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Hold on to your hospitalists

Expert advice on improving retention

From the October ACP Hospitalist, copyright © 2009 by the American College of Physicians

By Stacey Butterfield

Gwinnett Medical Center in Atlanta may not look much like a battlefield, but hospitalist program director Martin L. Austin, ACP Member, sees similarities.

“It’s like in the army. They say people don’t risk their lives because they want to save their country; they risk their lives because they want to save their buddy in the foxhole,” he said.

Hold on to your hospitalists

His physicians may be assaulted by admissions and lab results instead of an attacking army, but the sense of teamwork is the same, Dr. Austin said. At least in part due to that group cohesion, he has lost only one hospitalist from his force in the past 10 years.

It’s a remarkable retention rate for a hospitalist program. Accurate retention statistics are hard to come by, but the Society of Hospital Medicine’s 2005-2006 annual survey calculated a median annual turnover rate of 9%, and other estimates have gone as high as 20%.

Yet Dr. Austin’s program has grown from five hospitalists in 1999 to 17 physicians and six nurse practitioners (NPs) today, losing only one doctor and one NP along the way. There aren’t any surefire ways for other hospitalist programs to copy that level of success, but Dr. Austin and others do have some tips for hospitalist leaders looking to improve retention.

The nature of hospitalists

A certain amount of turnover is inherent to the specialty, the experts noted. According to John R. Nelson, FACP, medical director of the hospitalist program at Overlake Hospital in Bellevue, Wash., the relevant analogy is love rather than war.

“For many hospitalists this work is more like dating than marriage. You always have your eye on other possibilities when you’re a hospitalist,” he said. A certain subset of hospitalists enters the field with plans to leave for a subspecialty, while others are lured from a practice by some other means.

“There’s a lot of money chasing hospitalists right now. Supply and demand are out of whack. Someone else is going to make them an offer,” said Richard A. Sheff, MD, chairman of the Greeley Company, a health care consulting group.

Compensation is a major factor in retaining hospitalists and attracting the kind that are going to stick around, according to Dr. Austin. Hospitalists need to convey the importance of retention to the people making budget decisions.

“The administration has to really think that there’s value in having good people. We convinced them that if you have a person who’s been there for 10 years and really knows the system, it’s very expensive to replace that person,” said Dr. Austin. He credits his program’s generous compensation with helping hold on to hospitalists and easily recruit new ones when needed.

Start early

Compensation helps, but hospitalist leaders with shallower pockets can take heart in recent statistics showing that money isn’t everything. According to a 2006 retention survey by the American Medical Group Association and Cejka Search, 32% of physicians who left their jobs were seeking higher compensation, but 51% were departing because of poor cultural fit.

Cultural fit is one of the reasons that retention efforts should begin with recruitment, said Kenneth G. Simone, DO, president of Hospitalist and Practice Solutions, a consulting company.

Before even interviewing candidates, program leaders should think hard about their own practice culture, advised Kirk Mathews, CEO of Inpatient Management, a hospitalist management company. Ask yourself: “Is it a democracy or a dictatorship? Is it a practice that places a high value on social interactions away from work settings?”

Specific efforts can be made to bring in physicians who will change a practice culture, but for the most part, hospitalists who don’t fit with the existing dynamic will be more likely to leave. “If you’ve recruited someone in who really is a rule follower and wants to know all the rules and your culture is very loosely governed, then that person’s going to feel frustrated,” Mr. Mathews said.

Interviewees should also be given a clear definition of their potential role and responsibilities within the program. “Be positive, but reality-based,” suggested Dr. Simone. “If you provide a false picture to attract a candidate, it may lead to job dissatisfaction, negative or disruptive behaviors, and turnover for the candidate as well as other providers.”

Potential hires should also be encouraged to consider how their families will fit into the practice and the community. A hospitalist who would have to uproot a happily settled spouse and children is less likely to grab at a new job opportunity. Ideally, the hospitalist’s family should come along on an interview visit to see how the area suits them. “Maybe they have special educational needs. Maybe they have religious requirements,” said Mr. Mathews.

The buddy system

That community integration process can continue after hiring, through a buddy or mentorship program, Mr. Mathews suggested. The more tenured physician can help the newbie with everything from how to get lab results to where to find the best restaurants. Mentorship can also alleviate the disappointment hospitalists may feel after the wining and dining of recruitment ends, said Dr. Simone.

Formal check-ins between the new hospitalist and a practice leader should also happen frequently during the first year. “At 30 days, at 90 days, at 180 days, you’re back speaking with the physician about what they signed up for,” said Brian McCartie, vice president of business development for Cejka Search.

If the hospitalist has developed a problem over one of the intervals, he or she is more likely to stick around if there’s a means to correct or at least express the issue. “You want to make sure they feel like they have a voice in many things,” said Dr. Nelson. “They can’t vote themselves a raise, for example, but you want the hospitalists to have autonomy to maybe change the way compensation is paid out, how their schedule works, all kinds of things like that.”

The opportunity for input can be formal or informal, according to Mr. Mathews. He offered examples. “One day a week we’re going to have lunch together and discuss issues. It can be a much more formal process where you have a subset of the group which is charged with being a liaison to practice management. I should have the ability to go to my liaison committee member and say, ‘This is sticking in my craw. Can we change it?’“

The chance to change aspects of the practice will build a sense of ownership in your hospitalists and make them less likely to adopt a shiftworker mentality, Dr. Nelson said. “You want them to see themselves as owners in the success or failure of their enterprise.”

Part of the hospital

Hospitalists may also feel more ownership of their program if they have the opportunity to represent it on visible committees, “not just the low-level committees doing grunt work, but elected positions like chief of medicine,” said Dr. Nelson. “When you are elected to a position of authority, you start to believe we are valued here.”

Other methods for the hospital to recognize a hospitalist’s value include giving out awards or putting a photo of a hospitalist on the cover of marketing materials. But committee work fulfills other retention-related goals, such as integrating the hospitalists with the rest of the medical staff.

“I’ve been to places where there’s a free lunch in the doctors’ lounge and generally the doctors hang out there and visit, but the hospitalists run in and get food in a to-go container and all run back and eat it together in their own office,” said Dr. Nelson. Such social gatherings are opportunities for hospitalists to build relationships and gain respect from other physicians on staff, he noted.

Eating lunch came up surprisingly often in hospitalist leaders’ advice on retention. Mr. Mathews described one practice’s unifying strategy. “They eat lunch together every day. If Dr. Jones is tied up with a patient, the rest will try and wait if they can. There’s something about breaking bread together that really brings people together,” he said.

If lunch is good, dinner may be even better. Dr. Nelson’s hospital takes his group out to a swanky restaurant every so often, but Dr. Austin’s group organizes dinner more informally. “We have a lot of people from foreign countries, so we’ll do an ethnic dinner. Somebody who’s Korean will find the best Korean restaurant,” he said.

The hospitalist group also gets together to recognize when one of their own has done something special. For example, Dr. Austin’s physicians all chipped in for a plaque and a gift certificate to thank one member for designing new office space and online order forms.

Building a team

Although every program might want that kind of organic team spirit, it’s not always present. If it isn’t there, it may be possible to create it with mandatory team-building activities.

“Dedicating one day or one weekend each year for a hospitalist practice retreat is very effective,” said Dr. Simone. The retreat could include other members of the hospital staff and/or a team-building consultant.

Mr. Mathews was a little more ambivalent about taking physicians off-site for traditional corporate team-building. “Those can work with the right mix of physicians, but they’re a little more forced,” he said. Both experts noted that formal team-building can be difficult to fit into the busy schedule of a hospitalist practice.

Everyone has time for a quick meeting, though. Mr. Mathews recommends a group meeting every morning. “It’s a quick review of the patient load and expectations for the day, so that everybody generally has a sense of what other people are doing,” he noted. The meeting reinforces the sense of being a team and makes it harder for a hospitalist to feel like he is doing more or more difficult work than his colleagues.

Professional development activities can also give hospitalists a chance to bond with their colleagues and build loyalty to a program. “Whether it’s journal clubs or in-service training by specialists, those are all part,” said Dr. Sheff.

These activities can also contribute to hospitalists’ sense of identification with their field, which may currently be lacking. “Some physicians are seeing a [hospitalist] career path as being nothing more than a glorified resident,” Dr. Sheff said.

The novelty and lack of understanding about the hospitalist track may be two of the main causes of high turnover, according to Mr. Mathews. “It is a young specialty. In fact, it’s not a bona fide medical specialty yet. It remains a job description today.”

The good news is he predicts a change. “I really do think that turnover will settle down some as the specialty matures and people have a greater understanding of what to expect when they take a hospitalist job,” Mr. Mathews said.

In the meantime, he and the other experts recommend that hospitalist leaders start thinking about retention at the moment of recruitment, and do what they can to make their programs engaging, enriching places for physicians to practice. And try not to take it personally when a hospitalist, especially a young one, leaves despite those efforts.

“There is no utopia anywhere, but younger physicians are usually less aware of that fact and see greener grass someplace,” said Mr. Mathews.

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What helps?

  • Mentoring new hires
  • Scheduling formal check-ins
  • Soliciting feedback
  • Recognizing achievements

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