Occupational Shortages – Recruiting and Keeping Physicians
Part 3 of a 3 Part Series
By Mike Monahan, MEd, RN
More and more physicians are becoming direct employees of hospitals or having their practices purchased by hospitals and health care systems. Physicians have become, at the least, indirect employees. Academic medical centers have a long history of physician employment, with house staff, consultants, and attendings having some sort of employment relationship. However, this has not been true for most community-based hospitals and health systems over the last 50 years.
When reviewing the health care literature, several factors stand out: 1. More and more hospitals see physician employment as a guarantee to patient access, and therefore revenue and marketshare. 2. More and more physicians are struggling to maintain revenue in private practices and see employment as a potential solution. 3. The transition for physicians from private practice to employment is not easy or often positive. (Strategic Programs Inc.’s Physician Engagement Study data results 2010-2014). 4. Assimilating physicians into hospital staffs with HR Policies, work rules and productivity standards has been difficult and has produced turnover, management problems and created unexpected challenges. 5. Just as hospitals are growing dependent on fully employed, quality-focused, engaged and productive physicians; the number of available physicians to fill these needs is declining.
The trend in care practice focus is moving from acute, inpatient care to ambulatory care in a variety of formats. Primary care physicians, such as internists, pediatricians, and family practice physicians, will provide most of that care. The literature suggests that population growth through 2015, the additional people with insurance seeking care, and the retirement of aging “Baby Boomer” physicians will require an increase of over 50,000 primary care physicians to meet increased demands. Shortages in specialty positions such as general surgeons and a geographic mal-distribution of many other specialties are also looming.
The keys for hospital and health system employers, and particularly Human Resources professionals, will be to recruit sufficient numbers of physicians, get and keep them engaged, and encourage productivity and quality without offending their sense of clinical autonomy, as well as be prepared for the day when those efforts will not be sufficient to meet needs.
Keep in mind Physicians accepting employment are giving up the two “Sacred Cows” of private practice – Clinical Autonomy and Financial Independence. Hospitals make value-based purchasing decisions for equipment and surgical instruments, have restrictive formularies that might not include every physician’s favorite antibiotics or the latest rheumatology drugs, assign shifts or work hours to physicians, as well as have metrics around productivity that physicians may not understand or that they believe interferes with their clinical judgment. In addition, physician reimbursement is not directly related to the volume of work, procedures they accomplish, or outcomes they produce. Our physician satisfaction survey and consulting work indicates as a consequence that employed physician morale is lower than needed to produce the necessary levels of engagement.
Here are some interventions that may help your organization:
• Have a serious dialogue with physician employment candidates and practices concerning life and culture in the organization. Create realistic expectations.
• Involve physicians in setting of performance metrics, purchasing equipment and instruments, and constructing your pharmacy formulary.
• Have a salary program that takes into account physician’s contribution to your book of business, and is progressive in terms of allowing physicians to earn more by doing more and better.
• Get your medical staff services professionals involved in HR functions. Medical staff professionals have long served as the intermediary between community physicians and the hospitals in which they practice. Medical staff professionals know a lot about what physicians want and how to manage them.
• Support physician continuing medical education (CME). Most hospitals have stopped supporting continuing education (CE) for other professionals, reasoning that CE is a personal responsibility. Physicians need CME for maintenance of licensure and certification, and to create outcomes that have tremendous quality and financial implications for your hospital.
• Talk to your physician employees – not just their leaders. Use a good, data-based, physician engagement survey tool, such as Strategic Programs’ Physician Engagement Survey, and act on the results.
• Reach out to academic medical centers as well as other organizations that have a history of employing physicians to get advice on their lessons learned.
• Keep in close touch with physicians. Leaders cannot engage their medical staff from an office. To build solid relationships, they need to establish sincere, face-to-face, two-way communication with physicians. This doesn’t just happen. Leaders have to make it happen. Build time into your schedules to round on physicians. Studies show that when leaders round on physicians once a month, satisfaction results will be in the 87th percentile for likelihood of recommending the hospital to a colleague or patient. If you round quarterly, satisfaction is in the 75th percentile. If you round every six months, or never, it’s in the 50th percentile. So if you’re going to round, you have to do so at least once a quarter to make an impact.
• Look for ways to make physicians’ lives easier. Best-practice hospitals use simple tools such as a checklist nurses use when they need to call a physician about a patient. It lays out the information the physician wants to know (and in what order) and makes these interactions more efficient (and safer for the patient, too). Make readily available organizational notes created for each physician to let staff members know which rounding time each physician prefers, how each prefers to be contacted, and so forth.
• Treat physicians as respected partners and colleagues, not as subordinates or employees. Be the person who discusses financial matters with them, in person.
• Be as open and transparent as possible about financial matters. Start a monthly or quarterly presentation about financial results especially for physicians, outside of normal working hours so most can attend. Keep it simple – many physicians will not know even the basics of hospital finance. Don’t expect the entire physician staff to attend, but talk to those who do as if you were talking to all. Remember that questions, even ones that are really challenges, are indications of interest.
• Include physicians on internal oversight and governance committees, in particular a finance committee. If you don’t have one, start one. A few respected physicians who understand the hospital’s finances, and actively participate in its financial processes, will help build credibility with the entire physician staff.
• Involve physicians in communicating with physicians. When the messages are difficult, it can be very helpful to have a knowledgeable physician assure colleagues that their concerns are being considered. And when a “difficult” physician needs to be brought into compliance, a practicing physician of the same generation will be by far the most effective communicator.
• Seek physician input on major issues. Be clear that you value their thoughts because they are part of the team, and their clinical and mission perspectives are absolutely critical to making good decisions. At the same time, be candid about other factors and constituencies that also are critical and need to be considered. Make sure you listen to physician input and can explain how it was used in the decision process. Asking for input then ignoring it will do much more harm than good to your working relationship.
• Make sure policies, procedures and values apply to physicians as they do to any other member of leadership and all employees.
Fenstermaker, D. Personal Conversation. Internal Physician Recruitment Standards. Warbird Consulting, 2014
Green, L. et al. The Future Role of the Family Physician in the United States: A Rigorous Exercise in Definition. Ann Fam Med. May 2014
Patterson, S. et al. Projecting US Primary Care Physician Workforce Needs: 2010-2025. Accessed from annfammed.org at 2:00 PM on June 24, 2014
Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007. (Available on www.IHI.org)