT employee or even a nurse is that the IT employee walks across the street and is likely to be hired with comprarable or better compensation.

The physician manager who fires his physician employee for cause l has to notify the the Board of Registration perhaps dealing the fatal blow to the physician employee's career. It might be in the best interest of everyone for this to be the case but consider the consequences for other sub standard health care providers that that can be hired by other highly regarded institutions by meeting the threshold of filling out an application. These days the ability to get accurate references is nearly impossible and the normal hiring process, under the best of circumstances, does not hold a up next to the credentialling process of physcians, NPs, etc.

Everyone should be subjected to the appropriate evaluation of their performance and associated rewards and consequences but it is a complex issue... fired isn't a level playing field in a hospital. Physician mangers should be very thoughtful and follow due process and then do the RIGHT thing.

Anonymous said...

Anon 8:22 here.

Fair enough. I'm most interested in firings for larger business reasons than firings for discipline. I'm assuming that the firings based on conduct are no surprise to the affected workers, and they're not people you'd forseeably want back. I imagine coworkers would rather welcome their firing, since a problem employee on a team is probably making work worse for everyone.

But about those firings for business reasons. I'm still curious because business needs can be very specific and can change over time. For example, what if you find yourself with too many pulmonologists and not enough cardiologists. Let's say reimbursements for cardiology went up and reimbursements for pulmonology went down. Or Brigham and Women's opened up a new pulmonary clinic but closed a cardiac one. Whatever...you have a new situation where it makes business sense to fire some pulmonologists.

But the cardiologists and the pulmonologists are tight. They have common patients. They share a "cardiopulmonary" clinic space and eat lunch together every day. They have an annual cardiology-pulmonology soccer game. When you fire the pulmonologists--high-quality but low-value employees--how do you stop your best cardiologist from saying "They'll fire someone as good as my pal Jones just for MONEY? I'm outta here!" On a related note, what if next year the reimbursement picture or business climate flips and pulmonology is now critical and cardiology is oversupplied?

I hope I'm phrasing it better, but the question is the same. How do you handle "business firings" in such a way that you minimize ill will, convince the more valuable employees to stay, and maintain a positive enough relationship with the fired employee that they would consider coming back if the business situation changes?

You did answer this question in your reply, mentioning helping them find another job, creating a great work environment for employees, and so forth. But I'm curious if you have any more specific thoughts on this delicate business matter.