The saying, “It takes a village,” applies rather well to growing and maintaining a successful aesthetic practice. Although as physicians, we are the raison d'etre bringing patients in the door, our staff can determine if those patients will ever return. Our name may be on the sign outside, but without schedulers, receptionists, nurses, billers, and other staff, the practice cannot run, much less reflect our values and expertise. Therefore, facilitating strong relationships with and among employees, setting clear expectations of everyone on the team, and instituting regular procedures to allow communication are critical.
Communication From the Top Down
In the daily operations of a practice, a physician simply doesn't have the time to deal with the array of businessand human resource-related issues that may arise. Having staff-specific and/or office managers cushions the physician. The appropriate manager should be the first to hear staff complaints or suggestions. The issue may be something the manager can handle. If it isn't, a good manager should be able to filter the information and present it to the physician in a more clear and hopefully concise manner free of emotion or intrigue. Unfortunately, excellent medical office managers are often the most difficult employees to find.
Ideally, an office manager is smart and logical with a skill set that includes excellent personal communication and the ability to multi-task. This is the person who will deal at various times with physicians, staff, patients, and vendors. Since this is the person with access to everything in the practice, he or she also has to be someone you can trust implicitly. Though technically an employee of the practice, he or she must see the role as one of management and be an advocate for the practice. Traditionally, a male physician's wife managed her husband's medical office in practice even if not in name (or salary), as my mother did for my father before she went to law school. That paradigm has shifted with more two-income households and female physicians, although interestingly I know several female dermatologists whose husbands left finance or law to run her practice as CFO. Indeed, some very large aesthetic practices recruit CFOs from industry to do everything that an office manager does plus more. Unfortunately, many of us have neither of those options, and affording a CFO-level manager is out of our price range.
If you can't find or afford an appropriate office manager, all is not lost. In my private practice, we have a separate business administrator and nurse administrator, both of whom report to an outside healthcare solutions consultant who reports to us. As an outsider who works with medical practices of all types, she can be objective in helping us reach our goals and in dealing with staff issues with less emotional angst than might the physician employer. And she is clearly management and sees the issues as the physicians do. The business manager supervises the front staff, including reception, scheduling, billing and filing, and deals with related issues. The nurse administrator manages the clinical staff and deals with issues related to the clinical practice. In addition, we have a secretary who acts independently as our administrative assistant. She is in charge of building and grounds issues and reports directly to the physicians.
Whether you centralize or divide managerial duties, the need for open pathways of communication is equally important. Staff members must know to whom they report. It gives each employee a feeling of stability and can help diffuse situations more quickly. In addition, it makes it clear from whom they take instruction, avoiding bullying. Your manager's ability to communicate, delegate, and work with all members of the practice ensures the system will run optimally. For example, the system in my office may seem complicated, but the physicians can primarily focus on practicing medicine. Additionally, for the most part, everyone can vent in a safe way so that they are heard but it keeps things said in the heat of a moment from compromising the overall integrity of the team. And everyone knows his/her job description and responsibilities.
Interviewing and Hiring
Hiring can be done by your manager or through an employment agency, but be sure you have set clear guidelines for whom you are looking. If you allow me a little colloquialism: there are lots of “behinds” that can fill a chair, but you have to be more concerned about what is going on between their ears and what might come out of their mouths. Depending on the job being filled, the physician may or may not feel it necessary to be involved. In my practice, our outside consultant has always done the preliminary screening, followed by an interview with the doctors. As scheduling these combination “meet and greets” has become more difficult, we waived the interview with the doctors for front office staff. However, I insist on meeting all clinical staff before hire. We've been exceptionally lucky to have a very high staff retention (most 10 to 20 years). Recently, with the addition of a new associate, we started looking for additional nurses. We saved time by having our nurse administrator do preliminary screenings and interviews of candidates followed by our consultant and then me. Because she manages the clinical staff, our nurse administrator was able to screen out candidates who didn't seem to be a good fit with the existing team in personality, ability or energy.
Physicians are used to being interviewed—for college, medical school, residency, fellowship—and anyone who has gotten through competitive core cosmetic specialty training is clearly good at it. However, performing an interview is different. We often think fast and talk fast and want to make a decision fast—the same way we are used to evaluating patients efficiently and effectively. The people you employ are a reflection of your practice, but they aren't you, nor do they have to be. Think about what the specific job will require. Anyone with direct patient contact must have good people skills, be personable, positive, and speak well—Dr. Cheryl Burgess's ‘Nordstrom rule.' In fact, she suggests looking at resumes for candidates who have worked at organizations that stress customer service like Nordstrom or Starbucks. There are also companies that will administer and evaluate personality and aptitude tests you can use as initial screenings, but I generally find we can figure a lot out from having the series of interviews with your consultants and/or administrators and finally the physicians.
For the final interview, I stick with the classic questions we all prepared for school and training:
- Why do you want to work here?
- What are your strong points?
- What are your weak points?
- Where do you see yourself in five years?
- What questions do you have for me?
I also ask about any glaring points on the resume like skipping years of work or multiple job changes. Although for the future physician moving up the ladder, the hardest part of answering those became trying to make our answers sound unrehearsed; many, if not most people are unprepared and it is amazing what you can uncover by sitting quietly and listening. I've had people tell me their weak point is not handling stress well and wanting to go fetal or not taking constructive criticism well; neither of these is ideal in a busy physician practice (and doesn't everyone know the answer is, “I'm a perfectionist”?). In general we look for candidates who will become part of our team for the long haul, so a candidate who sees her/himself changing fields or not knowing where they'll be in give years bodes poorly. We also value the team member who understands the importance of following procedures. For example, as a dermatology practice, we send out a huge amount of biopsies. To make sure that no specimens are lost or mislabeled, all results are seen, and patients contacted and brought in for treatment as needed, we have a very clear and specific procedure for the doctors, nurses and front staff. Every step has a reason to provide checks and balances. So in the interview I am sure to let the candidate know that we “encourage initiative,” but that “mavericks won't do well here.” Finally, be aware that candidates may be petrified when meeting you. They may have read about you in magazines or seen you on TV or perhaps you did work on their relative or friend and changed his or her life; so be strong but also patient and kind to let the conversation flow toward you.
Training new employees is time consuming and costly, but one of the best places for your time and money. Whether it's the front or clinical office, shadowing someone else doing the job is a valuable experience. It might be for days or weeks depending on the job responsibilities. Then the new employee can start doing the job but now shadowed by the senior employee. Finally, the new employee can work alone with better skills and more confidence. The process can be slow, but it is also revealing. The new medical assistant or receptionist who just doesn't get it may never get it, and it is better to figure that out early. However, I've also been pleasantly surprised by others who suddenly blossom into powerhouse employees. And don't forget cross-training, especially in a practice with multiple physicians. Each physician has his or her own style, favorite instruments, regimens, procedure protocols, plus an individual ‘dance' or movement. In our fields, one wrong move into the physician can lead to a sharp injury for the physician, staff, or patient.
Of utmost importance, new employees should not be allowed to give medical advice that isn't verbatim from the physician or a senior employee. Patients won't remember who told them what. My long-term clinical staff members know the answers to many questions from patients, whether it concerns practice protocols or specific details about a particular product or procedure. Experience often varies with new employees, even those coming from other seemingly similar practices. Make sure that the trainee has seen you and the other physicians or ancillary staff in your office in action and that you or other staff members have confirmed that he or she understands the party lines. Although scripts can be helpful, I've spent too many hours of my life on the phone with representatives from airlines, phone companies and credit card companies who refuse to stray from the order of their script. It is very frustrating not to be able to get questions answered, and I finish the interaction feeling ignored and unsatisfied. I've always found that I retain and use information best when I understand the logic behind it. Taking the time to explain how products and procedures work, why one patient may or may not be a good candidate, and how an adverse event can happen will allow your staff to recruit, prep, triage and care for your patients better. People who understand concepts rather than just memorize facts are also better prepared to manage the unusual and to build on their knowledge base and will grow into more effective employees for the long term.
The faces of your staff are literally the first your prospective patients see—attached to which are bodies which need to be clothed. Unless they worked at some silicon valley high tech company started by a 20-year-old, the likelihood is that your employees are going to expect a dress code. That code should reflect your office's philosophy and “brand.” Since we keep a Chinese Wall-like division between the responsibilities of our front and clinical staff (so much so that they get different levels of OSHA training), my office dress code is business attire for the front (no sneakers or jeans on any day with office hours) and whites for the nurses (white scrub jacket, white tee, white scrub pants). The physicians wear street clothes or blue scrubs and a white physicians coat. That way it is clear to patients that the only people that will give clinical information are the folks in white. Personally, I like the tradition of white coats for everyone clinical, and they fulfill the OSHA personal protective equipment requirement. For someone else's office, having everyone in the same scrubs may be helpful so staff can cross cover positions at lunch or for vacations.
The dress code should be part of your personnel policy so there are no surprises. And that may include a description of what visible jewelry, body ornaments, and even nail color and length is acceptable during contact with patients. What is appropriate will vary based on the physician, patient population, and region of the country. Whatever you decide, review the details with an employment attorney to confirm that it isn't in conflict with any local, state, or federal antidiscrimination laws.
Appreciation and Bonuses
A patient showing appreciation for our efforts—with a simple thank you, a smile, or a box of candy—can be the difference between a good day and a rough one. Our staff is no different. Letting them know that you appreciate them is not only a kind act, but also good business. When morale is high, the team works better together. Staff will help each other and work harder for the practice when they feel their efforts are recognized.
Economic factors have made it impossible for many businesses to give their employees routine raises or traditional Christmas bonuses. Physician practices are no different. We all work longer and harder and pay more overhead for every dollar earned. At practice management sessions, colleagues describe programs like incentive bonuses split among the staff for the office reaching certain goals or employee specific bonuses for individual efforts above and beyond the normal.
But not all appreciation has to come in the form of a check. Celebrate major birthdays or life events with a cake and a card. Have Staff Appreciation Days. They can be the ones defined by Hallmark for nurses, receptionists, etc., or combine them. We celebrate Staff Day for all the staff on Administrator's Day. For over a decade, annually our local florist has put together individual miniature plants in a keepsake cup, bowl, or vase and decorates with model butterflies or birds. Everyone gets one. Since they can be replanted outdoors, many of these little gifts survive at our staff's homes still. Other forms of appreciation can range from Valentine's chocolates to low-key group outings to team tee shirts for charity walks. Since I frequently travel to meetings in the US and abroad, I try to always bring back some fun taste of the locale—chocolate, cookies, candies—to share my experience and thank everyone for holding down the fort while I was away. My regular “travel treats” are something I can do both in my private practice and in my faculty practice, where otherwise I have less in my power to do. The idea here isn't to be extravagant but just to show that you care and that no one is left out. Being heard is also a form of communication, so staff meetings at regular intervals where ideas and concerns can be shared can bond the team.
In a tough economy, even big business has cut down on holiday festivities. However, it is still a nice time to do something. Our staff is more mature, and most have family responsibilities; thus, heading out for a late night wouldn't work for anyone. Instead, we hold an annual holiday party luncheon on a Friday in December at a local restaurant for the staff. Office hours end early and we all head over to a restaurant for a festive lunch during which we toast the staff with champagne and hand out bonus checks. In a large faculty practice, it's harder to be inclusive and the physicians don't determine if the hospital provides bonuses, so most physicians I know either take their core staff to lunch or dinner or give them gifts. The week before Christmas, I also walk around the department with a large tin of fresh chocolate chip cookies for everyone to partake. It's become an annual tradition that staff on the floor look forward to enjoying.
Reviews and Termination
For better or worse, some staff will excel, some will do just what is necessary and no more, and some will fail. Providing individual evaluations at regular intervals lets the really great employees know that you recognize the extra effort, puts the lagging ones on notice that improvements are needed, and documents everything clearly for future reference. Generally, new employees get a first review at six months and annually thereafter unless there is a specific issue to address. The process can be streamlined by having the appropriate manager fill out a standardized review form that the physician then edits. Having both the employee's superior involved and the physician reduces bias and keeps everyone in the loop. The physician may not have known that the employee regularly filled in when others were out sick or spent downtime finding useful projects to do like restocking rooms without being told. The manager may not know the employee is fantastic at anticipating the physician's needs and educating patients. The reviews themselves include questions about interpersonal relationships, technical abilities, cost consciousness, and special achievements, and they are graded on a numeric scale. The physician and manager meet with the employee to discuss the review, the employee signs it, and it is put in their personnel file.
Having documentation using formal reviews isn't enough. It is also wise to include dated and signed notations when and if an employee does something notable whether it's good or bad. Even for the small boutique practice with few employees the file provides an easy way to measure the employee's trajectory. Negative issues should be addressed as close as possible to the time of a representative incident. If termination is a consideration, warnings should be documented with the cause prior to the final decision.
As mentioned earlier, discussing problems may be best done first by the employee's direct supervisor or manager. As physicians we've probably all had the experience of getting too emotional when an employee made a mistake and disrupted our schedule or a procedure. In the heat of frustration, angry words can be said and can sound like personal accusations. Instead, keep comments professional, and, if you can't, let someone else handle it.
A Complicated Relationship
As the physician, you are responsible for generating revenue for the practice. If it is your business then you are the one who is responsible for providing your own living as well as the livings of all your staff members. This fundamentally renders relationships with staff very complicated. There will be times that the physician has to make unpopular decisions: Cutting staff hours, extending patient hours, keeping the office open on a weekend. You'll get complaints from even the most loyal staff and can feel betrayed. You may wonder: “Don't they know that I'm working the hardest and have the most liability and responsibility and am at the office at all hours catching up and moving forward to keep the doors open because the buck stops here?” Yes, of course they know, but that's the job you chose. And because they trust you, they work for you and know you'll keep it all going.
Ultimately, choose your staff with as much care as you choose your close friends. These are people with whom we spend most of our awake time, often more than we do with our own families. So pick people you can enjoy working with and who also have an understanding of life and responsibilities. There is no greater measure of a good, mature staff than when your own personal matters arise. In these instances, nothing can be more gratifying than a supportive team. My staff was incredibly protective of me and my schedule when I was in the midst of chemotherapy. They watched out for my father with whom I work after my mother died to make sure he stayed hydrated and kept busy with patients.
Unfortunately, we can never predict how things will turn out. There will always be people who we misjudge or who let us down. As in any relationship, mistakes and miscommunications will happen and it can get emotional on both sides. Our relationships with our staff members are a balance of intimacy and hierarchy resting on a fulcrum of respect. Through hard work, a steady stream of communication and a certain amount of good fortune, you can build a happy office family.