Your thriving practice is situated in a working-class neighborhood where many families still pay cash for your services. Soon after you learn that your most reliable chairside assistant is expecting her third child, she tells you that she must cease working because of pregnancy difficulties. You hire Marta, an experienced assistant who has moved to your town from another city. You attempt to assess her employment history, but this becomes impossible for a variety of reasons. She is a hard worker, and within a month or two she remembers each patient by name. Your receptionist even remarks that “the kids love her—they say she’s so gentle and so patient!”

About 3 months after Marta begins work, you notice that your petty cash envelope has only $50 of the usual $100 you always keep on hand. You replenish the funds, and when you check the envelope again in 2 weeks, you notice that money is again missing. You ask your receptionist whether the policy of maintaining petty cash has changed, and she looks back in disbelief as if you are implying that she is dishonest.

One attribute that sustains our reputation is trust. The ethical principles of fidelity (keeping one’s promises) and veracity (telling the truth) are the pillars of developing and sustaining trust among those around us. Reciprocally, we extend trust to our patients and to our staff. In the context of business management, our ability to identify employees who are trustworthy is as important as our assessment of their skill levels. When our trust in others is violated, our disappointment can be more damaging than even a costly financial loss.

A pioneer in the study of the sociology of crime was Professor Donald K. Cressey (1919-1987) of the University of California. Dr Cressey realized that most employees who commit dishonest acts have no intention of doing so when they are hired, nor are they career criminals. Rather, these people succumb to a trilogy of conditions that emerge in their workplace. Three essential conditions induce dishonesty and comprise Cressey’s “fraud triangle.”

The first leg of the triangle is pressure. This is defined as a “nonsharable financial need,” frequently with the objective of achieving and maintaining social status. Once the desired status appears to be too elusive to achieve by legitimate means, the offender resorts to dishonest acts. For example, consider a person who purchases an extravagant, prestigious car and finds that he cannot satisfy monthly payments by his own means. He therefore resorts to stealing from his employer.

The second leg of the triangle is rationalization. The offender rationalizes his behavior as justifiable in the set of circumstances that has evolved. The offender might feel entitled to the money he steals because he perceives that the employer has been stingy in salary increases or vacation pay, and hence that his illegitimate behavior is appropriate. The employee does not see himself as a criminal but, rather, as someone who is “just taking what I deserve.” He might consider his illicit behavior to be temporary or even plan to eventually replace the stolen funds.

The last leg of the triangle is opportunity. This is the ability of the offender to secretly commit the deed. The opportunity must be inconspicuous or secretive to avoid detection.

Cressey maintained that all 3 components of the triangle must be present to create employee dishonesty. He labeled employees who choose to become dishonest as “trust violators.” Although it is difficult for an employer to affect an employee’s sense of pressure or rationalization, employers can often limit the opportunity and decrease the temptation for violation of trust.

Your thoughts skip back to Marta, who could be embezzling cash from not only your petty cash envelope, but also your cash receipts. A prompt discussion is in order. Your words need be well chosen to avoid accusation, but you want her to know of your suspicion. And you hope your previously incredulous receptionist will concede to witnessing your ensuing discussion with Marta. You’ll need her there.