Batya Swift Yasgur, MA, LSW

The interview lies at the heart of the hiring process. This face-to-face encounter enables physicians and other staff to get to know a candidate in ways that go beyond a resume on a desk and letters of recommendation.

“A critical step when hiring a physician is to do your homework to understand what’s important to your own practice and what is the culture of the medical group,” says Jack Chou, MD, physician-in-charge at Kaiser Permanente Baldwin Park, part of the Southern California Permanente Medical Group in Baldwin Park, Calif.

Once clarified, bring those criteria into the interview, he adds.

Here are five questions that can help a practice ascertain if a physician candidate will indeed meet those criteria.

This open-ended question is an important starting point, although the practice already has information about background, credentials, and experience from the candidate’s resume.

“I like to hear individuals describe their own background to hear how they communicate, since communication skills are a critical part of being a good physician,” says Rick Kellerman, MD, professor and chair for family and community medicine at the Kansas University School of Medicine-Wichita.

Don’t be too specific at the beginning, he advises. A practice will want to know if the person’s self-report matches their resume and how he or she accounts for gaps in employment or other issues that might stand out. Then ask clarifying questions, he says.

“Why did you choose this profession?”

Chou notes that healthcare is a “service industry”and providing service goes beyond “talent and quality.”

Since the reasons for choosing a medical career reflect the candidate’s values and goals, they will highlight the candidate’s ability to provide service that transcends clinical skills. “So you want to find out why your candidate chose this particular profession,” Kellerman advises.

“Why are you interested in our practice?”

Understanding the motivations of a candidate is crucial in determining if he or she is a good fit.

Ask, for example, “Are there geographical motivations, perhaps nearby family?”

Interviewers should inquire how much a prospective candidate knows about the practice, which gives a sense of how much due diligence they have done and how thorough they are.

“Can you recall a disruptive patient?”

One way to ascertain whether a candidate is a good fit is to see how he or she relates to the nonclinical challenges patients often pose.

Chou’s group engages prospective physician associates in behavior interviewing, but their questions do not entail creating hypothetical “what-if” scenarios.

Instead, Chou asks open-ended questions such as, “Can you recall a patient who was disruptive and how you handled it?”

“A red flag would go up in my mind when a candidate is having difficulty coming up with situations that he or she dealt with or is trying to make up hypothetical answers,” he says.

An equally important component of the interview is hearing what questions the candidate asks.

“Candidates who have no questions show a lack of interest in your group,” Kellerman warns.

And the types of questions candidates ask can help ascertain what their real interests. If they ask primarily about the salary and other financial arrangements, he notes that their major interest is monetary.

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This face-to-face encounter enables physicians and other staff to get to know a candidate in ways that go beyond a resume on a desk and letters of recommendation.

5 interview questions for your next physician hire

Smartphones are ubiquitous. Beyond phone calls and texting, rarely does a moment go by without an urge to peek at the latest Facebook message or newest Instagram picture. While this may be fine at home, it can cause some problems in a medical practice setting if staff members use their smartphones to access social media.

Nitin S. Damle, MD, MS, MACP, board member and physician at South County Internal Medicine in Wakefield, R.I., says his staff are instructed to leave their phones in their lockers and turned off during work hours.

“There is no reason anyone should be getting onto any website other than one that is related to work during working hours,” he says.

Some practices allow use of staff smartphones during breaks, but within specific guidelines. For example, personal social media accounts must be clearly personal and not representative of the office, practice, or health system and no protected patient or other office-related data can appear anywhere on those personal accounts.

Damle adds that the same rules that apply to use of social media at work apply to personal phone calls as well. “There are certainly exceptions in more acute circumstances-for example, when an employee has an ill family member-but an employee who has to be constantly accessible to an elderly parent, for example, taking multiple phone calls from the parent or caregivers during patient care hours wouldn’t bode well for work performance,” he says.

A more challenging issue is personal social media relationships between staff and patients. Sometimes office staff may refer friends or relatives to the practice, which can also be tricky where social media is concerned.

In situations like these, the staff member already has a relationship with the patient, so physicians should emphasize that they should not use social media to give medical advice, information, scheduling, test results, or any other practice-related communications via their personal account.

Instead, practice-related communications should flow through normal channels, such as the secure patient portal.

Although it is more difficult to control staff members’ social media behavior outside the office, ground rules can still be established.

“Clearly, staff members shouldn’t talk about patients, even if they de-identify them, or about co-employees, or employers,” he says. Patients also should not post photographs of the work site, patients, physicians, or medical personnel. 

He emphasizes that if this type of activity comes to his attention, “it is immediate grounds for dismissal.” However, if the staff member is a friend or relative of a patient, it is acceptable to post pictures that might include the patient in an out-of-office setting.

Photographs taken within the office might seem innocuous, but can also potentially compromise the privacy of other staff members. For example, perhaps one of the physicians has pictures of his family on his desk-or of patients, even after hours. These posted pictures can also give the misimpression that the photographer is speaking on behalf of the practice.

Damle concludes by stressing that patient care “is at the center of any medical practice” and anything that causes a distraction or interruption of that care, such as inappropriate use of social media, should be avoided.

Frequent use of social media is common, but it can cause some problems in a medical practice setting.

When to police staff social media use

Many physicians hire family members as employees in both clinical and non-clinical roles at their practice. After all, why hire a stranger rather than a family member who presumably is more personally committed and likely to go the extra mile?

Some also want to help their family members by giving them a job. Perhaps a high school student needs summer work, or a newly licensed dietician is ready to step into his first employment setting.

This is especially the case in rural areas, says Robert Wergin, MD, a primary care physician in Milford, Neb.

“Sometimes, if you’re surrounded by cornfields rather than cities or suburbs, it can be hard to find people with the skillsets you need,” he says.

So, “if you’re looking for a dependable person for a particular position, it’s not uncommon for rural practices to have family members work as receptionists or office managers, for a father to take his son into the practice, or for a doctor to hire a spouse as a nutritionist or nurse,” says Wergin.

But there are also some serious downsides.






Nitin Damle, MD, immediate past president of the American College of Physicians, says it generally is not a good idea to hire family members at a practice. 

“It creates a fair amount of potential for conflict with other employees, who may be on the lookout for potential nepotism in hiring or promotions,” says Damle, senior/managing partner at South County Internal Medicine, Inc., an eight-physician practice in Wakefield, R.I.

Other employees might also feel that poor performance in the family member will be brushed aside because of the family relationship. “You can get into issues if the employed family member isn’t performing adequately but the physician employer overlooks it,” he says.

To address these concerns, Wergin advises physicians to be vigilant about favoritism and treat all practice employees the same professionally. A practice operates as a team, he says, with each person playing a key part in operations.

“If they feel that you are professional, clear, and transparent about roles, and that you accord all team players equal respect, they are less likely to feel resentful and more likely to feel genuinely valued,” says Wergin.



Family members do not always get along, and family squabbles can potentially find their way into the workplace.

“It can be tricky when family members feel they are being overworked, and this can lead to resentment,” Damle says.

“Part of being professional is leaving relationship issues and emotions outside the front door,” Wergin stresses.

But if that is too difficult, and if the personal dynamic is causing problems with other employees or with patients, “you might have to sit down with your employee and have an honest, straightforward talk to say that this scenario isn’t working out,” he says.



Damle advises physicians “separate out clinical positions from non-clinical positions, such as office management, front desk work, or other positions that do not involve direct patient care.

His internal medicine practice has a policy not to employ family members for non-clinical positions.“However, if a partner’s son or daughter is a physician or nurse practitioner, for example, and we had a position available, we would be open to it, but we would want to make sure we base our decision on the candidate’s merits,” he says.

The decision to hire a family member is complex and carries both benefits and drawbacks.

“All team members, whether family or non-family, need to be on the same page in making the work environment as inviting and patient-friendly as possible,” Wergin says.

Many physicians hire family members as employees in both clinical and non-clinical roles at their practice, but there are serious downsides.

The pros and cons of hiring family members as practice employees

	The beginning of a new flu season marks a time for primary care physicians to consider how to vaccinate patients without falling into costly pitfalls.

	“Some physicians are confused about vaccine schedules or about coding or they are afraid that they may lose money,” says Sandra Adamson Fryhofer, MD, an Atlanta, Georgia-based internist in solo practice and an adjunct associate professor of medicine at Emory University School of Medicine.

	All of these obstacles are surmountable, says Fryhofer, who is also the American College of Physicians’ liaison to the CDC’s Advisory Committee on Immunization Practices (ACIP).  

	“If coding and ordering are done properly, you should not lose money on vaccinations, and you should even be able make a small profit,” she says.

	Before physicians dive into flu season, they need someone to lead a flu shot campaign for patients.

	“When you are offering immunizations in your office, you need to find a champion, someone who will lead the march to encourage adult immunization and get patients on board,” says Fryhofer. A “champion” does not have to be the physician, but can be a nurse, office manager or medical assistant. And there can be many vaccine champions who take up the cause. 

	“To champion it, you have to have resources,” she adds, noting that the ACIP website has extremely useful patient information sheets. Fryhofer keeps a copy of all the educational sheets in a notebook in each exam room, and asks the patient to read about the vaccine while she engages in other tasks. “These materials tend to answer about 95% of the questions that patients will ask,” she says.

	Studies, including a recent one published in May in 

 by CDC staff, have shown a recommendation from a physician is one of the most important deciding factors in the patient’s decision to be vaccinated. Peng-Jun Lu, MD, Ph.D., one of the study leaders, told 

 that incorporating vaccine discussion as part of the standard patient assessment can help reduce missed opportunities for adult immunization. 

	“All healthcare professionals should routinely assess patient vaccine needs and recommend the appropriate vaccines to ensure their patients are protected against serious, sometimes deadly, diseases,” she says.

	Fryhofer’s passion to ensure that patients receive appropriate vaccinations led her to develop “Move the Needle: Raise Adult Immunization Rates,” an online toolkit of resources, including information about vaccine schedules, the financial aspects of offering vaccines, coding information, updates and research and other vaccine-related materials that are relevant to medical practices.

	Once practices have appointed a champion and compiled the necessary resources, it’s time to decide how to balance supply, cost and demand-a challenging process, according to Jack Chou, MD, a primary care physician in Baldwin Park, California.

	“I always liken it to standing on the deck of a ship at sea and trying to play darts. It can even be hard to get your footing, let alone accurately hit the target on the dartboard,” he says.

	Chou recalls that in 2015, when there was a vaccine shortage, his practice saw a delay in receiving its supply resulting in a smaller number of patients being vaccinated within the practice until late October or early November. 

	Since they had used the small amount they received at the beginning of the season to vaccinate higher-risk patients, many of the practice’s other patients had already been vaccinated elsewhere, leading to leftover vaccines and a financial loss, Chou reports. 

	One way that he addressed this issue was by continuing to offer vaccines through the end of flu season. And even though the vaccines had been administered at the end of March, which marks the end of flu season, it did not deter him from administering vaccines to the same patients at the beginning of flu season the following September.

	To avoid ordering too many vaccines and being stuck with leftovers, Chou says, “I look at my patient volume, which is pretty consistent, and at their demand and patterns. I look at how many people we vaccinated last year, and if the practice is growing, I give a little buffer.” However, Chou recommends that smaller practices order in smaller quantities (with the exact number depending on patient panel) to reduce the risk. 

	Persuading patients to get vaccinated can pose a challenge that has financial implications, according to Chou. In 2014-2015, the vaccine’s effectiveness rate was 19%, resulting in low patient confidence the next year, he reports.  

	This was not the fault of the manufacturers, he says, but lies in the nature of the disease itself. “The medical community must make a judgment call regarding the substrains that will be addressed,” he explains. Manufacturers then produce them. But events occur that might change the predictions-for example, there can be a shift in antigens so that the type of flu changes during the season. 

	Patients’ refusal to receive the vaccine, despite educational efforts, resulted in some financial loss, Chou says. But that started to change during the subsequent two years, when there was approximately a 50% success rate. By last year, things were better, so his practice vaccinated about 85% of the patients.

	Ryan Kauffmann, MD, a solo primary care physician in Bellefontaine, Ohio, notes that at his previous practice he encountered significant financial difficulties in connection with the flu vaccine.

	“We used to stock vaccines and sometimes put incredible amounts of money into them,” he recounts. “It was a model that made no sense financially. We had to get our orders in months ahead of time, and we had to pay even if the stock was not used up. And if we ran out, we could not replenish.”

	Kauffman recommends vaccine purchasing groups as a cost-effective way of providing immunizations for patients. 

	Vaccine groups purchase the physician’s current inventory and provide vaccines directly from the manufacturers at no cost, as well as offering automatic billing services and ways to keep track of inventory. 

	However, vaccine purchasing groups can be tricky, warns Fryhofer. For example, many vaccine purchasing groups are willing to take back certain amounts of unused flu vaccines, but they do not always publish when or under what circumstances they will take them back. 

	“Always ask,” she emphasizes. And physicians should check with their state, since vaccine purchasing groups can operate differently.

	And however physicians get the vaccine-whether purchased directly from the manufacturer or through a vaccine purchasing group-it is important to keep track of inventory. The group can certainly help with this, but sometimes, simple is better.

	Fryhofer says she uses a board attached to the side of the refrigerator on which she records when the vaccines are ordered, when they come in and how many are used. 

	She advises physicians to look at the needs of their practice and determine what will work for them.

	Insurance reimbursement for flu vaccinations has always been complicated but complications have mushroomed in recent years.

	Coverage-related questions abound among physicians-for example, differences between Medicare Part B and Part D, Fryhofer says, noting that Part B covers the flu vaccine, while part D covers the shingles vaccine.

	At present, under the Affordable Care Act, all ACIP-recommended vaccines have first-dollar coverage with no cost sharing, which can relieve the financial barrier for patients. Nevertheless, it’s important to be vigilant about reimbursement. Fryhofer notes that in order to be compensated correctly, proper coding is mandatory.

	ICD-10 vaccine coding is simple, Fryhofer notes, as the diagnosis code is z23 for all vaccines. Things get a little more complicated with CPT codes (see sidebar on page 19).

	Coding information is also available on the websites for the Centers for Medicare & Medicaid Services (CMS) and AAPC. 

	One of the best ways of smoothing the process of vaccination is to have standing orders, according to Chou.

	“We have patients fill out a questionnaire to be sure that there are no contraindications, and I leave standing orders so that the patient can get vaccinated, even before seeing me. Any practice can institute that type of protocol,” he says.

	Fryhofer agrees that standing orders reduce barriers to adult vaccinations, adding that the Immunization for Action Coalition (IAC) offers information and support to practitioners seeking to implement standing order.

	This includes protocols for establishing standing orders and who is authorized to administer the vaccines, steps for implementing standing orders and sample forms. 

	“You are not going to get rich by administering vaccinations, but you also do not have to lose money,” Fryhofer says. She adds that, “vaccination has a much bigger purpose than just the dollar amount. You will be making your patient population healthier and protecting them from getting sick, which benefits not only the patient but also society and the population as a whole.” 

The beginning of a new flu season marks a time for primary care physicians to consider how to vaccinate patients without falling into costly pitfalls.

Author | Batya Swift Yasgur, MA, LSW

Articles

5 interview questions for your next physician hire

When to police staff social media use

The pros and cons of hiring family members as practice employees

How to maintain a successful flu vaccination program