What have been your most unusual experiences or biggest challenges as an employee manager?

Paul J. Carniol, MD, FACS: An interesting, important and challenging subject is how to select employees. For most employers this is quite difficult—many problems can be avoided by the selection process.

Gregory A. Buford, MD, FACS: In 13 years of practice, I fortunately have never had to fire anyone for anything related to theft, etc. The biggest issue I have had is with someone not integrating well into and “fitting” the corporate culture. I recently read a comment by Tony Hsieh, CEO of Zappos, on this very topic and he emphasized that this was also a critical factor in determining whether to keep or not keep an employee.

Jason N. Pozner, MD, FACS: We have over 80 employees in our practice and always have issues. A problem is that many times real personalities come out over time, and by that time the employees are trained and ingrained and hard to fire.

Steven Pearlman, MD, FACS: Another issue is when staff start breaking into “factions.” I had one receptionist who created two “sides,” where half the employees were one group and they gossiped and had issues with the other. She had to go for other reasons, but this was one big one.

Steven H. Dayan, MD, FACS: It is my impression that when we have an issue with staff, if I devote myself to clearing it, almost always I can find a solution to the problem if we sit down and openly communicate. If two staff members are in a tiff and it is disrupting staff morale, I sit in a room with them, and we openly discuss the issue and find a resolution. If they are unhappy with a decision I made, I try to bring them in and openly listen to their criticism and then tell them why I am making the decisions.

Heidi Waldorf, MD, FAAD: The most frustrating issue for me is that, despite staff being long-term (most over a decade), and our regular appreciation/morale boosters, when there is anything new in the office, we are told it is too much. They need more money. We need to cut back patients, etc.

The most recent example is EMR. We've cut patients as recommended, etc., but we get pushback.

Joe Niamtu, III, DMD: Most practices are purchasing sexual harassment/employment discrimination (technically called Employment Practices Liability Insurance “EPLI” ) insurance policies. You can get $100K of coverage for about $3K. This scam is worse than malpractice, as an opportunist can cry wolf and the plaintiff attorney knows that most docs (even if unfounded) don't want the negative coverage and will settle. Someone can make your world bad with little or no foundation. None of this is covered by other insurance, so employers need to protect themselves. We are targets and tall trees catch the wind.

Brooke A. Jackson, MD, FAAD: There are certainly issues with being the female boss—from female employees who are “haters” to male employees who resent having a female boss. I have always thought that having a spouse/ family member in the office smoothes these issues a bit, although I have never had that opportunity. This is nothing new—there are lots of Harvard studies about how women in power are perceived in contrast to men in the same position. I have always had a witness (office manager or management consultant) for all disciplinary conversations and terminations.

Regarding sexual harassment, we have a policy in our handbook to the effect that any employee who feels harassed has a duty to report it (so they cannot then claim you ignored and allowed it to continue). We have also had office meetings about definition of harassment and how to handle it. I had one touchy-feely employee who thought she was being helpful by giving other staff shoulder rubs at the end of the day...had to ask her to stop.

Did you ever miss a red flag in a “problem” employee's behavior or actions?

Dr. Buford: I have had a few employees who were burned out and ineffective and I simply didn't recognize the negative impact they were having on my overall practice. When I let them go, I was blown away by the number of patients who came forward praising me for my actions and saying that they never really liked their interactions with that particular employee. My policy now is to go with my gut. If I feel that someone doesn't fit, then they probably don't. So far I have been right on!

Haideh Hirmand, MD, FACS: It is easy to miss red flags or to convince yourself that it is not really a red flag. The first impressions are always right, and they always come back to haunt you. Most times, I have fired someone for exactly the reason that I had documented as being in question during their interview or their office visit. Best to take action sooner than later, but one never seems to learn!

Amir Moradi, MD: We have become much more selective with our hiring practices, we do background checks, more than one interview, and working interviews to get a feel for office interactions.

Jeanine B. Downie, MD, FAAD: I do background checks on everyone before I hire them. I have uncovered two identity thieves, among other unscrupulous individuals, from these background checks.

Joel Schlessinger, MD, FAAD, FAACS: Red flags happen all the time. We just need to recognize them from the ‘white noise' of red flags we see every day. We all try the best to differentiate the mildly upset/disaffected employee from the one who is going to pilfer, quit in a huff, or passive- aggressively harm the practice.

What are challenges in terminating employees or employees resigning? Have you ever had an employee who voluntarily left your practice who later applied for unemployment?

Dr. Pearlman: The hardest thing to do is fire someone, even though you know you must. There's an ingrained sense of responsibility—and that sense you are taking away someone's income and livelihood. This is even worse in a down economy, as happened over the past five years, and getting a new job is so hard. Unfortunately, you must, since this individual is likely hurting your practice or you wouldn't think of firing them in the first place.

Dr. Schlessinger: We always ask for a written note when staff resign, and if they don't give one, we document it with two folks having observed the separation. We always contest unemployment claims and usually have won. The time we didn't win was when an employee told us she was quitting and we had her work the rest of the day. Because of that, we lost her unemployment.

Dr. Jackson: In 10 years I've only lost two claims and won all others. Document, document, document! Write employees up, when appropriate, and have them sign the write up. It all comes back to your employee handbook. Mine is 69 pages.

Dr. Dayan: Most of our greatest fears are that we don't like the aggravation or we fear the unknown if we let someone go. But the reality is every time I let an employee go we seem to improve our staff morale and efficiency.

Dr. Downie: I've had several employees leave the practice voluntarily and then file for unemployment. I fight every one of these. One quit by text. She is over 50 and then applied for unemployment. A second one wanted time off a month after starting at the practice. When I told her that that week there were already two employees on vacation and she could not have it, she said “no problem.” She simply did not show up that week because she had already bought nonrefundable tickets; Her job is also nonrefundable.

She just recently filed for unemployment and I'm fighting that one, as well. This is one position that I keep trying to fill over and over and over again. Both of these women are a testimony to why it is difficult for employers to hire those who are out of the workforce for two or more years. Both of them only wanted to work for me for a short amount of time to re-up their unemployment. For both of them I wrote extensive letters to the New Jersey Department of Labor, stating that Chris Christie does not want his unemployment checks going to people who quit.

What is the one thing you do in your practice for employees that they seem to appreciate most?

E. Victor Ross, MD, FAAD: As far as the greatest motivator, I believe it's just telling people they do a good job when they do a good job.

Dr. Schlessinger: Appreciation: a simple thank you goes a long way! I tell my nurses and front desk staff that all the time!

Dr. Hirmand: One thing I have found that intelligent employees appreciate most is caring about their professional growth and giving them opportunities to engage in what they enjoy and are good at. Also team-building activities are another good thing: trips, conferences, outings.

Dr. Moradi: We have weekly staff meetings. Everyone has the chance to have any issue put on the agenda, then have it discussed with the entire office during the meeting. We end all our office meetings with a team building exercise.

We have a “Compliment Box.” During the week when an employee does something nice for someone else in the practice, a compliment is written and put in the box. We draw a compliment from the box and that employee gets to pick a present from a pile of presents...Big hit with our staff!

Dr. Downie: The majority of my employees—10 of them—have been with me since the year 2000. The thing they seem to appreciate most is me thanking them at the end of the day, the free lunches, and their bonuses!

Dr. Dayan: Staff often appreciate when it is clear that you work hard you get rewarded and if you don't you have to go. If they all know the culture and that they are replaceable it seems to up their game…I now call it the “Two-year Rule.” The first six months they are in awe of me, the second six months they are starting into the groove and liking their job, the third six months they are now gelling and becoming increasingly comfortable and really helping the practice to grow but the last six months they think they made me! If I can get them past the two years, then I am more likely to keep them for a long-term basis.

Dr. Pearlman: Empower employees to own and take pride in doing a good job. That way you create a business partner who is in a career and doesn't count hours until they leave instead of a job that they rue going to and can't wait to leave at the end of the day.

Dr. Buford: The one thing I am trying to do more of is to recognize my employees for the good they do and the simple things they accomplish to continually improve our customer experience. Our goal is to be a customer-centric practice, and so I rely on my team to help accomplish that goal.

The future of medicine is heading in a direction that is going to require not only expertise from the staff and the physician but also one that will provide a distinct and branded customer experience. And if you don't believe that, just ask yourself how Starbucks can charge what they do for a simple cup of coffee! It's all about the experience!