Recruiting: How Long Will You Be Staying?

Her interview with the physicians in the practice she wished to join was going well, and J. Summer Liston felt confident. The family and internal medicine practice met all the criteria set by this young doctor about to complete her residency: It was in Michigan, where both she and her husband grew up; the physicians were willing to allow her to continue practicing obstetrics; and she would be able to work with medical students through the practice’s affiliation with a local medical school.

Then one of the interviewers remarked to Liston, “We’re really looking for a physician who could spend his or her lifetime of practice with us.”

The comment left her searching for an appropriate response. “I felt challenged by that,” she says. “And then one of the practice’s physicians commented on how a lot of young physicians leave a practice within three years, and he asked me if I saw myself doing that. I certainly could respond that I did not see myself having that short-term of a plan, but I could never be certain what the future held, and so I felt sort of stuck.”

Liston, a freshly minted family physician launching her career at age 28, had reason to pause. Physicians are most likely to leave a practice within three years of starting, according to the 2006 Physician Retention Survey conducted by the Alexandria, Va.-based American Medical Group Association (AMGA) and the St. Louis-based physician recruiting firm Cejka Search.

But the survey also found that doctors right out of residency accounted for only 9 percent of physician turnover. Fifty-seven percent were physicians with six or more years of practice experience, and 34 percent had been practicing from one to five years.

Indeed, the survey found no strong correlation between the length of physicians’ tenure with a group and their likelihood of leaving. 

It was not her youth that should have concerned Liston’s potential new employers (with whom she now practices). According to experts, the most important factors practices should consider when evaluating potential new hires include doctors’ “cultural fit” with a practice, the quality of life that a practice affords its physicians and their families, and work schedule flexibility.

“Compensation and a desirable work schedule are typically discussed in great detail during recruitment,” says Joseph Scopelliti, president of the 225-physician Guthrie Clinic in Sayre, Pa. “There’s a generation of physicians who have been graduating from medical school for a long time - 10 years or maybe even more - and they have a different set of expectations. … They want more structured work schedules, more flexibility in accommodating personal and family needs, and they expect that an organization like ours will accommodate those individual needs.”

Due to widespread physician shortages, doctors of all ages have more bargaining power now than ever before. “Candidates have a choice today,” says Carol Westfall, president of Cejka Search. “I can’t think of candidates who aren’t choosing among opportunities.”

New priorities

Regardless of a practice’s size, losing a physician can cost big. Recruiting a new hire is taking an increasing amount of time and money. Scopelliti also cites the “loss of value in patient satisfaction and loyalty” when a doctor leaves a group. Typically, administrative disruptions also occur, as physicians are often responsible for a specific program or department within a practice. “That’s why we spend so much time on retention,” explains Scopelliti. “We don’t want to have to deal with that if we can help it.”

But before a practice works to retain its physicians, it must first hire them. Neglecting to put the time and effort into hiring the “right” type of person for your specific practice will likely have you searching again before long. “Sometimes practices are in such dire need for a particular specialty that when they find a particular physician who expresses interest, they are so excited, they jump on it, and may take some shortcuts in terms of the screening and the interviewing,” says Westfall.

Although she is happy with the practice she chose to join in 2003, Dawn Buckingham, an ophthalmologist and oculoplastic surgeon, says recruiting is generally not a strong suit among physicians. “Most doctors don’t have interviewing techniques,” she says. “They aren’t very good at it. You sort of sit there without them knowing what to say.”

Like Liston, Buckingham found that her current practice was interested in her staying power. “I think they want to know two things,” she says. “Most groups are interested in someone who is going to work with them long term, and they want to know if you have a personality that will mesh with the other doctors.”

AMGA and Cejka Search’s annual survey - compiled from the input of 92 AMGA respondents, whose groups collectively employ approximately 17,000 physicians - indicates that practices may need some help in both of the areas Buckingham identifies. The 2006 Physician Retention Survey revealed a physician turnover rate of 6.7 percent, up slightly from the 6.4 percent rate it found in 2005.

Survey respondents were asked to report the most frequently mentioned reasons departing physicians gave upon leaving a practice. “Poor cultural fit with the practice” topped the charts at 51 percent. A desire for higher compensation was cited 32 percent of the time, and “incompatible work schedule” and “excessive call requirements” were each mentioned 17 percent of the time.

And it appears that practices must strive to accommodate the needs of physicians’ families as well. Forty-two percent of physician respondents said that contributing to their decision to leave was a wish “to be closer to [their] own or [their] spouse’s family.” Twenty-two percent said their move was necessitated by their “spouse’s required job relocation.” Twenty percent said that “relocating to find a better community fit” contributed to their choice.

Recruiting for life

None of this is news to Jennifer Grebenschikoff, vice president of the Tampa, Fla.-based Physician Executive Management Center, a physician executive search firm. Grebenschikoff teaches part of a course called Managing Physician Performance offered by the American College of Physician Executives. While most of the course is devoted to changing the undesirable behaviors of physicians already employed by practice heads, Grebenschikoff tells physician executives that they wouldn’t be there in the first place if they had “brought in the right people” to begin with.

She says that effectively recruiting and retaining the physicians best suited to specific practices should begin long before candidates are invited into a practice for an interview. She advises groups to carefully examine each candidate’s credentials and to ask themselves, “Does this person meet on paper the goals that we set out in our job description?”

The Guthrie Clinic exemplifies this advice in its recruitment efforts. “Using an employment application, we obtain references, and we do as much background checking on a candidate as we can before we schedule an interview.” Scopelliti explains. “The idea is that, one, we want to understand and know the person so that if we think they are a good fit we can modify or customize the interview by covering the important items for the candidate and his or her family. The second part is that we spend a little time working on what their family needs are - spouse, children, cultural, religious, whatever items that are out there that are unique; we want to make sure that we incorporate those items into the interview day.”

Grebenschikoff recommends that when interviewing a candidate, physicians use behavioral interviewing techniques that employ open-ended questioning. She says a candidate’s responses to such questions can shed considerable light on his potential for success within a specific practice: “They focus on getting the candidate to talk about how he or she has done work in the past rather than where the work was done,” explains Grebenschikoff. “The idea here is that success in the past predicts success in the future. And so when you ask people questions, you want those questions to be very open-ended; you don’t want to bury the answer to the question in the question itself.”

Examples of this type of interviewing Grebenschikoff gives include: “Tell me about the last time you had a major conflict with a patient. How did you resolve it? Tell me about the kinds of complaints and compliments you usually get in your practice. Tell me about an area of practice that’s particularly challenging for you.” A handout that Grebenschikoff distributes to her students is copied below.

Westfall adds that customizing behavioral interviewing can help a practice determine whether job candidates are good cultural fits for their specific group. For example, says Westfall, if your practice is particularly concerned about staff relations, she suggests asking, “Can you describe for me a time when you provided recognition to a staff member?” It’s a simple question, but Westfall says the response can be revealing. If the candidate has trouble answering, that may tell you something. But if the candidate readily recounts performing simple gestures such as bringing in doughnuts for a receptionist’s birthday or rewarding front-desk staff with pizza after a particularly long day, that tells you something as well.

Grebenschikoff says that each time she teaches this course (offered several times each year), she is faced with “60 to 70 people in the room who’ve never heard of what I’m talking about.” She says she fields “loads of questions” about how to do reference checks, conduct telephone interviews, and best present a practice to a desirable candidate, leading her to agree with Buckingham that, for one reason or another, interviewing does not come easy to physician employers.

Liston says that when she interviewed with her current employer, Marshall Internal and Family Medicine in Michigan, she was invited to a dinner that included two of the practice’s physicians and its practice manager. She fielded questions about her criteria for a desirable workplace, and she was asked to justify why the practice should hire her over a more experienced physician. She says the collegiality of her future coworkers impressed her, and she felt that the group was a good fit for her personality.

Buckingham had a different experience. She says the physicians who interviewed her (now her current partners) were awkward and seemed not to know what to ask her. But she adds that she detected their efforts to determine whether she would “be a good cultural fit with them,” as they did pose open-ended questions about her past dealings with patients and physicians. It was a clear choice for Buckingham, who says she “pestered” the senior partner while he was her residency director until he agreed to hire her. “It was an easy fit,” says Buckingham. “I liked everybody in the group.”

You’re hired! Now what?

Experts emphasize that practices must maintain active retention efforts during the “initial critical period” of a new physician’s tenure at a group, which they say can range from the first six months to the first three years.

Some groups are better at this than others. “Some organizations have a one-day formal orientation, and that’s it,” says Grebenschikoff. “Here’s where you park, here’s where your locker is, and you’re on your own.”

Buckingham’s “orientation” essentially reflects the “baptism by fire” approach that Grebenschikoff describes. “It was pretty much sink or swim,” she recalls. “I showed up, and they were like, ‘All right. You’re here. Good deal. Now go to work.’” She says she didn’t mind having her independence thrust upon her, but today she says she makes an effort to offer personal help to new hires if she detects that they need assistance.

Liston, who was finishing up her residency at Oregon Health Sciences University in Portland when she received her job offer in Michigan, got a bit more hand-holding. She says that her new colleagues both welcomed and challenged her before her arrival. She recalls that when she was in town one day, a physician at the practice “went above and beyond to invite me to lunch and really make me feel part of the group.” At other times, she was invited to shadow her future colleagues during clinic hours. And the group’s administrative staff assisted her with her credentialing process and payer enrollment paperwork.

Grebenschikoff teaches her physician students to go beyond these efforts once an offer of employment has been extended and accepted. At the very least, she says, someone in the group should create a calendar that meets the incoming physician’s needs well before the first day of work.

“So if it’s going to be six months before the physician gets here, there should be someone in the organization calling the candidate maybe every three weeks or so, asking, ‘How’s it going? Can we help you with anything? How’s the move going?’ Whatever it is. Just stay in touch so the candidate knows there’s a strong continuing interest in the candidate and the family.”

It’s also essential to bring a new employee into the practice’s “information loop” as soon as possible. Grebenschikoff suggests putting new hires on your group’s internal newsletter mailing list and purchasing for them subscriptions to your local newspaper to help them and their families get acquainted with their new hometown. These gestures don’t require much time or money, but they can make a world of difference to a family that’s relocating.

Other inexpensive gestures that can help an incoming physician feel part of the team before reporting to work include printing up and sending newly hired physicians their business cards before they arrive, says Grebenschikoff. Adding new hires to a group’s internal e-mail list can keep them apprised of news coming out of the practice. And sending them the IT tools (such as PDAs or laptops) they will be expected to use can help them become familiar with the technology before they join the office.

Finally, Grebenschikoff says that facilitating the move itself is essential. She recommends helping the physician’s family find a realtor, identify temporary living space if necessary, and provide assistance in acquiring admitting privileges and appropriate licensing: “These measures should be all ongoing from the day of signing so that all of that is completed, and Day One is not just a big paperwork day.”

Grebenschikoff believes orientation efforts should continue throughout a physician’s first year at a new practice. She calls this the second, “informal orientation” that she recommends practices adopt to keep tabs on their new hire. She advises that someone in the group take responsibility for overseeing the new doctor’s needs and concerns throughout that first crucial year. If a practice is large enough to support multiple departments, she suggests that this person be in a different department from that of the new physician, so he feels more comfortable talking about issues that may arise with immediate colleagues. Such a mentor, says Grebenschikoff, can give the new hire insight into the practice’s internal politics and provide advice on how to best handle difficult situations.

However, most practices don’t heed Grebenschikoff’s advice. In the 2006 Physician Retention Survey, only 40 percent of all groups indicated that they have a physician retention program.

Red flags

Both Westfall and Scopelliti name disengagement as the first clue that new physicians are either not fitting in well or are unhappy with some aspect of their employment. “It can be obvious very early,” says Scopelliti. “A physician is very enthusiastic during the interview and hiring process, and then when he first arrives, he suddenly disengages, is not connected to discussions about the department, and shows little interest in the future of the organization.”

Westfall agrees. “If I had to name one warning sign to look out for, it would be poor interaction on the part of the new hire,” she says. “If a physician - or any employee - is for some reason becoming unhappy with his or her work, very often they stop talking and become even more isolated.” If you see this occurring, Westfall advises employers to act quickly. “You have to work to find out what’s on their mind before something festers and it gets to a point where they’re dissatisfied enough to leave.”

In the end, hiring and retaining the type of physicians you most desire requires effort and attention, starting well before the job interview and lasting long after the first day. It’s a simple matter of taking relatively common-sense steps to help protect your most valuable assets.

“This is not rocket science,” says Grebenschikoff. “It’s just that most organizations don’t pay a whole lot of attention to it.”

Barbara A. Gabriel holds an MA in English literature and is the associate editor of Physicians Practice. She has served as editor and writer for numerous healthcare publications over the past 10 years. Barbara can be reached at bgabriel@physicianspractice.com.
This article originally appeared in the July/August 2007 issue of Physicians Practice.