American College of Physicians: Internal Medicine — Doctors for Adults ®


Problems retaining physicians? Try these strategies

A little education and support at work and home can go a long way in keeping new recruits happy

From the February 2001 ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By Bryan Walpert

After five unhappy years in a specialty practice in Peoria, Ill., gastroenterologist Stephen P. Holland, ACP-ASIM Member, was fed up. He was tired of competing with his colleagues for patients. While the partners happily let Dr. Holland do consults for their patients, he said they didn't invite him stand in for higher-reimbursing procedures. They also didn't let him stay at any one hospital long enough to build business and prove himself productive.

So in December 1999, Dr. Holland left for the partner track at Christie Clinic, a multispecialty practice in Champaign, Ill. Today, his schedule is predictable, his bosses are appreciative, his coworkers are friendly and cooperative.

"I like being on a team where we're all part of the same system, working hard together to be successful," Dr. Holland said. That kind of working environment, he added, "is as important as getting fair reimbursement."

If you're planning to recruit physicians, persuading them to join your group is only half the battle. Experts say it is just as important to form strategies to keep them. A practice has a one-in-two chance of losing a new physician within six years, according to the Cecil G. Sheps Center for Health Services Research in the University of North Carolina, Chapel Hill.

Losing that physician is costly—to the tune of a quarter million dollars in recruitment costs and lost productivity, according to one study. While money is a factor in a physician's decision to stay, it often does not top the list.

"If physicians like the practice, feel good about contact with patients and get what they hoped out of daily work, their pay receives a lot less attention," said Donald Pathman, MD, associate professor and research director of family medicine at the Cecil G. Sheps Center.

Here are some strategies to help your practice retain the physicians it has:

  • Manage expectations. A group's retention program begins before a doctor signs on. The key: Set realistic expectations and avoid false promises.

    New physicians need to understand the implications of a compensation arrangement. For example, if the first-year guaranteed salary might give way to one that is production-based, be clear with new recruits, said Nelson A. Tilden, PhD, founder and partner of Medical Search Institute, a consulting and training firm in Shenandoah, Iowa, that focuses on recruitment and retention.

    You should also avoid misleading candidates with optimistic practice growth projections, he said. If you know that reimbursement rates or salaries will dip, don't hide it from recruits.

    "It may be a successful recruiting strategy, but it's the kiss of death for retention," said Dr. Pathman of the Cecil G. Sheps Center.

  • Educate recruits up front. Continue to manage expectations once new hires arrive. At Maryland Primary Care Physicians, a 40-physician group based in Millersville, new recruits attend a "business 101" meeting. Here they learn the formula for how they are paid—the connection, for example, between the overhead at their site and the number of patients they need to see to make the income they want, said Donald P. Buntz, chief executive officer.

    Retention is easier, Mr. Buntz said, "when people clearly know the expectations and have some control over the economics. It's not just some accountant coming up with a number."

  • Communicate both criticism and praise. Gary Matthews, president of Physicians HealthCare Advisors in Atlanta, has seen plenty of senior and associate physicians who don't get along. Often, difficulties arise because the older physician hasn't taken the time to explain what the associate is doing right or wrong. Mr. Matthews suggested an evaluation every six months.

    A little feedback goes a long way. Dr. Holland treated a patient who later told the clinic's chief financial officer how pleased he was with his care. The practice's financial officer quickly passed along the praise to Dr. Holland.

    "It's not just receiving feedback, but that it comes in a timely fashion," said Dr. Holland. "As good and bad things come up, I hear about them all."

  • Don't treat new physicians like second-class citizens. The worst mistake to make with new physicians is to "take advantage of them," said Christopher Kashnig, director of physician recruitment at Christie Clinic.

    Some practices take advantage through money. Paying high producers less than their fair share is a guaranteed way to provoke a quick exit. Mr. Kashnig recalls an ob/gyn who came to a group on a standard salary, but quickly produced twice that amount. Feeling his pay was inadequate, the physician left to start a practice across the street—and "beat them at the referral game," Mr. Kashnig said.

    Call schedule is another source of abuse. Some practices put new hires on a more frequent call schedule than the partners. This may be a traditional strategy, but it is likely to cause frustration and resentment.

    Fair treatment of new hires also extends to less tangible factors. Physicians who can attend monthly practice meetings, share in financial discussions and freely speak their minds—even if they don't yet have a vote—are more likely to stay.

    Donna Goldman, MD, a gastroenterologist and hepatologist, joined Northwest Gastroenterologists in Arlington Heights, Ill., in September 1998. The seven physicians share call equally. In addition, physicians who finish their work on time at one hospital take turns staying late to help colleagues with overflow patients at another.

    "The seven doctors in the practice work equal hours regardless of seniority," Dr. Goldman said. "That's a big plus. In some practices, the junior person gets dumped on. That's not the case here."

    Experts also suggest practices encourage new physicians to get involved in the community. For example, support their efforts to be active in both medical and nonmedical activities.

    Dr. Goldman, for example, said her colleagues support her attempts to promote hepatology. They have encouraged her to clear space in her schedule to give lectures and conduct grand rounds, to pursue a faculty appointment and to serve on the advisory board of the American Liver Foundation's local chapter. Moreover, when she gives lectures, they attend. And they defer to her judgment on protocols for patients with liver disease.

    "Working in an environment of mutual respect is more important than hours or call," Dr. Goldman said. "Your practice flourishes if you have all this support. Everything else is icing on the cake."

  • Help new physicians adapt. Young physicians fresh out of residency need assistance. "They start to see patients the in same way they were trained—typically in a university hospital setting, which differs greatly from a medical office," said Mr. Matthews of Physicians HealthCare Advisors.

    Problems with coding and other administrative issues can cause so much tension that new physicians simply leave in frustration. Consider sending new physicians a superbill to review before their first day on the job so they can become familiar with your practice's coding. Have new hires spend a few hours training with an administrator or coding specialist before seeing patients.

    Be prepared to spend some time with new physicians when they arrive. Don't immediately expect high productivity; such expectations lead to resentment, frustration and, possibly, departures.

    And don't wait too long to hire someone. "The older physician is burned out and really tired," Mr. Matthews said. "The young physician arrives and the senior physician takes a vacation for a month."

  • Create a mentor system. Senior physicians should take new recruits under their wing, said Dr. Tilden of Medical Search Institute.

    At Northwest Gastroenterologists, for example, new doctors partner with senior physicians for six-week rotations at the each of the three hospitals where the practice has privileges. "It helps us to establish the Northwest Gastroenterologists culture," said Stewart Gibbs, practice administrator.

    But mentoring doesn't have to be so formal. Take the new hire to breakfast or lunch from occasionally, or play golf together.

    "The mentor must have a commitment to maintain monthly contact for six months to a year," Dr. Tilden said. "It's just an organized way of ensuring that somebody is talking to the new physician."

  • Help the physician and spouse feel at home. Mentoring should extend beyond the practice's walls. If you're located in a small community, it's helpful to have people from outside the practice serve as mentors to the physician and his or her spouse.

    Heartland Health, a health system in St. Joseph, Mo. (population 72,000), created a program to recruit and retain physicians on its medical staff, both those who work for system-owned practices and those who work for independent community practices. Each volunteer couple on the retention committee-typically nonphysician professionals-"adopts" a new physician couple. For a year or two, they invite the couple to dinner and check in regularly.

    The "buddies" discover the interests of the physician's spouse. They also provide contacts for children to get involved sports and arts programs. "If the spouse is happy, that's at least half the battle," said Heidi Hornaday, medical staff development coordinator for Heartland Health.

    Heartland's "retention committee" also hosts a half dozen events each year for new physician families recruited in the past few years. Events have included miniature golf mixers, wine tastings, dinners, cookouts, cookie-decorating parties and museum and shopping trips.

    The goal is to create social structure for new hires. "When you have friends, you're able to overlook a lot of other things that may not be perfect," Ms. Hornaday said.

    Personal attention seems to work. In the late 1980s and early 1990s, Heartland lost a dozen or more of its physicians each year. Since starting the program in 1995, turnover has dropped to about five physicians a year.

    Personal attention doesn't go unnoticed. When Edward P. Kammerer, ACP-ASIM Associate, an internist with Specialists of Internal Medicine in St. Joseph, came straight to the eight-physician practice from residency in 1998, he ran into trouble buying a house. The bank insisted that Dr. Kammerer sign papers prior to closing, but he couldn't leave residency at the Mayo Clinic in time.

    He mentioned the problem to Ms. Hornaday at Heartland. After a health system official called the bank, the problem "mysteriously disappeared," he said, and the purchase went through.

    Two months later, he and his wife had a baby. Several physicians' wives brought meals for them. They showed the same hospitality when he and his wife had another child late last year.

    "My situation is very good," Dr. Kammerer said, citing the quality of his job, his coworkers and the friendly community. "If things remain the way they are now, I'll stay forever."

Bryan Walpert is a freelance writer in Denver.


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