Practice Economics

Toxic Employees


The providers in every hospitalist practice should be a good fit for the practice’s culture. They should have reasonable relationships with their colleagues in the practice, patients and families, and other staff at the hospital.

I can’t imagine anyone arguing with this point of view. But in my work with hundreds of hospitalist practices over the past 15 years, I’ve found that many practices seem to have a hard time ensuring their providers meet that standard. I can think of lots of reasons for this. The first that comes to mind is the difficult HM recruiting environment. Almost all hospitalist practices needed to grow quickly, and many lowered the bar in the qualifications and the fit of the candidates they hired to make sure they filled all of their positions.

Even if it later becomes clear a provider isn’t a good fit for the group culture, or worse still lacks the knowledge base and judgment to perform well, many practices are reluctant to replace the hospitalist because it might be difficult to find a replacement—and there is no guarantee the new person will perform any better. Because of this, a number of practices have ended up with providers who in many cases have a negative influence on others in the practice, and both the practice and the problem provider would be better off if the provider went elsewhere.

The best approach is to prevent such problems from coming up. The best way to do this is to be very careful when hiring new providers.

The Problem Physician

To their credit, most practices do act when a provider simply lacks the skill and judgment to perform adequately. This can mean close proctoring/mentoring for an extended period, or requiring specific CME course work to correct a skill that is lacking. But it also means reassigning the person to a different job, or termination.

But in the case of someone with a toxic personality, practices often are more reluctant to act. I’ll often hear the leadership of a practice say something like, “We knew Alice wasn’t a good fit for our practice within a few weeks of her start date.” The start date was several years ago and nothing has been done about this. Not surprisingly, Alice still performs poorly.

I’m not talking about someone who has occasional problems. I’m talking about people who cause problems almost every time they show up to work. Here are some real anecdotes, with fictitious names to ensure anonymity for the person and institution:

  • Dr. Lee routinely disappears for several hours, during which he doesn’t answer pages. This even happens when he is the only doctor covering the practice.
  • Dr. Lifeson, while generally getting along well with his fellow hospitalists and the nursing staff, can be counted on to complain bitterly about all levels of the hospital administration and leadership. He never misses an opportunity to try to convince other hospitalists that the leadership is not only inept, but also clearly has a malicious intent toward hospitalists.
  • Dr. Peart complains incessantly about even tiny inequities in the work schedule or patient load. Others in the group have found that it is easier to ensure he always has the best schedule and lightest patient load, hoping they won’t have to hear his constant complaining. But even that hasn’t stemmed the steady downpour of negativity from him.

In all three of these cases, it seemed clear that the doctor should be terminated. And while the practice leadership agreed with me, they offered several excuses for why they hadn’t taken this step.

  • “Who knows if we can find a replacement who will be any better?”
  • “But he’s actually a decent doctor and doesn’t get a lot of complaints from patients.”
  • “He’s such an angry guy, we worry about litigation if we fire him.”

I can’t offer any clear rule about when a practice should stop trying to improve a provider’s behavior and recognize that it is time to terminate the provider. But it is worth remembering that waiting too long has many costs, including the satisfaction of others in the group. Everyone will think less of the practice they are part of if poor behavior is tolerated.

Assess the Situation, Then Take Action

Most doctors who serve as the lead physician for their group have little or no experience dealing with problem behavior, let alone experience ensuring that necessary steps are followed prior to disciplining or terminating someone. But every hospital has someone who is very knowledgeable about these things; they should be engaged for advice, and, in the case of hospital-employed groups, should participate in the process of counseling and/or termination. It is important to take advantage of the expertise that is available.

Of course, the best approach is to prevent such problems from coming up. The best way to do this is to be very careful when hiring new providers. Checking references carefully is probably the best way to get an idea about whether someone might have behavior or personality problems. There are “job fit” survey instruments that you can use, but I’m not sure how effective they are, or how much value they add for a hospitalist practice beyond other means of assessing the candidate. And in the process of hiring someone, be sure to set behavior expectations very clearly. A new candidate should know that you will not tolerate not living up to behavioral expectations.

When dealing with bad behavior, make sure that you follow a careful and well-documented process. If someone still makes it through the hiring process only to be revealed as a troublemaker soon after their start date, don’t wait to sit that person down for very clear counseling; insist that their behavior change. Take notes of each meeting, and consider having the problem doctor sign and date the notes. While it might be easier to just wait and see if the first instance of bad behavior was an anomaly, that usually is a bad idea.

You should consider bringing the problem provider into the tent. The root of some bad behavior (i.e. criticism of leadership) is a person’s insecurity and lack of a feeling of ownership or control of their role in the practice. In that case, it might be reasonable to invite such a person into a role of greater responsibility in the practice so that they feel more in control. For example, a doctor who constantly complains about the work schedule might be invited to join the group’s executive committee or take on some other formal leadership role in the practice. This could backfire, so it should be tried only in carefully selected cases, and with the problem doctor’s clear understanding that they are being given a chance to have a bigger role in the practice but must improve their behavior or face serious consequences that could include termination.

I have seen this work beautifully in some cases, curing the problem behavior and turning the doctor into a valuable asset. I only wish there were a reliable way to know when to try this strategy. Sadly, it just requires judgment and intuition. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm ( He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

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