We trusted. We hired.We got burned.

Misdiagnoses, inappropriate referrals, slipshod medicine.The signs were there. Why didn't the two partners see them?

When your new associate is likable and echoes your views on medicine,you want things to work out. My partner and I certainly did. We thoughtit was a real coup when we hired a board-certified family physician--let'scall him Jeff--to join our small-town practice. Although we didn't checkhis references, we had no reason to doubt his competency.

In the beginning, we thought he was a godsend. It had taken us a longtime to find anyone willing to join us. That may well have been becausemy partner and I are related to each other and have worked together for16 years. Although we advertised for an associate in the local residencyprograms, let the hospital know of our needs, and kept our eyes open, itseemed no one wanted to risk being the outsider in our practice--until Jeffshowed up. He had heard about the opening through the grapevine.

Jeff was two years out of residency and working at a large clinic. Hisambition, he said, was to settle in a private family practice in a smalltown. After meeting with us several times, he told us that our very personalizedapproach to fee-for-service medicine was exactly how he envisioned buildinghis own practice. We were only too glad to let him take some of the load;we'd gotten far too busy.

After careful deliberation, we worked out an arrangement: The contractwould be for a year, initially. We'd pay malpractice insurance, dues, andCME expenses. Jeff would receive a percentage of his collections based onour overhead, with an income guarantee. He'd get patients new to our practice,unless a patient specifically requested me or my partner.

With that behind us, we ordered new prescription pads, stationery, andbusiness cards. We adapted our office space to make room for Jeff and hireda new nurse, Angela, and an extra secretary to help with the anticipatedincrease in paperwork and front desk activity. Jeff's name was added tothe sign outside our office.

A missing CV signals trouble

Our first inkling of trouble came the day I asked our office manager,Tracy, how Jeff's application for hospital privileges was going.

"I can't do anything until he gives me his CV," she snapped.

I was amazed. That application should have been in weeks earlier. Withouthospital privileges, Jeff wouldn't be able to share call with us. When Iasked him about it, he seemed puzzled. "Tracy has my CV, surely,"he said with a worried frown.

"She says No."

Jeff's eyebrows rose ever so slightly. "Don't worry," he said."I'll talk to her." Apparently, he turned in the necessary paperswithin a couple of days.

Eventually, the hospital privileges came through and, with them, thesummons to the regular meeting of the hospital's family practice department.

"Do you want to ride with us tonight?" I asked Jeff.

He frowned.

"I'm not that bad a driver," I joked.

"I don't think so," he said.

I thought he was joking, as he often did. He wasn't. I told himhe'd lose his hospital privileges if he didn't attend the requisite numberof meetings. Besides,
I said, getting to know colleagues was a good way to become part of thelocal medical community.

That night, he came with us. But we never could persuade him to attendthe evening dinner meetings sponsored by pharmaceutical companies. We goto those to keep in touch with colleagues and stay up to date on new drugsand treatments.

What Jeff was doing to keep abreast or earn CME credits was a mystery.There were no medical magazines and journals in his office, unlike ours,where desks were piled high with publications waiting to be read. I evenoffered to lend Jeff the audiotapes we've used to keep up on medical advances.But he just wrinkled his nose.

His comments after a drug rep left our office one day should have beentelling. The rep brought lunch and talked about guidelines for treatinghyperlipidemia. My partner and I found his talk very basic. But Jeff saidhe'd learned a lot from it. At first, I thought he was being sarcastic.But looking back, I realize he was serious. He didn't know what he shouldhave.

Blank appointments hint of a lazy streak

Jeff didn't seem any more ambitious about building his patient base thanhe did about pursuing CME. Although we enjoyed a little respite when hefirst joined us, as the months went by, my partner and I were as busy asever. But Jeff's appointment book still had plenty of spaces.

One day, after he expressed concern over his meager collections, I advisedhim to make the most of his lulls. "Spend extra time with your newpatients; show them how thorough you are," I said. "If they thinkyou're good, they'll tell their friends. That's how you'll build your practice."

But he didn't heed this advice. I watched from an adjoining suite andnoticed that he was in and out of the exam room in just a few minutes. Nordid he follow through on my suggestion that he volunteer to replace theretiring team physician at the local high school. And Jeff liked sports!

Even his referrals suggested laziness. While we waited for several ofour insurance companies to add Jeff to their panels, my partner or I hadto sign all referrals. When I noticed that Jeff had referred a patient withan ingrown toenail to a podiatrist, I had to remind him, "We can dealwith that here." One week later, however, I saw he was requesting areferral to an ENT--for the removal of ear wax!

"It was really impacted," he said when I confronted him. "Noway could I get that out." He was persuasive.

"You should record that in the chart," I told him. "Itdoesn't even mention that you tried."

Lax patient care is the final straw

What forced our hand, ultimately, was Jeff's less-than-meticulous careof patients. Several incidents come to mind.

One evening when I was on call, a woman phoned seeking a renewal of herpain medication. I didn't recognize her as one of our patients. After establishingthat this wasn't an emergency, I ended the conversation. I suspected shewas an addict.

When I returned to the office in the morning, however, I discovered thewoman was Jeff's patient. And her chart was a mess! The patient had complainedof chronic pain in various parts of her body. Jeff had prescribed severalpain medications, most recently one that's highly addictive. Jeff, or moreoften Angela, had called the prescription into the pharmacy a number oftimes. If Jeff had ever given the patient a detailed examination, therewas no record of it. It seemed to me he gave the patient the drug on demand.That made me angry.

"Jeff, this chart is unacceptable." I pointed out the inadequateannotation and the dangers of prescribing a highly addictive drug. The patienthad seemed unstable to me.

"But what could I do?" he asked. "The patient kept askingfor it."

"Tell her you're not happy prescribing that particular drug forher, and refer her to a specialist who can deal with her problems,"I advised.

From that point on, we began to observe Jeff more closely. It seemedlike an infringement on his privacy, but we reasoned that this was ourpractice and these were still our patients. We didn't like what wesaw. For instance, Jeff was fond of prescribing a variety of inappropriateand sometimes very expensive antibiotics for minor upper respiratory infections.He made diagnoses with no symptoms or signs recorded to substantiate them.He prescribed medications in incorrect doses.

Were we overreacting? I was afraid so, until I did a follow-up on oneof Jeff's patients. He had seen her for a headache just a few days beforeand had diagnosed sinusitis. The woman's symptoms had gotten worse. My nursecircled the blood pressure reading, which was alarmingly high. On a recentvisit, her blood pressure had shown a moderate rise. During her visit toJeff, however, her blood pressure hadn't been taken.

"Now look, Jeff," I said. "You know that it's office policyto do a blood pressure check on every adult patient at each visit. Especiallyif she has a history of a high reading. You've got to insist that your nursedo that."

"I can't double-check everything," he said.

"But you have to. You're the one responsible."

I also noted that his charts were still missing notations on patients'current medications.

Jeff's response surprised me: "Do you think we should let Angelago?"

A week later, I saw another of Jeff's patients. This young man had presentedwith a cough and a wheeze. Jeff diagnosed bronchitis and prescribed an antibioticand an expectorant. Two days later, the patient returned, no better. Hehad a history of asthma, and Jeff had even recorded that he'd heard a wheezein the patient's lungs. He had diagnosed pneumonia, injected an inadequatedose of a potent antibiotic, and prescribed an expensive substitute forthe antibiotic pills the young man was already taking.

This visit with me was the patient's third time back to the office. Mynurse had already made the diagnosis and had the asthma breathing treatmentwaiting before I went into the exam room.

I spoke to Jeff again, feeling almost embarrassed to be lecturing a board-certifiedfamily doctor on the basic diagnostic steps, the guidelines for treatment,and the inappropriateness of some antibiotic therapies. I couldn't helpthinking that if he had come to meetings, he would have had the basics rammeddown his throat repeatedly. But he hadn't.

Sloppy charts reinforce a painful decision

As Jeff's contract was coming up for renewal, my partner and I agonizedover what to do. Jeff was such a nice young man, gentle and kind with patients.Could we educate him? we wondered. Or should we part ways? We talked aboutit endlessly.

Obviously, things could not continue as they were. Our practice, onewe had worked hard to build, was being tainted. We'd fought hard for ourreputation.

So we told Jeff goodbye.

After that, we discovered just how unsuitable he was. It was all therein his charts: the misdiagnoses, inappropriate referrals, slipshod medicine.In a way, the evidence was a relief--it told us we were right to let himgo. What's frightening is how long it took us to do it.

What have we learned?

Lesson 1: It's hard to get to know someone until you actually work withhim. Our initial contract was for a year, but it might be a good idea toinsist on a probationary period.

Lesson 2: Check references! We didn't with Jeff, because we didn't knowany of the individuals he listed and didn't think the check would yielduseful information. But we will check references in the future.

Lesson 3: Trust your instincts. There were plenty of signs of troubleearly on. But we so badly wanted the arrangement to work out that we overlookedthings we shouldn't have.

In retrospect, it's amazing how much slack we cut Jeff. For instance,he left far too much to his nurse and refused to supervise her properly.Although it's our policy to list the patient's current medications and vitalsigns at each office visit, Angela didn't. Perhaps she took her cue fromJeff, because she always did these tasks when working for my partner orme.

Besides that, Jeff and Angela spent a lot of time chatting, even whenthere were charts on the shelf, with patients waiting to be seen. There'sno excuse for making people wait.

Lesson 4: Don't be afraid to enforce your values. My partner and I knewthat any incoming doctor would feel like an outsider, so we bent over backwardnot to criticize. Besides, how do you police another doctor without appearingboorish? And when we did point out chart omissions, Jeff didn't change.

However, we didn't want to seem too picky. There's a difference betweenstandards and preferences, which may be less meaningful and little morethan habit. For example, my partner believes in washing his hands afterentering the exam room, to show the patient he's meticulous about cleanliness.I prefer to wash them before entering the room, so I can shake the patient'shand. Several years ago, I decided he might have a point. But by shakinghands and then washing them, I quickly ruined the image I was tryingto create. So my partner and I agreed to disagree on this.

With Jeff gone, we're still looking for a replacement. This time, we'llbe far more skeptical. In addition to checking qualifications and references,we'll watch our associate much more closely after we make the hire.

We'll explain to our "Jeff of the future" that we had an unfortunateexperience in the past, and urge him--or her--not to be offended by closescrutiny. We'll make sure we're satisfied with his current knowledge andCME programs. We'll review his charts on a regular basis. We'll make itclear we expect him to promote himself in the community. This is a narrowpath to travel, but I think our natural desire to trust the new associatewill come across.

Perhaps our new hire will bring with him some refreshing ideas. And thatleads to the final lesson: Don't be afraid to make changes--and don't beafraid not to.

Cutting the risk of failure with a new hire

Combine hiring mistakes with inadequate supervision, and the result isoften a scenario like the one described in the accompanying article, warnsJudy Bee, a principal of the Practice Performance Group in Long Beach, CA.

"It's strange that physicians who are so assertive with hospitalworkers are so nonconfrontational with colleagues," she observes. "Lotsof physicians take a 'hands off' management approach with a new employee.They're inclined to accept the candidate's claims at the interview stageand hope for the best."

To improve the odds for hiring someone who'll work out, you've got tobe fairly aggressive during the interview--and afterward. Here's how:

Probe the candidate's approach to practice. Develop questionsfor the interview that will help you discover whether that approach wouldmesh with yours. Describe a fairly common problem, suggests practice managementconsultant James A. Kimble of Gilmore, Jasion & Mahler in Toledo, andask, "How would you handle this?" Then listen carefully, and trustyour instincts, Kimble adds.

You might carry this investigation a step further by inviting the potentialnew hire to spend a week at your practice before signing an agreement, saysconsultant Michael D. Brown of Health Care Economics Inc. in Indianapolis.That will enable you to check clinical and charting skills.

Be diligent about checking references. The prospective employeris seldom acquainted with a candidate's references, Judy Bee notes, "butthat shouldn't deter you from checking them."

In the situation described in this article, says Dorothy Sweeney of TheHealth Care Group in Plymouth Meeting, PA, the author should at least havechecked references from "Jeff's" training program and from theclinic where he was working at the time. "We recommend checking withsupervisors, teachers, and also employees, such as the head nurse or officemanager," she says. "You'd be surprised what you can learn abouta physician from a nurse."

Spell out expectations before offering a contract. Certainly,you'll want to address how many patients you expect the new physician tohandle on a routine day. Beyond that, you should spell out your expectationsin terms of the new physician's marketing himself, obtaining CME credits,attending hospital meetings, and other key aspects of the job. This willaccomplish two things, says Sweeney: It will make you focus on what youwant from your new hire, and it will let him know what points will be importantin his evaluation.

Create a formal evaluation process. The new doctor's early performanceneeds close, formal evaluation, and plenty of feedback. Such evaluationsare often provided for in the hiring contract, says Sweeney. If deficienciesare identified, they should be put in writing at the evaluation, and thedoctor's subsequent performance should be monitored to measure improvement,says consultant David C. Scroggins of Clayton L. Scroggins Associates inCincinnati.

In the situation recounted in the accompanying article, "a formalevaluation might have prompted an earlier decision to terminate the newdoctor," notes Gray Tuttle Jr., a consultant with Rehmann Robson/PCIof Lansing, MI. "Some of the better- organized groups hold formal appraisalsevery six months."

Include a "terminate at will" clause in the contract.This gives you the right to fire an employee on the spot. You can even doit without cause. If you do, though, you'll have to provide severance thatmay amount to as much as 90 days' pay, depending on your state's law, saysKimble.

Maintaining a contractual right to fire an employee on the spot is betterthan designating a "probationary period," he says. The latterimplies that the employment relationship becomes permanent once the probationperiod is over.

The author has been granted anonymity.

We trusted. We hired. We got burned.

Medical Economics

Oct. 25, 1999;76:135.