It's Even Worse Than You Thought

October 1, 2005

Questions and Answers with workplace culture expert John-Henry Pfifferling.

Most Practices Suffer From Some Level of Workplace Dysfunction, According to Expert John-Henry Pfifferling. The Good News: You Can Begin to Fix It Today.

We asked Pfifferling for his insight on the nature of practice dysfunction, why he thinks it's so common, and what physicians can do to recognize and fix the problem.

Physicians Practice:How common is workplace dysfunction in practices?

We don't even have an agreed upon criteria for what a dysfunctional practice is. No one's done a study on how common it is, because "it" means lots of different things. But if you're asking how common is it for many people in a practice to feel the practice is a toxic workplace, I would easily say more than 60 percent of people in practices would say that theirs is an unhealthy workplace. That doesn't prove anything. ... But certainly when you go around the country and say, "What's the quality of life in your medical practice workplace?" - if you ask practice managers and administrators, "How unhealthy was the environment in the practices you've been in?" most will say, "Rarely have I been in a healthy one."

Physicians Practice:Do you think this problem is worse, or different somehow, than in other kinds of small and medium-sized businesses?

Yes. Because the expectations are different. The expectations are for compassion, conscientiousness, and caring for patients, and therefore for each other. And so you run into a clash ... when you discover that's not the case, you have anger and conflict. In healthcare, by definition you're caring for others, so you expect they'll be caring for each other in terms of collegiality within the same status and within higher and lower status, and then you discover that's not the case. If you watch the doctors, you see how poorly they are as colleagues to each other. That sets the entire tone. So if you have physicians who are isolated and not collegial, you're going to do that yourself as a midlevel provider or staff member, and then you become isolated, gossiped-about, etc. And then there's the classic myth about how 'greedy' doctors are, and how "They always take care of themselves but they never take care of us." That's the folklore that goes from person to person, from the staff's perspective. And that makes people suspicious, not open up, and not creative.

Physicians Practice:My sense is that, unfortunately, a lot of physicians think this sort of thing is not important - that as long as people are showing up to work and doing the basics of their jobs, who cares if people aren't whistling as they go through their day?

That's because they don't have a global business sense - they don't realize how dysfunction affects the goals and business objectives of their practice. They don't even know what the goals and objectives of the practice are. ... They're not on the same conceptual viewpoint as the staff, or particularly the practice manager. They just want to delegate and delegate. And what we get involved with [at the Center For Professional Well Being] so often is the embezzlement or the sabotage, or on the other hand, the blaming of the business manager for all the practice's problems. The doctor says, "I don't have time for that."

Physicians Practice:So what are the top three or four negative consequences of not dealing with office dysfunction?

From a business perspective, lack of problem resolution - the same problems keep on coming up over and over again, and so you end up wasting time. It's a tremendous inefficiency in problem resolution, and therefore you're disorganized. The more you're disorganized, the less time you're going to have for real serious issues for the success of the practice. Those things take time - developing a vision, a strategic business plan, the assurances that we can make midcourse corrections. All the kinds of things that the corporate world takes a tremendous amount of time to deal with, so they can be fast-changing, deal with competition, and be on the cutting edge - we just don't do that in medicine. Very rarely. So, there are short- middle- and long-range efficiency and communication consequences.

Physicians Practice:As far as the reasons these issues go un-dealt-with, is it because physicians just don't want to deal with it, they're unequipped to deal with it, they don't know what's going on ... ?

All of the above. They don't want to deal with it because it means they'll have to admit their vulnerability and lack of education about something. That's the No. 1 reason - they're afraid that they'll have to share their deficiencies regarding the interface between interpersonal skills and the practice of medicine. They're unequipped because all of the curriculum in medical school and residency is geared toward the scientific content, and anything else is put down as "soft" or "irrelevant." That's the second reason. Third, it doesn't generate income - "If I'm doing four heart procedures today, why should I spend time looking at the phone system? I'll just delegate that." ... And they're completely unaware because no one has shared it in such a way that they can learn it and be comfortable learning those skills, and still be physicians.

Physicians Practice:What do you mean by that?

I'll give you an example: Typical physicians who talk to us about problems in their practices tell us, "I got ripped off by ..." fill in the blank. A major piece of technology or medical device. They say they "didn't have the time" to do their homework. And they wouldn't take the time, according to the practice manager. ... They complain they don't have any time, but they haven't thought through things to make sure they have quality time. So they're not aware, and they're even put down in training for being aware of things that are not purely medical.

Physicians Practice: I wonder if there are going to be physicians reading this, thinking, "Gee, maybe I am unaware, but how do I know I'm unaware?" Are there things they should be looking for - some basic signs of dysfunction?


Absenteeism. Psychosomatic illness in their staff. High turnover. They should conduct exit interviews with people leaving the practice - I know so few physicians who do that. After a person has quit, or been fired, you should do an exit interview with that person, then the physicians should get together and talk about what the person said. We have no feedback loop. There's no application of science - meaning feedback, data collection - to the practice. Also, how many physicians go to practice management meetings and really listen? They don't. They say, "It's not in rheumatology, it's not vascular surgery, so I'm not going to a meeting like that." They should also seek advice from other practices. ... We asked a practice once "Who is most concerned about the health of this practice?" And they said "Our spouses." And so we said, "Well, why don't you hire your spouses and pay them to go to every other practice in the community and see if there's anyone who will help them look at things that could be beneficial to your practice?" And lo and behold, they listened and learned a lot.

Physicians Practice:So what are the two or three steps physicians can take today that can help to address these problems?

Ask every member of your practice - every single member - "Do you know what we are? What our goals and objectives are?" If you find there are inconsistencies, that people perceive very different things, then the message your clients are going to get - your referrers and patients - is going to be inconsistent. That has to do with listening to your staff, predicated on what your goals and objectives are. What are the principles of your practice? What do you all really believe in? Have you even taken the time to ask your colleagues? Second, once you figure that out, check that your staff agrees - because if you have different principles from your staff, you're in trouble. Third, check to see that those principles are manifest in your highest agents, like your practice manager. Has your practice manager spent time with you to figure out what your complaints are? Have the physicians spent half a day a year shadowing the practice manager to better understand what she does? We have a problem if our expectations clash: It causes emotional conflict, frustration - and are you regularly addressing your items of frustration? If you run away from it, you're going to end up calling me for help.

John-Henry Pfifferling is the director of the Center for Professional Well Being, a Durham, N.C.-based organization that focuses on career satisfaction and stress management for physicians. He can be reached at 919 489 9167 or at cpwb@mindspring.com.

This article originally appeared in the October 2005 issue of Physicians Practice.