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Strategies for recruiting and retaining top hospitalists

Hospitalist Management Advisor, May 1, 2007

Twenty tips from hospitalist leaders

Early this spring, Robert Bessler, MD, director of Sound Inpatient Physicians of Tacoma, WA, and a member of the Hospitalist Management Advisor editorial advisory board, joined with Aaron Gottesman, MD, director of the hospitalist program at Staten Island (NY) Hospital, to talk to hospitalists, hospitalist program directors, and other hospital executives about recruiting and retaining hospitalists during the HCPro audioconference “Best Practices for Recruiting and Retaining Top Hospitalists.” (Go to www.hcmarketplace.com/prod-4973.html for more information.) Following are 20 things they said can help you find and keep the best physicians.

Understand your turnover. Bessler said there is a difference between a hospitalist

who leaves so his or her spouse can pursue a job elsewhere and a hospitalist who leaves your program to join the hospitalist group across town. Whereas the former situation may be an ordinary occurrence, the latter may signal that something bad has happened. Knowing why people are leaving your program is key to figuring out whether your program is experiencing retention problems.

Know your potential pool of candidates. There are 122,000 physicians in internal medicine in this country, 85,000 of whom actually practice internal medicine. Of those, 62,000 are board certified. There were 6,400 residents who graduated from internal medicine residencies in 2006. “That’s your pool,” said Bessler. In some regions, there will be a tiny number available. For example, there are fewer than 300 internal medicine physicians in Montana, where Sound Inpatient Physicians has two hospitalist programs. If they want to grow their business in that state, they may have to find candidates outside of the state. California, on the other hand, has twice as many physicians as any other state.

Know your community. Your recruiters need to know about more than your hospital and hospitalist program. When Bessler’s recruiter starts seeking candidates for one of its 16 practices, he or she sets up a practice profile that includes information about everything from local schools, housing, and job prospects for spouses, to airport locations.

Put the entire practice on the recruiting team. Another reason why Sound Inpatient Physicians has been successful—they hire about seven hospitalists per month and have a low turnover rate—is that they get all of their team members involved in the recruiting process, said Bessler. The recruiter and all physician leaders screen candidates. When a candidate makes it past the initial screen and comes out for a visit, he or she spends the day with the entire team with which he or she will work.

However, if you use more than one person to sell the physician about your practice, make sure they all give the recruit the same information.

It is self-serving for everyone to be involved in en-

suring that the best person joins the team, he said. “If they are engaged and don’t view [recruiting] as someone else’s problem,” the team will be the better for it.

Present information first. Bessler said his recruiters have told him that they often feel like career counselors. Their first job is to answer questions about the opportunity, not sell the position—at least not at first. Present the opportunity and provide information first, he said.

Check more than the usual references. Along with the usual reference checks, Bessler said that his organization always checks nursing references. It also does a complete background check “so we don’t miss something important,” he said. These references give the hospitalist practice a complete picture of the recruit.

Use a variety of strategies to recruit. The Internet has transformed the way

practices recruit physicians, but there are some effective old-fashioned recruiting techniques your program should continue to employ. For example, don’t abandon traditional mailers, professional conventions, and meetings.

Don’t skimp on relocation costs. This isn’t the place to save money, Bessler advised. “You are asking people to move across the country.”

Beware of long delays. Bessler said his hospitalist practice has learned that the longer the time period between a job offer and an acceptance, the more likely it is that a candidate will say no. And if he or she says yes after a long period, there may be issues. It should raise a red flag.

Don’t rule out new blood. Gottesman said that although urban areas with large teaching hospitals have a larger pool of potential recruits than smaller communities, the tendency to recruit fresh graduates has pitfalls.

Novel approaches and points of view from people who have not been a part of your institution can be valuable, he said. You need to create a balance between people who have great inside knowledge of your facility, its policies, and its procedures, and the value of second opinions from those who have worked outside of your institution.

Bessler said he has taken over failing hospitalist programs in which one of the mistakes was hiring all of the local people in town to “do the things they have always done.” Although local people can provide instant credibility, it is important to also have people who can provide fresh eyes.

Know the pros and cons of your schedule model. A schedule based on rounding maximizes daytime coverage and minimizes volume surges, said Bessler. Continuity of care is good, but you have high relative value units (RVU) per full-time equivalent per year, a high number of days worked per year, and trouble getting weekend

coverage. The need to take call can lead to situations where someone has to be up and then work the next day.

“Then you are back to a 36-hour shift, like residency,” he said. If one of the hospitalists wants to take a day off, the volume for the remaining doctors increases. It can reach unacceptable volumes if two or more want or need a day off. And nevermind trying to schedule vacations.

Shift work provides predictability and has a great upside for both recruitment and retention. There is no call. There is reasonable continuity of care if there is a seven-on, seven-off schedule or some permutation of that. However, rigidity is a problem.

There also are issues with the switch day. Monday morning is common, but that is the worst day, said Bessler, as the hospital is often loaded with weekend patients who couldn’t get into long-term care or rehab facilities over the weekend. In addition, there are significant financial costs of covering nights, when there is much less revenue generated.

Review your compensation program. Gottesman said there are three formulas for compensation: pure productivity, pure salary, or a hybrid of the two. There are issues of concern with the former two.

In the first, physicians are encouraged to worry about RVUs, not necessarily quality. In addition, there isn’t any impetus for the physician to move the patient through the institution—the longer he or she is there, the more RVUs. In the second case, pure salary, physicians may think that they have to see only their set allocation of patients and may not be willing to stretch beyond that. There is no financial incentive for them to do so. Thus, a hybrid program is best.

But how you balance out the guaranteed salary and the part that is productivity-based will depend on a variety of factors. In general, you should try to keep the number of variables for getting a bonus small and ensure that they are measurable.

Remember the nonfinancial compensation. Don’t forget that compensation is more than just the money the physician is paid each month. Vacation time, how much the program pays for the physician’s continuing medical education, and other nonmonetary perks are also part of the compensation package, said Gottesman.

Don’t try to meet everyone’s needs. Bessler said no program can create incomes and lifestyles to meet the desires of all hospitalists. What is important is that you have a transparent program that gives hospitalists a clear and understandable path to reaching their bonus, and that the path is not complicated and involves measurable criteria. Make the measurement timely.

Bessler noted that his organization has done away with bonuses that cue up from the prior quarter. “If you worked hard in January because it is our busiest month, then on March 1, you will be rewarded for that,” he said.

Beware of survey data. There will always be someone who wants to quote a compensation number from a survey. There are many salary surveys out there, and they all differ. Gottesman said you should take the numbers with a grain of salt, don’t hang your hat on them, and understand their limitations.

Watch for burnout. Understand the potential for staff burnout, said Gottesman. If your hospitalists don’t feel that they have the ability to push back or argue against something with which they don’t agree; if they are attacked and abused, particularly by people whom they don’t view as having any authority over them; or if they feel powerless, they are in danger of burnout.

Keep in mind that burnout is more than a hospitalist seeing too many patients day after day. Burnout can also result from a hospitalist’s sense that he or she has lost autonomy, is viewed as a “super resident” rather than an attending physician, is not being given the opportunity to contribute, and does not feel part of the team.

Show appreciation. People never get tired of being appreciated, Gottesman noted. “There should be no sense that your bank account of ‘thank yous’ is depleted.” Many physicians feel grossly underappreciated. Your ability to let them know you appreciate their efforts will be rewarded. “People outside healthcare view us as having achieved something,” he said. But internally, this isn’t the case.

Pay attention to the needs of the group leader. In a 1999 article for the Harvard Business Review, authors Peter Frost and Sandra Robinson came up with the notion of the Toxic Handler—a person who runs interference between multiple stakeholders and often takes the heat from multiple sources about multiple issues. This is a critical role for an organization, but a difficult one to be in, particularly because there is little training that can prepare one for it, said Gottesman. Natural abilities will only carry one so far, he added. This person needs to be encouraged to find an outlet for any frustrations. “Don’t expect them to just suck it up,” he said.

Create a sense of ownership. Gottesman said one of the best ways to make something speak to a physician is to show them data. Give them information about their performance and the performance of the group. Make the information transparent. “Physicians respond well to this,” he said.

Be flexible, but stay within limits. Although flexibility is fundamental to the health of an organization, nothing can function if there are no standards. “Only flexibility and no standards create nothing but dysfunction and confusion,” said Gottesman.

Some flexibility is necessary, but you can’t bend over backward for every person, on every issue, every time. n

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