Managing Underperformers as a Physician Leader
Managing Underperformers as a Physician Leader
Nobody goes into medicine dreaming about the day they get to sit across from a colleague and say, "Your performance isn't meeting expectations." And yet, if you've stepped into any leadership role in academic medicine, that conversation is coming. Managing underperformers as a physician leader is one of the hardest parts of the job, and most of us received zero training for it.
I want to be honest: I struggled with this early on. I assumed that smart, credentialed people would self-correct. They rarely do.
Why Underperformance in Academic Medicine Is So Tricky
Academic physicians juggle clinical duties, teaching loads, research expectations, and institutional service. Underperformance academic medicine leaders encounter is rarely simple laziness. More often, it's a faculty member who excels in one domain while quietly falling behind in another.
A surgeon might be technically brilliant but perpetually late on peer reviews. A researcher might be publishing well but generating constant friction with trainees. The multi-dimensional nature of academic roles makes it easy to rationalize gaps and delay action.
As Dr. Lara Gallin noted in BMJ Leader, physician leaders often avoid performance conversations because they fear damaging collegial relationships with people they still depend on clinically. That tension is real, and ignoring it does not make it go away.
Diagnose Before You Prescribe
We would never treat a patient without a proper workup. The same principle applies here. Before you label someone an underperformer, do your homework.
- Clarify expectations. Were the performance standards explicit? Or were they assumed? Many faculty genuinely do not know what "good" looks like in every dimension of their role.
- Gather data. Look at clinical productivity numbers, teaching evaluations, publication records, and peer feedback. Impressions are not enough.
- Consider context. Has something changed? A new personal stressor, a shift in departmental resources, a role that no longer fits? Underperformance is often a symptom, not a diagnosis.
I once prepared for weeks to address a faculty member's declining clinical output, only to learn they had quietly absorbed an unfunded administrative burden from a departing colleague. The problem was structural, not individual.
Have the Conversation Earlier Than You Want To
Here is a pattern I see constantly in the chairs and division chiefs I coach: they wait too long. By the time they finally address underperformance, resentment has built on both sides, and the rest of the team has noticed the gap and drawn their own conclusions.
Early conversations are easier conversations. Frame them as collaborative, not punitive.
- Lead with curiosity. "I've noticed X. Help me understand what's going on."
- Be specific. Vague feedback like "you need to step it up" gives the person nothing to work with.
- Co-create a plan. What support do they need? What does success look like in 90 days?
Think of it like a coach pulling a player aside after the first quarter, not waiting until the team has already lost the game.
Build a System, Not Just a Reaction
If you are only addressing underperformance when it becomes a crisis, you do not have a performance management system. You have a fire drill.
Strong physician leaders build regular touchpoints into their leadership practice:
- Annual performance reviews with teeth. Not a checkbox exercise, but a real conversation tied to written expectations and development goals.
- Quarterly check-ins. Brief, informal, forward-looking. These normalize feedback so it does not feel like a summons when you need to deliver something harder.
- Transparent metrics. When everyone can see what success looks like, underperformance becomes self-evident rather than something you have to "catch."
When the Conversation Doesn't Work
Sometimes you do everything right and the person still does not improve. Academic medicine's tenure structures, clinical dependencies, and small-community dynamics make separation extraordinarily difficult.
But keeping a persistent underperformer in place sends a message to your entire team: standards are optional. That cost is invisible in the short term and devastating in the long term.
Document thoroughly. Involve HR early, not late. And recognize that managing someone out of a role, when done fairly, can be an act of leadership integrity, not cruelty.
You Were Not Trained for This, and That Is Okay
Most physician leaders inherited the role because they were excellent clinicians or researchers. Nobody handed you a playbook for managing underperformers in a department with competing priorities and limited resources.
That gap is not a personal failing. It is a systemic one, and it is exactly the kind of challenge that benefits from outside perspective.
Learn about coaching for departments.
Managing underperformers as a physician leader will never be comfortable. But with honest conversations and a willingness to act earlier than feels natural, it becomes manageable. Your team is watching. Make it count.
