When a Doc Pulls a No Show

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Dear Director: I have a doc who would have missed two shifts had we not called and told them they were supposed to be at work. Generally, they show up on time but twice in a year seems like a lot.  Should I just fire them?

While the expectation is that everyone will manage their calendar correctly and be on time (or early) for every shift, the reality is that sooner or later, one of your docs will screw up and not show up to work. Maybe this is because we rarely follow a fixed schedule. While I personally haven’t forgotten to show for a shift, I have missed my alarm clock before and once showed up to work only to find out that I wasn’t on the schedule (never been happier to have a day off). I’m not condoning missing shifts but I’ve worked in enough EDs and with enough different providers that I know it happens. Typically a phone call to the doc about 10 minutes after they were due to appear results into an OMG apology and they’re on their way to work. In my administrative career, twice we haven’t been able to reach the doc on their home or cell phones over a period of hours and then given how reliable they were thought to be, I actually called the police to check on them. The first time it happened, it turned out that the MIA doc had gone out of town and didn’t have good reception with his cell. The second time, the police found the doc asleep (it was noon and he was due in at 10am) and he was shocked to see the police at his door. He was in the ED 30 minutes later and told me he didn’t have the shift on his calendar.

First Time Offenders
We all survived residency so working in a shift work world shouldn’t come as a surprise. Part of the skill set that should be learned in residency is how to manage one’s calendar. Therefore, no one should get a free pass when they forget to show up to work. With that said, given the craziness of our lives, I can understand that it happens. However, even a first time offender needs a sit down with the department chair to discuss what happened and how it can be prevented in the future. Often, these conversations don’t need to take more than five minutes. The conversation needs to determine the root cause of the problem. From there, a solution to prevent it from happening again usually isn’t that difficult. Throughout my career, I’ve seen a variety of excuses, though we’ve usually come up with new ways to manage their calendar fairly easily. For one doc, I suggested he post his schedule on his kitchen fridge (I thought that was a given for ER docs) instead of next to his computer in his office. Another doc I know who is technologically challenged, carries a photocopy of the group schedule in his wallet so he can check it every day. I’ve also worked with a doc who entered his shifts into his phone every month but in this case had missed inputting one. I showed him how to download his schedule automatically from our web-based program. These are easy fixes and should prevent a recurrence. As a chair, I’m constantly checking my calendar to see what meeting I have next or to put in another meeting. Call it paranoia about missing a shift, but I also use that opportunity to know what my clinical schedule is for the next couple of days and I always check the schedule located on my fridge each evening when I get home so I know what I’m doing the next day.

Repeat Offenders
While a one-time event deserves a casual conversation, in my mind, no one should be a “no-show” for more than one shift, at least over a few year period. While your threshold may be different than mine, and potentially each situation has a unique reason, at the very least, there needs to be a formal sit down meeting for a second occurrence. Fortunately, we have a performance management technique in our toolbox. Therefore, after thoughtful analysis with the provider trying to get to the root cause, including making sure the physician isn’t ill or has an issue with alcohol or drug abuse, it’s entirely reasonable to construct a Performance Improvement Plan. I recommend doing this with someone from your human resources department. At the very least, the PIP should contain a section identifying the problem (i.e. no show at work), a section outlining the desired outcome with a time period (100% attendance for all scheduled shifts over the next year), and the consequence of not achieving the desired outcome. The desired outcome and any consequences of failing to achieve the outcome should be consistent with your HR policy. Examples of consequences might include: a loss of stipend, bonus, administrative responsibilities, or a preferred shift status, or there could be a financial penalty like paying the group back the dollar amount that the physician who actually worked the shift got paid. The consequences may even extend all the way to termination.

A Plausible Excuse
There are a couple of excuses that I might buy for missing a shift. In the prehistoric days, before online scheduling programs that automatically sync with your gmail calendar, docs would make trades, and sometimes wouldn’t make the change on the paper “master” schedule (usually kept in a drawer near the docs computer). I know of a few cases where one doc thought there was a trade but the other hadn’t agreed and then no one showed up for the shift. Then there would be numerous phone calls to figure out who owned the shift and where they were. If you’re still on paper, at the very least, there should be email confirmation from each party about trades and the scheduler should be included in the loop. Online programs typically allow docs to click to confirm a trade and then it automatically updates the schedule. There’s also the situation where changes are made to the schedule after the schedule is published. There are a lot of reasons this might happen. Most recently at my group, we did it for someone who went on FMLA. Whether people are volunteering to pick up a shift or the scheduler is giving people an extra shift, once changes are made to a published schedule, the scheduler owes it to the provider to confirm that they’re aware of these new shifts and are available for them. There’s nothing worse than having plans to go out of town on your weekend off only to find out you’ve been assigned a shift that weekend. Except if you’re out of town and your cell rings because you didn’t know you were supposed to be covering the shift because no one told you. A different problem can occur for docs who cover several EDs for their group. Whether you do 80% of your shifts at one facility, or you split your shifts between three hospitals, unless your schedule is clearly marked on your calendar, I could see showing up for a shift at the wrong hospital. I’ve talked to docs where this has occurred. Hopefully the hospitals are close so you can get to your correct hospital. When there’s humans involved, there’s always the possibility of a mistake occurring. These situations are almost forgivable but with a little bit of preemptive planning, also avoidable.

Tardiness
My daughter’s lacrosse coach’s motto for practice was “Early is on time, on time is late and late is unacceptable.” I think we can apply that same motto to our shifts since there really is nothing worse than being ready to leave your shift and not having your relief show up. You start to consider whether to let patients continue to accumulate in the “to be seen rack” or risk picking up new patients and then staying hours late to finish them up. From a flow and quality point of view, having a doc not show up on time contributes to the ED clogging up and delays patient care. These are real administrative issues. After meeting with these chronically late docs, the best success I’ve had in changing behavior is to use a 360 degree evaluation. Ask docs to rate each other on five different things, including “shows up on time and ready to work.” Being rated poorly by your colleagues, even if the individual only shows up five minutes late on a regular basis, goes a long way. The caveat to successfully converting your doc from a late arrival to one who shows up on time is the conversation you have with them to discuss the results. You must remind the doc that it takes 6-12 months to change the perception in your colleagues mind and one of the best ways to do this is by coming in every shift 10 minutes early. Over time, I’ve seen reality and perceptions change with this technique. Of course, the PIP is still in your tool belt.

Conclusions
I was a second year attending when my vice-chair didn’t show up to relieve me from my shift. After half an hour, I called him and fortunately reached him as he was opening his first beer at a family picnic. He was apologetic and was at the hospital 30 minutes later. Forgetting about a shift can happen to anyone. But the department chair needs to address it to make sure it doesn’t happen again and always keep the PIP in mind for any type of repeat performance issue.

ABOUT THE AUTHOR

EXECUTIVE EDITOR
Dr. Silverman is a partner at Emergency Medicine Associates and is chairman of emergency medicine at the Virgina Hospital Center. He authors the Director's Corner each month in EPM. Dr. Silverman’s practical wisdom is now available in an easy-to-use reference guide. Order today on Amazon.

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