Chapter 29. Best Practices in Physician Recruitment and Retention

Much has been made of the fact that the practice of Hospital Medicine has become the fastest growing specialty in the history of American medicine. Most experts agree that there are approximately 30,000 physicians practicing as hospitalists as of 2010. The Society of Hospital Medicine reports a membership of approximately 10,000. Yet even with the rapid increase in hospitalist supply, the demand remains even greater. Many believe the demand will reach 40,000 hospitalists in the next several years.

As a result, recruiting competition for hospitalists is fierce. Therefore, it is imperative that hospitalist practices maintain a high performance recruiting function as a core competency. Recruiting physicians requires a good understanding of human nature, a proven process and the discipline to apply that process to a large number of candidates. It is hardly an exact science, yet there are several important principles that must be applied. This chapter will attempt to provide employers with a basic understanding of these principles as well as some tips and suggestions to enhance their recruiting performance.

Many employers make the mistake of believing they are actively recruiting if they run a recruiting advertisement in medical journals or perhaps even if they have engaged a recruitment agency. In most cases, these are merely passive recruiting efforts. Actively trying to locate candidates through existing relationships and Internet recruiting will yield much better results. In the current competitive recruiting environment, it is critical that the employer have an aggressive candidate sourcing strategy.

Every good candidate sourcing strategy begins with the establishment of candidate parameters, including training requirements (MD, DO, internal medicine, family practice, etc). It is important for the employer to have a good understanding of their customer, the referring physicians, when establishing the candidate parameters. For example, the decision to hire family practice physicians as hospitalists should only be made with the approval of the referring medical staff.

The candidate sourcing plan should be thorough yet budget friendly. The following are all potential sources of candidates that should be considered by the employer.

Existing Medical Staff

Often, the best hospitalist that a hospital could hope to hire might already be on staff. Confidentially asking formal and informal medical staff leadership about who might be a good candidate could yield great low-cost results. Medical staff leadership will probably know which physicians are the best clinicians as well as who might be thinking about exploring a change in their practice situation.

Medical Staff Referrals

Hospitals must be intentional about asking existing medical staff members for referrals. Most physicians are so busy they will not take time to really think about colleagues who would be good hospitalists without frequent prompting. Of particular value are recent additions to the medical staff. Newly trained physicians will be aware of physicians coming behind them in the next graduating class and recently relocated experienced physicians will be aware of former colleagues that might be good candidates. Employers should approach these new members of the medical staff and intentionally “jog” their memory to uncover these referrals. Some employers offer a financial incentive for candidates hired as a result of a medical staff referral.

Other Local/Regional Hospitals

Recruiting physicians from other local hospitals can be very effective since these physicians have already made the decision to live in the area. If the hospital is a “friendly” competitor or a patient referral source, some political and/or business caution should be exercised. It is also advisable for the employer to be attentive to signs that the local competitors might also be recruiting their physicians.

Journal Advertising

This popular sourcing tool can produce candidates when used properly. Journal ads should be eye-catching and brief. No ad can provide enough information for a candidate to decide they want the job, but it can provide enough information for them to decide they do not want the job. The goal of any ad is to prompt the candidate to take action—either place a phone call or visit a Website to learn more. Some of the more popular journals for sourcing hospitalists include The Hospitalist (a publication of the Society of Hospital Medicine), Annals of Internal Medicine, and The Journal of the American Medical Association. The employer should also look for ways to leverage their journal ad investment. Many medical journals also offer online job boards. Often, job postings on these boards are discounted or free for employers who run print ads. In some cases, these boards are only accessible to employers who run print ads. Employers should evaluate the relative value of print ad vs Internet job postings and minimize their print investment (small black and white ad vs full page color) if they believe the online posting is more valuable.

Online Hospitalist Job Boards

Internet recruiting has dramatically changed the business of physician recruiting as many candidates now do most of their investigations online. These sites charge employers to post their ads. Some provide employers with CVs; others provide a more detailed candidate profile of those candidates visiting their site. The Society of Hospital Medicine has developed an excellent candidate sourcing tool with their Career Center at www.hospitalmedicine.org/careercenter. Other popular sites include www.hospitalistjobs.com and www.practicelink.com.

Direct Mail

Direct mail has long been used to source physician candidates with varying degrees of effectiveness. Employers choosing to use direct mail should purchase a very targeted mailing list and design a mailer to prompt the candidate to action. Since direct mail campaigns usually generate a very low return, an inexpensive and colorful postcard is usually the most cost-effective direct mail tool.

Career Fairs

Career fairs can be excellent sources of candidates for hospitals within a reasonable distance of the event. These sponsored events are designed to assist second and third year residents to get exposure to various employers. These fairs allow employers to begin the recruiting relationship with any given candidate “face to face.” To enhance the return on the investment in such a fair, employers can contact (via e-mail, phone, or postal mail) residents in the area and arrange to meet them at the fair.

Residency Program Relationships

Employers should establish relationships with all the residency programs in their region. Getting to know the program directors of all the programs within 200 miles can yield outstanding low-cost results. Offering to provide a noon lecture or some other resource to the program director can be an excellent way to begin to develop the relationship. Such events also provide excellent exposure to the residents. This exposure is valuable for future recruiting—even exposure to first and second year residents.

Recruitment Firms

Recruitment firms are only as good as the individual recruiter assigned to complete the assignment. Many employers choose to use recruitment firms to extend their reach on difficult-to-fill searches such as hospitalist positions. Contingency-based companies only charge a fee if they are successful. This is a risk-free approach but this financial relationship creates a candidate-focused recruiting effort. A contingency recruiter will locate a good marketable candidate and then “shop” him to a variety of potential employers. With no real obligation to the employer, recruiters are most likely to shop their candidates to their most attractive client locations, increasing their chances for a placement. Retained recruiting firms typically charge a monthly fee in return for monthly effort to fill the assignment. Retained firms rarely offer a guarantee of success, so the employer is taking the risk of making a significant investment without successfully hiring a candidate. Both types of firms can produce results, so it is important for employers to be very comfortable with the recruiter assigned to their search before they engage any recruiting firm.

In summary, a candidate sourcing plan is similar to an investment portfolio—diversity is good. Placing all the eggs in one basket is a high-risk approach to sourcing good candidates.

This section is focused on completely assessing the candidate prior to extending an invitation for an onsite interview. Onsite interviews are time consuming and expensive, so the employer should be reasonably certain that they will want to extend an offer to the candidate prior to inviting a candidate to the interview. This should minimize the possibility of learning something about the candidate during the onsite visit (once the time and money have already been invested) that eliminates them from consideration.

However, prior to assessing any candidates, it is highly advisable for the employer to assess their own practice. Only in knowing their own practice well can they determine what candidate characteristics will create the best opportunity for a good long term fit. What skills/training are required in this practice? How do the physicians communicate? What is the governance structure, a democracy or a dictatorship? Are there strict policies in place or do physicians work things out informally or “on the fly”? How much social time do the physicians spend together? Understanding these things about their own practice should enable the employer to recruit and retain a better candidate.

Accordingly every effort should be made to thoroughly assess the following aspects of each candidate prior to an onsite visit:

• Training and clinical skills: Be aware of any gaps in the candidate's training. Gaps can be unavoidable in many cases, but they can also indicate a problem. Most candidates will be able to provide a thorough explanation for any gaps in their coverage without difficulty. Employers should verify the candidate's explanation whenever possible. They should also verify that the candidate has the skills (such as procedural skills) required for the practice.
• Prior work experience: Discuss all prior work experiences with the candidate. Asking the candidate about the reasons for terminating each employment relationship can uncover a pattern of discontent or employer dissatisfaction. If the candidate has numerous previous jobs, constructing a timeline can be helpful to reveal any gaps or overlaps in their work experience, either of which will require further explanation/investigation.
• Communication skills: Good verbal communication skills are critical for a hospitalist. Many employers make the mistake of talking too much when assessing a candidate (as well as during an onsite visit). It is important for the employer to set the stage with a question, and then to get off the stage and allow the candidate to speak as long as they wish. The employer should make note of both the content of the answers, as well as the ease and comfort with which the answers are provided.
• Work ethic and workplace attitude: These are two of the more difficult candidate characteristics to evaluate, yet are among the most important to understand. Practices in which the physicians are mismatched in work ethic and workplace attitude are at the greatest risk of turmoil and turnover. The following are some questions that an employer can ask to help determine a candidate's work ethic and workplace attitude:
  • How many patients do you feel you can comfortably see in one day?
  • Describe a situation where you felt overworked.
  • How hard to you like to work?
  • When do you typically begin your workday?
  • Describe a time when you were asked to work overtime without compensation.
  • Describe any volunteer work that you have performed.
  • What personal gratification do you get from your work?
• Checking references: Unfortunately, the process of checking references has become less and less valuable. Most employers are afraid to say anything negative about the candidate for fear of legal recourse. As a result many have resorted to simply providing the dates of employment for the candidate and nothing more. Many residency program directors are hesitant to give a poor reference on a candidate because of the same legal concerns or perhaps because it would be a poor reflection on their program. As a result, they often prefer to only send a “To whom it may concern” form letter. When pressed, they will sometimes “rate” the candidate on a variety of topics. However, it is extremely rare for a program director to rate a candidate as “poor” in any category. The common practice seems to be rating the lesser candidates as “average.” However, unfortunately, checking references remains a required element of any recruiting process, so how can an employer benefit from such a potentially flawed process? Here are a few tips to enhance the referencing process:

  1. Ask for specific references. The employer should not simply rely on whomever the candidate decides to provide. The employer should always ask to speak with the candidate's supervisor or residency program director. Other potentially valuable references might come from the hospital administrator, a referring physician who has had patients cared for by the candidate, unit nurses who have worked with the candidate, and ED physicians who have worked with the candidate.

  2. Speak directly with the reference whenever possible. There is much to be gained from listening carefully when the reference is questioned. “Pregnant pauses” and voice inflections are absent from reference letters and forms, but can speak volumes about what that person believes about the candidate.

  3. Describe the practice. When speaking with a reference, the employer should describe their own practice and then ask how the candidate will perform in such a practice. The employer should not simply ask “yes or no” questions or only ask the reference to “rate” the candidate on a scale of 1 to 10. The employer should attempt to engage the reference in a meaningful dialogue about the candidate's strengths and weaknesses.

The employer should keep in mind that the goal of the referencing process is not to simply avoid a bad hire; the goal should be to determine whether the candidate can succeed in their practice and become a good long-term, productive member of the practice. The referencing process can be a valuable tool not only in the hiring process, but information uncovered in the referencing process can be valuable in managing the candidate once they are hired.

For most employers, the onsite visit/interview is when the practice leaders evaluate the candidate in order to determine if they will extend an offer of employment. However, in a high-performance recruiting process, the onsite visit will provide confirmation of an evaluation that has already been conducted. Only the final element of the candidate evaluation should be performed during the onsite visit, that is, a face-to-face confirmation of facts already reviewed. This approach allows the employer to focus on (what should be) the real goal of the onsite visit—convincing the candidate that they want this job!

This approach to recruiting is foreign to most employers but is best illustrated by considering how major universities recruit their star athletes. College coaches never invite anyone to visit their campus for official recruiting visits before they thoroughly examine them. A college coach will watch hours of game films of the prospective recruit. They will interview the candidate by phone. They will interview the recruit's high school coach, guidance counselor, and sometimes even their girlfriend! Only after they are convinced the athlete is someone they want to recruit do they invite them to campus for the official visit. During the visit, the recruit will briefly visit face-to-face with the head coach, and the rest of the visit is organized in such a way to convince the athlete that their athletic and academic goals can be achieved at that university.

When a physician candidate has “passed” the pre-interview assessment and there is a high likelihood that the candidate will receive an offer during the onsite, then (and only then) should the candidate be invited to an onsite visit. That visit should include the following elements:

• Ice-breaker event: Often a meal, coffee, or an open-house type of event is best for an ice breaker. The event should be casual and informal with plenty of opportunity for discussion.
• Business discussion: This is the time to review the financial elements of the position, including a review of the employment agreement. The employer should make sure the candidate has the opportunity to ask any questions about the financial arrangements including income, benefits, vacation, etc.
• Community introduction: This should be more than a simple community tour and should include introductions to key people in the community that might play a role in the candidate's life upon their relocation. For example, if the candidate has children of junior high school age, a drive by the junior high school would be nice. However, making an appointment for the candidate to meet the junior high school principal is much better!
• Time with future colleagues: Every onsite visit should provide time when the physicians can communicate with some of the other physicians in the practice about how the practice functions on a daily basis. The candidate should feel free to ask any questions they might have about practice operations.
• Hospital tour: A hospital tour should include some time with key hospital leaders, both physician and nonphysician leaders. For example, even a brief hello and handshake with the hospital CEO can convey a valuable message to the candidate that the hospitalist program is important to the hospital.
• Wrap-up discussion: The wrap-up discussion is perhaps the most important element of the onsite visit. This is the time to get the candidate's initial feedback from their visit and (most importantly) correct any false impressions that may have received. This is also time to directly ask the candidate if they want the job.

Here are some tips to keep in mind when planning a candidate visit.

1. Honesty is the best policy. Since no practice is perfect and no community is utopia, the employer should never try to hide any deficiencies from the candidate. However, employers should take care not to unduly overemphasize a potential concern. This can happen inadvertently when every person who speaks with the candidate mentions a negative aspect of the community. They are doing so with the best of intentions and the candidate's best interest at heart, but in so doing might give more weight to the concern than is warranted. One way to avoid this is to assign one person to mention this concern and make sure the entire interview team understands who will be doing so.

2. Control the agenda. The employer should control the agenda with every member of the interview team well prepared for their role. The interview team should be composed of the very best the practice has to offer. The employer should hand select this team and avoid placing chronic complainers on the team.

3. Always bring the candidate spouse. The employer must understand they are recruiting the entire family, not just the physician. Often the spouse represents more than 50% of the decision to accept or decline an offer. If the candidate cannot bring their spouse on the visit, every effort should be made to set a different date when they will be able to attend.

4. Avoid bringing the candidate's children. Encourage the candidate to leave their children at home if at all possible. One (or both) of the parents will be distracted at some point during the interview if the children attend. If the candidate insists in bringing the children, arrange for child care during the visit so the parents can focus on the visit.

5. Strive for a one visit process. If the preinterview assessment and the on-site visit is well structured and thorough, the employer should be prepared to complete the process with only one visit from the candidate. Many employers make the mistake of thinking if they like the candidate on the first interview, they can bring them back for a second visit. In the current recruiting environment, they may not get a chance at a second trip. They should prepare the candidate to make a decision after the first visit because…

6. Time kills all deals. The candidate will rarely be more excited about the job than immediately following the visit. Because the competition is tremendous and the candidate's opportunities are many, the employer must act with a sense of urgency. This means responding to candidate questions immediately and providing a sample agreement during the interview and an executable agreement immediately following the visit.

7. Expect the unexpected. The employer should be flexible enough to allow for unexpected and unavoidable changes to the interview agenda

Finally, it cannot be overemphasized that time kills all deals. It is critically important for employers to respond to candidate's questions and concerns in a very timely manner following the onsite visit. Every candidate should receive a follow-up phone call within a day or two of the visit.

When a candidate wants to negotiate one or more elements of the contract, the employer should implement “Big Picture Negotiations.” Both parties are best served when each can consider specific contract requests in light of all requested contract concessions. The employer should inform the candidate of this policy and instruct them to thoroughly review the employment agreement, and present all concerns/requests at one time. This approach will help the employer from making a significant concession without knowing if another significant request will follow. If the candidate presents a long, unreasonable list of contract requests, the employer should be honest with the candidate and ask them which, if any, of the requests are “deal breakers.” The employer should address these first, as it is very frustrating to work through a long list of relatively minor concerns only to see the deal fall apart at the end. These negotiations should always be conducted in an unemotional, businesslike manner. This will give the candidate confidence that the practice leaders handle difficult issues with professionalism.

One only needs to attempt to add up the total cost of physician turnover to understand the importance of good recruiting. “Getting it right the first time” is critically important in recruiting hospitalists. Consider the following scenario:

One of your hospitalists has just given notice that they will be leaving your practice in 120 days. What is the potential financial impact on your practice? The answer is found by adding up some (or all) of the sample expenses in Table 29-1.

The subtotal in Table 29-1 assumes the candidate is sourced, interviewed, signed, licensed, credentialed, and relocated all within 120 days in order to avoid any gap in physician coverage for your program. Depending on the desirability of your location and the availability of candidates interested in your location, this 120 days may be achievable. However, for many practices, 120 days is sadly only a dream. Some hospitals cannot even get hospital privileges granted in 120 days! If your remaining physicians cannot absorb the patient volume once their departing colleague is gone, the practice will be faced with locum tenens coverage that could cost up to $2,000 per day! For every month the position is unfilled, the practice must pay $60,000 in locums fees. It is easy to see how the $87,000 can quickly become $147,000 or $207,000. The cost of turnover is high! And this table does not even begin to try and calculate the cost of decreased collections (when locums docs are used or while the new doc is getting up to speed on the billing software, etc). Furthermore, losing an experienced hospitalist who has positive working relationships with your primary care physicians and a working knowledge of the hospital may further compound the financial impact and adversely affect the smooth functioning of the service.

The best protection against turnover is to recruit well the first time. Every practice should work really hard to make sure the candidate is a good fit for the practice during the recruitment phase of their relationship. However, every practice will experience turnover. Some more than others, but it will happen to everyone eventually. Here are a few tips to consider regarding retention:

1. Never stop recruiting your physicians! Hospitalists are too hard to come by, so never stop paying attention to the factors affecting their job satisfaction.

2. Create a work/life/compensation balance that makes sense and do everything possible to keep it in balance. If any one element of this three-sided scale is significantly out of balance with the other two for an extended period of time, turnover is inevitable.

3. Assign each new physician a mentor, a sort of big brother or big sister within the practice. This person should not only help the new physician navigate their new professional surroundings, but be available to advise the new physician on community issues such as neighborhoods, schools, and community resources.

4. Provide a physician feedback forum of some kind. Frustration will build when physicians feel like their issues are not being heard. They may not always get the answers they wanted, but fair-minded physicians will understand if they are at least allowed such a forum.

5. Use team-building exercises or events to avoid any one physician from feeling isolated within the group. Sometimes these can be social events and sometimes they might be professional retreats.

An understaffed hospitalist program will quickly become an unstable program with far-reaching consequences that are both clinical and financial. It is imperative that hospitalist programs become very proficient in recruiting the physicians they need to provide the outstanding care their patients deserve. Hopefully, this brief chapter will provide employers with an added nugget of advice that will help them improve the performance of their recruiting process.