How a primary care doc can keep staff from running off to Kaiser or the specialists

The bad ones get fired and the good ones race for the exit

A returned Peace Corps volunteer who spent her two Peace Corps years in Mali, Lisa was one of the best M.A.s we’ve ever had, but now she’s a second-year medical student at U.C. San Francisco.
  • A returned Peace Corps volunteer who spent her two Peace Corps years in Mali, Lisa was one of the best M.A.s we’ve ever had, but now she’s a second-year medical student at U.C. San Francisco.
  • Image by Sarita Vendetta

"This policy makes it clear what we should do about Jessica and Christine." Two medical assistants who worked in our office until they decided they would try going to Kaiser to improve their incomes, Jessica and Christine now, less than two months later, wanted their jobs back. Annette, our affable chief administrator, was explaining to us how we would handle this, the most recent of the many annoying personnel problems we have confronted this year. In doing so, she was also reinforcing the authority her business suits and title implied she held.

“Christine gave us two weeks’ notice and worked out her two weeks without any difficulty,” Annette continued. “She can, therefore, come back to work for us. But Jessica walked out on her job the day she gave notice, and she is therefore not rehireable.”

Stephen, the family practitioner with whom I have shared office space, personnel, and overhead expenses for the past six years, raised the backs of his clasped hands toward his salt-and-pepper beard and nodded in agreement. “Makes perfect sense to me,” he acknowledged, not hiding the disgust he felt, as we all did, that we had to spend time in swivel chairs in his office discussing how to handle such matters. I also agreed with Annette’s new rule, which was: anyone who leaves us with less than two weeks’ notice gets terminated on the spot and can’t ever be rehired. To us, changing jobs without giving notice is equivalent to saying, “I don’t mind screwing you or your patients, and I don’t have any gratitude whatsoever for what you have done for me.”

Stephen and I used to make all the decisions and policies. Three years after graduating from the UCSD School of Medicine and three months after finishing my family-practice residency, I took over Stephen’s associate’s family practice in Berkeley. From October 1992 until we allowed a pediatric group to buy our practice on New Year’s Day 1997, I ran the business. I wrote the checks, did the taxes, and kept the books. Stephen helped hire and train staff. Without any business or accounting training, I learned on the job. In less than three months, we had to fire someone; Kathy had taken money from my predecessor and could not be relied upon to show up for work on any given day. In four and a half years, we hired a few people we should not have, at least one of whom stole cash from us.

A bigger problem has always been keeping good employees. Our first hire was our best: Rhonda. She’s still with us and is the only employee we’ve had who invests herself as much in our work as we do. They’re her patients, too. That and her loyalty to me (and now to Annette) are why she has stayed. The other good ones have all left, most for money, a few to advance their careers.

Primary-care doctors in private practice don’t make enough money to pay their staff as much as specialists, so our offices are training grounds. Medical assistants (M.A.s) who come to work for a primary-care physician often don’t have much experience. As a family practitioner, I do pretty much everything, including pediatrics, orthopedics, internal medicine, obstetrics, gynecology, and geriatrics, so my medical assistants get to learn a variety of useful skills. When they get proficient, they can look for an easier job in a specialist’s office and make more money, or they can step up to a higher level. Lisa did the latter. A returned Peace Corps volunteer who spent her two Peace Corps years in Mali just before my wife did the same thing in the early 1990s, Lisa was one of the best M.A.s we’ve ever had, but now she’s a second-year medical student at U.C. San Francisco. Ella, another one of our stars, left us for a job managing the medical records department for a Contra Costa County prison. So if you are wondering why every time you go to your primary-care physician’s office there are new people working there, now you know. The bad ones get fired. The good ones leave. Dream M.A.s who stay, like Rhonda, are rare. You have to find someone who cares about your practice and for whom being a medical assistant is enough to fulfill his or her career goals.

I find the revolving door for personnel painful, even now that I am not primarily responsible for hiring and firing. My colleagues tell me not to get attached to employees, and my life would be easier if I didn’t, but I do and I don’t think I can change. At 35, I’m close to the same age as most of our employees. Almost every employee I’ve ever had has come to me for personal advice. It’s not my nature to ignore people’s personal lives; that’s why I’m a doctor. I also can’t seem to shake the belief that employees will work harder and do a better job for our patients if they care about me and know I care about them.

That approach has burned me on several occasions, the most recent of which occurred just over a year ago. In the late spring of 1997, Annette hired Negar for a management- training position. A bright, tall, slender 22-year-old woman owing her olive complexion to her Iranian ancestors and her perfect nostrils to her plastic surgeon, Negar was sure she wanted to be in a helping profession but suffered from the confusion and anxiety typical of recent college graduates. I knew she had higher aspirations, but I thought I could get her excited enough about what we do to get her to stay. She did not have any practical experience nor familiarity with the forces driving our health-care system, so while she learned on the job how to work in our front office, I took extra time to teach her how the medical industry works and how our practice operates within it to help patients solve problems. In return, she taught me a few Farsi phrases that I passed on to my wife to help her communicate with one of her first-graders.

Naive and idealistic as Negar was, she got caught in what she saw as a contradiction. In our tutorials, I mentioned that I’m the medical director for a volunteer organization, the Coalition of Concerned Medical Professionals (CCMP), which provides health care free for people without insurance, most of whom work in service industries that the Taft-Hartley Act forbids from forming unions. Once a month I see patients free of charge at CCMP’s health services center. But at the front desk, she saw how we verify every patient’s insurance and, without exception, insist on collecting everyone’s copayment or owed balance at the time of service. She hated that we sometimes refused to see patients whose insurances turned out not to be valid or who, for other reasons, could not demonstrate any ability to pay for our services. About two months after we hired her, she quit, saying she couldn’t work for a place that was only concerned about whether we would collect our billed charges. I sat her down in my office and gave her a lecture about how many of my primary-care colleagues in Berkeley had lost their practices because of declining insurance reimbursements and about how I couldn’t help anybody if we couldn’t keep our doors open. The sermon changed her mind for a few days. When she told me about five days later that she was working her last day, I felt so used and misunderstood that I struck my office’s wall with my open palm, an uncharacteristic break in my usual calm demeanor that frightened her a bit, I think. I had seen her as a spiritual ally within the office who could see the big picture and use her youthful vision to help us fight to change it, and instead she left because “You all only care about money.” I felt terrible for hours and bad for weeks.

Negar would admit she didn’t do great work for us; she will use her talents better elsewhere. I cannot say the same about Marsha, Joe, or Gina. They did high-quality work for others before coming to us, showed promise during their short time with us, and walked out without notice under murky circumstances, all in the past 12 months. Gina was the latest and the fastest to leave. She came to our office September 14 exuding experience, competence, and courtesy and informed us at the day’s close that the job involved too much front-office work and she therefore would not be coming back.

Marsha and Joe both came in at managerial-level positions having earned rave recommendations from previous employers. Both impressed me with their professional skills, particularly Joe, who came in to shape up our business office at a time when I was working with that department to improve its performance in collecting family-practice charges from insurance companies. Within three months, we turned the family-practice business around from monthly losses to monthly profits. I went on paternity leave during June.

When I returned in July, it took me a few days before I noticed the absence of Joe’s friendly Filipino face; he had bailed out during my absence, citing problems with upper-level management. The day Gina rejected us I found out that Marsha, who had left last winter, could not stand the people for whom she had worked in our organization (my employers). She told this to one of my family-practice colleagues, who runs his own practice in Oakland, after he hired her to manage his office just after she left us.

That’s not the kind of reputation I want my employers to have. Nor do I enjoy watching capable workers race to our exits. While my employers have raised the overall quality of our personnel, I’m not sure they’re giving everyone the respect they deserve, particularly the people who come to us with higher skill levels and strong opinions about how their jobs ought to be done. I feel a meeting coming on, one that I will

have to call and one in which I will have to walk the fine line between educating and insulting my bosses. Bring on the swivel chairs.

I do get vindicated sometimes. For all her loyalty, Rhonda has left us twice, once to work for a cardiologist and once for a surgeon. In fairness to Rhonda, she drives about 35 miles to and from work each day, and both of the other jobs had much shorter commutes, as well as higher salaries. Both times she encountered such terrible work environments that she came back to us begging to get her job back and both times we couldn’t refuse, even the time we had to tell her replacement that the position she had filled didn’t exist any longer.

More recently, my wife and I have reestablished contact with Elia, the one who left us for a prison job. The money is still good for her, but the breakup of her ten-year marriage and the depressing surroundings in which she has to work six days a week, doing a job that once required two people, has led her to miss the clinical work she did for us. But unlike Rhonda, Ella won’t come back; she thinks she can’t afford the pay cut. I think she would be happier working for someone who cares about her. Then again, she would be one of those employees coming in with high-level skills, so we wouldn’t be able to take her back now, we’d lose her. Perhaps Annette can solve that one, too.

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