The résumé was strong. The interview felt easy. You made the offer, exhaled, and told yourself the staffing gap was finally handled. Six weeks in, the familiar friction is back. Missed notes, a flat presence in team meetings, work that comes back needing a second pass. No single thing is wrong, and yet the fit is off. It is easy to file this under bad luck. There is a more useful way to see it. Who you hire is the first culture decision you make, and most small practices treat it as a seat to fill instead of a decision to design.

The therapist who left gave two weeks and a kind note. So did the one before her. You raised pay where the budget allowed, ran the team lunches, wrote the values on the wall, and the turnover kept coming anyway. At some point the math starts to feel personal, as if the problem must be you. It isn’t. Most of what looks like a people problem inside a small practice is a systems problem in disguise. The difference matters, because you cannot fix what you have named incorrectly.