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10 recruiting tips to stay fully staffed in a tough market

From the February ACP-ASIM Observer, copyright © 2003 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

One solution to physician recruiting problems: physician assistants
Considering a locum? Try these tips

LAS VEGAS—How hard is it to recruit new physicians? According to physicians and practice administrators attending last fall's Medical Group Management Association (MGMA) meeting, it's very tough indeed.

When asked about their recruiting efforts, half the attendees indicated that their practice has been looking for a new physician for at least six months, while a quarter claimed they had been looking for a year.

"With malpractice pressures mounting in many states and demand outpacing supply, the search is getting harder than ever," said Joan M. Roediger, JD, a partner and health care attorney with Obermayer Rebmann Maxwell & Hippel LLP in Philadelphia.

While those factors certainly complicate recruiting efforts, Ms. Roediger said that recruiting can be a success. Here are steps she outlined to make the best of a tough situation:

1. Look at your staffing needs. Medical groups should assess their recruiting needs at least once a year. Do you want to open new offices or offer new services? Are any of your physicians talking about retiring or taking time off to spend with family? The sooner you spot looming recruitment needs, the earlier you can start seeking candidates.

Ms. Roediger suggested thinking about recruitment in early spring, when you can contact program directors about residents coming on the market in July. And have administrative staff keep credentialing applications on hand from all third-party payers and providers to speed the hiring process when you find the right recruit.

2. Define your ideal candidate early on. You can't recruit successfully until you know what kind of physician you need and why you're looking. As Ms. Roediger put it, "Are you looking for 'Dr. Right' or 'Dr. Right Now?' "

If you want to expand your number of full-time physicians, open a new location or offer a new service, "you need to be able to build that service from the ground up," Ms. Roediger said. "'Dr. Right' would be the way to go."

If, however, you are coping with the sudden death or illness of a partner, or if an associate has unexpectedly left or been terminated, time is more critical. Consider using a locum tenens physician to tide you over until you can recruit a permanent replacement. (See "Considering a locum? Try these tips.")

Make sure your time expectations are realistic. Finding a permanent recruit who's a good fit with your practice can take one to two years, Ms. Roediger said, while finding and hiring a good locum candidate typically takes three to six months.

And Ms. Roediger suggested one option to ease recruiting headaches: If your ideal candidate is the associate who plans to leave, use a retention bonus to try to convince that person to stay-or at least stick around a few more months to buy you some recruiting time. Ms. Roediger said she has seen practices offer key associates retention bonuses of $20,000 and more.

3. Know when to get help. You probably don't need a recruiter if you have ready access to a local academic center with your pick of graduates or you're offering a plum flextime position with no call.

But other practices should consider hiring a recruiting firm, Ms. Roediger said. "You can easily justify the cost when you factor in the time you'd spend beating the bushes to get candidates."

Financial considerations will certainly influence that decision, although Ms. Roediger claimed that recruiters' fees can be negotiated. She has seen a typical $35,000 fee talked down to $20,000.

Look for a firm that has experience recruiting for your specialty or type of practice. Find out if your position will be handled by a designated recruiter or by the firm's overall staff.

And negotiate a "make-good" provision in case something goes wrong. If the physician the firm finds you leaves within three months to a year, for example, "the second recruiting round should be on them," Ms. Roediger said.

4. "Sell" your practice. One thing recruiters can do for you—and you should do yourself, if you go it alone—is produce a brochure that promotes your practice and community. It should include a color picture of your practice if you have a nice office, and list all those factors—golf courses, theaters, schools—that make your community attractive.

Ms Roediger said you should make copies of the brochure available when group physicians attend medical meetings and hand them out to program directors and prospective candidates.

5. Cast a wide net. List openings with specialty societies and in professional journals. (You can also list job offers online at the College's Career Resource Center.)

Ms. Roediger also suggested advertising on at least one nonphysician Web site. "The Internet is where everybody—particularly young physicians—looks for jobs." She recommended www.monster.com, www.headhunter.net, www.hotjobs.com and http://careers.msn.com.

And if you face "insurmountable" recruiting problems because of liability insurance problems or a market controlled by a few stingy payers, aggressively courting physicians in local training programs may be your best bet. "By the time they finish residency, they often have developed ties to the local community," she said.

6. Screen candidates over the phone. You don't have to call every physician who sends you a resume. When you do call, use the phone interview to screen out candidates who won't be a good fit.

Be explicit, for instance, about the call schedule you'll expect associates to take, as well as the office schedule. "One of the most common mismatches occurs in practice styles," Ms. Roediger said. "Practices may be scheduling patients every 15 minutes or expect physicians to see a certain number of patients each day. That's something you need to spell out up front."

7. Offer the right salary and incentives. Salary is the single most important factor candidates look at when considering a position, so make sure yours is competitive. Ms. Roediger recommended using the MGMA's "Physician Compensation and Productivity Survey," keeping in mind that data are one to two years old and may need to be adjusted.

Guaranteed yearly bonuses are also hot, and most candidates expect them. If you're already guaranteeing a high salary, however, a bonus may not be warranted.

You should pay recruits' moving expenses, although you can set a limit. Ask them to get two estimates from local movers and pay within that range. Any extraordinary moving costs—like shipping an antique car collection—should be the candidate's responsibility.

Another key incentive, particularly for doctors finishing training, is signing bonuses. "They're all broke," Ms. Roediger said, "and that bonus is a huge carrot." (If you do offer a signing bonus, stipulate that they will have to pay back some portion if they leave within a year or two.)

Some groups also offer new associates help—or line up financial relief from a local hospital—to repay student loans.

And it is standard to offer at least two weeks' paid vacation a year, plus one week for CME; sick and family leave; and health coverage for the physician, if not for his or her family. Even if you don't offer family health coverage, consider extending it to a local candidate who won't incur high moving costs.

Malpractice coverage is another negotiating point, particularly if you live in a claims-made state or your practice has claims-made coverage. Ms. Roediger suggested that practices start by asking recruits to pay their own tail coverage, but recognize that they may have to compromise and split it 50/50 in a tight recruitment market.

Also negotiate who pays the tail coverage if associates leave or are fired. "If they leave or are fired for cause, it is not unreasonable to ask them to pay the tail," Ms. Roediger claimed. "Similarly, if they're fired without cause, you would then pay the tail insurance cost."

You need to verify candidates' state licensure and find out if they have any listings in the National Practitioner Data Bank. But Ms. Roediger does not recommend running a credit check unless a new associate will be handling the practice's finances. "A lot of young physicians will be offended by it," she said.

8. Send a letter of intent. Once you've identified your top candidates, Ms. Roediger advised sending them each a nonbinding letter of intent to sign.

What's the advantage of such a letter? "It doesn't distract candidates the way a 20-page employment agreement can," she said. And if you're pursuing several candidates, you can gauge their interest levels by whether or not they sign and return the document.

The letter should spell out succinctly—usually with bulleted points—key aspects of your offer such as salary, bonus, restrictive covenants and partnership options. The letter can also help head off last-minute negotiating snafus.

"If they've signed a letter of intent that says your practice is prepared to pay $125,000, it makes it harder for them to ask for more money later," Ms. Roediger said.

9. List details in an employment agreement. When you find the right candidate, use an employment agreement to spell out the physician's base salary plus yearly salary increases, bonus opportunities, termination procedures (including a "terminate without cause" clause), benefits, partnership and confidentiality details, a schedule of evaluations and business expense coverage.

Most agreements also include a restrictive covenant, but Ms. Roediger warned that courts have started to overturn far-reaching covenants. Before crafting a covenant, she suggested, have your computer system identify the zip codes where most of your patients live and protect those areas in your agreement.

"When your practice is in a metropolitan area and has a covenant with a 100-mile radius or a 10-county area, a court most likely won't enforce it," she said. "They'll start to ratchet it down, and you won't know where they'll stop." Plus, contracts with over-reaching restrictive covenants may scare off your best candidates.

10. Beware of contract pitfalls. Watch out for contract language that could ruin the deal, especially if the candidate will have his or her attorney review the agreement. Make sure the agreement includes such candidate-friendly items as a pro-rated schedule for paying back a signing bonus and salary increases for subsequent years.

Have a senior physician, not an attorney, explain sensitive areas of the agreement, such as the reason for protecting zip codes in a restrictive covenant.

And never let your practice's attorney—or a physician partner—adopt a "take it or leave it" negotiating stance, which can kill the deal for candidates who may have many other options. By the same token, if candidates you're considering reveal a rigid personality or inappropriately demanding behavior during negotiations, think twice about signing them on.

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One solution to physician recruiting problems: physician assistants

In the shrinking physician pool, cardiology is one of the hardest subspecialties to recruit. According to Andrew Ross, MD, a cardiologist with Western Piedmont Heart Centers in Hickory, N.C., it can cost a practice up to $800,000 to recruit a new cardiologist.

"That assumes a first-year salary of $250,000 for a general cardiologist to $400,000 for a good interventionalist," Dr. Ross said. "You'll give them any amount of money, if you can find them."

With training programs annually turning out less than 700 cardiology fellows and nearly 8% of practicing cardiologists retiring each year, Dr. Ross said the specialty has been slammed with a significant physician shortage.

His group has gone a long way to solve its manpower problems by hiring physician assistants trained to work in cardiology, Dr. Ross told attendees at the Medical Group Management Association's annual meeting last fall. The booming Western Piedmont practice—which has three sites and runs two full-time hospital-based cath labs—is now staffed by 10 cardiologists and five physician assistants (PAs).

The physician assistants are integrated into all levels of the practice, he pointed out. PAs, for instance, run the clinics for arrhythmia, congestive heart failure, coumadin, lipids and wellness that feed the group's diagnostic testing and interventional procedures.

Physician assistants are just as important in the hospital. They do rounds, triage cardiology cases in the emergency department, take patient histories, perform physicals, order laboratory and diagnostic tests, give physicians patient data and get patients quickly to the cath lab if they need to be there.

PAs also discharge most patients, write discharge summaries, take call and do patient follow-up in the office. Using their own provider identification numbers, they bill (at 85% of the physicians' fee schedule) for the hospital consult, history and physical, and discharge. Their office follow-ups are billed as incident-to encounters.

Dr. Ross noted that Western Piedmont is trying to give some physician assistants an even bigger role: assisting in the cath lab. The practice is now trying to credential PAs to prepare patients for catheterization, insert sheaths, close the femoral site and follow patients for complications.

"We're certainly testing the threshold of physician assistant use," Dr. Ross explained. "In North Carolina you can push that boundary fairly far." Other states, he pointed out, have more restrictions. PAs in Indiana, Ohio and Louisiana, for example, are not permitted to write prescriptions.

When the practice hires a physician assistant, Dr. Ross said it can take up to a year for both the PA and the physician to reach the level of comfort needed to start assigning patient responsibilities.

And when the practice first began working with PAs in 1998, Dr. Ross added, it faced some minor hurdles. Some referring physicians, for instance, worried that patients might experience lapses in continuity of care. But patient satisfaction has been very high, Dr. Ross said, because the PAs have worked effectively as liaisons with hospital medical staff and the larger community.

Each physician assistant brings in as much as $700,000 a year in practice revenues, Dr. Ross estimated. "Even more importantly, the cardiologists need them in order to maintain our own level of billing," he said. "They free us up to focus on more complex patients."

And it is much cheaper to recruit a physician assistant than a cardiologist, he said. Recruiting costs for a physician assistant—including first-year salary—run less than $100,000. But there is one wrinkle: Competition for the few physician assistants who are trained in cardiology is becoming increasingly fierce.

"It may be cheaper to recruit PAs than cardiologists," Dr. Ross said, "but we now have the same kind of trouble finding them."

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Considering a locum? Try these tips

Joan M. Roediger, JD, a health care attorney in Philadelphia, said that practices should consider using locum tenens physicians to deal with short-term needs, such as when a partner takes an unexpected leave or an associate suddenly quits. Here are tips she gave for recruiting a locum physician:

  • Shop around among locum agencies to get the best terms, and negotiate daily locum fees. Change any "payment due on demand" language in an agency contract to "net 30 days" to avoid late fees.

  • Expect to pay locums' housing costs while they're working for you and their travel expenses when they interview. But be specific about what travel expenses you'll pay for, Ms. Roediger warned. Stipulate "coach" class, or offer to make their travel arrangements yourself.

  • Have the locum agency screen physicians' references and look for possible Medicare compliance violations. Ask if the agency will help with candidates' credentialing, although Ms. Roediger said practices should be prepared to do it themselves.

    Tell your hospital that a locum candidate will need temporary staff privileges. And see if the hospital is willing to pay some of the locum's daily fees, especially if you have a big inpatient practice.

  • While you should shop around among agencies, Ms. Roediger cautioned against using multiple sources. It's hard to track which agency sent you whom, she said—which can come back to haunt you if you end up hiring someone a locum agency once sent as a candidate.

    When interviewing locum physicians (or prospective full timers sent by recruiters), keep a written record of the candidates you see. Locum agencies typically prohibit practices from independently hiring a candidate for up to two years-and may try to levy hiring penalties as high as $35,000 if you do.

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