As one of the first CEOs in healthcare to author his own blog, Paul Levy of Beth Israel Deaconess Medical Center has established a cult following with outspoken posts tackling the issues he faces as the top manager at one of the most influential hospitals in the country, writing on everything from insider debates over the publication of hospital mortality and infection rates to negotiations with labor organizers and the wise use of information technology. Today he tackles a delicate subject sure to provoke debate – and enthusiasm – on the THCB discussion boards …

Several years ago, before taking this job, I was asked to turn around a
relatively small clinical trials data processing company. I had to lay
off a number of people who were not critical to the company’s success,
and one of these included a doctor who had been hired to expand the
business into a certain area that we determined was no longer
appropriate. This was not a case of incompetence or lack of energy or
enthusiasm. He was great guy with terrific credentials, but we just
could not afford his particular expertise in that troubled little
company.Recently, we had a chance to meet, and he confessed to
me that my decision to lay him off had caused him to have a real crisis
of confidence. He had never been fired before and, as he put it, his
view of himself as a person and the job he did was one and inseparable.
Here, I had torn them apart, and it took him a while to remember and feel
that he was still as adept and valuable a physician as he had been
before he was fired. Indeed, he was able to thank me, years later, for
teaching him the important lesson that a particular job does not define
who he is.I replied to him that I thought that his initial
reaction explained to me why doctor-managers often find it difficult to
fire other doctors. They too quickly internalize how it would feel to
themselves to be fired, and they project this onto others. They
conclude that they cannot devalue the professional abilities of a
fellow physician by terminating his or her employment. They have
difficulty separating the business imperative from the degradation of
one’s self esteem.

(When I talk about safety and quality
improvement in public forums, I often refer to an aspect of this
problem. If you are a doctor, you have to assume that you are a good
doctor and that you are taking good care of your patients. How could
you live with yourself otherwise? You have devoted your life to this
calling, and you have spent years and years in training, and you often
live a lifestyle that is very demanding in service to your patients.
And yet, we need doctors to understand that they are often part of
systemic flaws in patient treatment that leads to death or injury.
Admitting that makes them no less able as physicians. Quite the
contrary.)

In the business world, personnel decisions have to be
made for the greater good of the organization — sometimes to save the
jobs of hundreds of other workers. Good managers do their best to help
employees who are not working out in a particular position by
mentoring, training, or offering other support. But every now and then
someone has to be fired. Notwithstanding that business imperative,
doctor-managers are often overly influenced by physicians’ view of
themselves. I have seen dozens of cases in which this leads to leaving
physicians in positions when the good of the organization demands
otherwise.

Oddly enough, many of us in other professions seem
more comfortable at being fired. In fact, we sometimes too easily tend
to blame the boss for our own flaws. In any event, we often move right
on to the next job, scarcely looking back. Maybe, too, that is why we
are more adept at firing people. We understand that a termination
notice is not necessarily a statement about a person’s inherent worth.
More often that not, it is just business.

I don’t want you to
read this and think that I am a person who enjoys firing people. Those
who have worked with me know otherwise. They also know, however, that
when the time comes to terminate someone’s employment — whether a
physician or otherwise — for the good of the majority in the
organization, I do not hesitate.