Published in the October 2009 Special Issue for Residents
Mark Williams, MD, has a long track record recruiting residents out of training into hospital medicine programs. Dr. Williams, after all, helped begin and grow the Emory Healthcare hospitalist program in Atlanta “the nation’s largest academic program “and is now chief of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago.
Looking back, Dr. Williams has one word to describe his former recruiting efforts: frantic. “I struggled to hire people in the early 2000s at Emory,” he says. “And at Northwestern, we shot up from 17 hospitalists in 2007 to more than 50 over a couple of years.”
Since then, however, the job market for hospitalists has begun to plateau. “There’s not quite the feeding frenzy for new candidates that we saw in the past,” Dr. Williams explains.
That’s not to say that residents launching a search for their first hospitalist position won’t find opportunities. In fact, hospital medicine experts are still forecasting very robust growth for the specialty.
But residents entering the job market for the first time will find a changing landscape. For one, the salary and benefit packages being offered, particularly in non-rural areas, may not have quite the amount of wiggle room to go higher than they once did.
And expectations for hospitalists just starting out are also higher. Experts say that timelines for board certification, for instance, have gotten tighter. As a result, residents looking for their first job need to be more flexible when it comes to location, schedule and type of program.
A big drop in attrition
Many hospitalist programs and recruiters report a thriving recruiting environment. Data released this summer by Merritt Hawkins & Associates in Irving, Texas, the country’s largest physician recruiting firm, showed that hospitalist positions were No. 3 on the firm’s list of the most hotly recruited specialties, after family medicine and office-based internal medicine. The most recent survey of the Society of Hospital Medicine found that physicians coming out of residency or fellowship still account for roughly half the supply of new hospitalists.
But most residents interested in hospital medicine positions for 2010 will not find the buyer’s market of just a few years ago. Several factors are behind that recruiting change, including the economy.
The poor housing resale market, for instance, is prompting hospitalists who might have moved on to stay put, slashing what used to be considered “normal” attrition rates. While hospitalist programs used to lose 10% to 15% of their physicians in a given year, that number has shrunk to 4% in some markets.
Stephen Houff, MD, is CEO of Hospitalists Management Group (HMG), which is based in Canton, Ohio, and employs more than 300 hospitalists in 45 programs. He says that the vacancy rate in HMG programs is now at 8%, the lowest in the decade-old company’s history, and less than half what it was a mere three years ago.
The job market for residents is “still very favorable,” Dr. Houff notes. “But rather than giving hospitalists a contract five minutes into an interview, prospective employers now want to conduct a more formal pre-employment interview.”
There is also “more scrutiny now about candidates’ willingness to work with the schedule that’s been set,” Dr. Houff adds, “and the ‘any warm body’ mentality is definitely gone.” HMG’s client hospitals are also taking a harder look at a prospective hospitalist’s likelihood of staying with the program.
The good news, Dr. Houff points out, is that many hospital medicine leaders believe the specialty is still looking at overall growth of about 15%. That growth, however, tends to be more concentrated in non-urban areas.
“Residents need to be a bit more flexible in terms of geography,” says Dr. Houff. “It’s not like four years ago, when residents could pick a spot and find a hospitalist job.”
Some market saturation
There is another major factor reconfiguring the recruiting landscape for residents. With hospital medicine now well into its second decade, well-established programs have reached a level of saturation that has caught many experts by surprise.
That saturation is apparent, for instance, in academic programs. “There are jobs out there,” Dr. Williams says about academic slots, “but some residents aren’t going to get their first picks. Those who want an academic setting should start looking in multiple cities.”
Saturation is likewise a factor in nonteaching hospitals in the nation’s most desirable markets. In the Denver metro area, for instance, recruiter Karen Zeller, president of Rocky Mountain Medical Search in Fort Collins, Colo., says that she’s aware of only a few openings. “In the heyday, four years ago,” Ms. Zeller explains, “hospitalists could have had several competitive offers.”
The same is true for Southern California. “Five out of 10 calls we receive from physicians looking for jobs are from hospitalists and residents who want to be in the Los Angeles area,” says Virginia Turano, director of recruiting for Merritt Hawkins. “And they don’t care if the pay is less than somewhere else or if the schedule is tougher.”
But that’s not the situation in the Dallas/Fort Worth area. Ms. Turano says that one company that had previously asked her firm to find 11 hospitalists last month called and said it needed four more. “My sense here is that some of the large programs need more hospitalists,” she says, “and several of the groups in this area welcome new residents.”
And while some saturation in established programs is being reported in Seattle, Boston and Miami, it isn’t a big issue in the New York area. Ethan D. Fried, MD, vice chair for education in the department of medicine at St. Luke’s-Roosevelt Hospital Center in Manhattan, says his residents are faring pretty well in the local market.
“All of our residents who wanted hospitalist jobs got them and not too far away,” Dr. Fried observes. “My people are getting hospitalist jobs here in the city, upstate, on Long Island and in Connecticut. The ones who want to stay in the tri-state area are finding jobs.”
As evidence for that availability, several New Jersey hospitals have yet to establish hospital medicine programs. Market data show that even some facilities with up to 400 beds have yet to launch hospitalist programs.
Making smaller markets more desireable
Experts say that market saturation doesn’t necessarily mean that residents shouldn’t bother applying for positions in those areas. Programs that may be undergoing a management change “an outsourced group that is being brought in-house, for instance “are more likely to have openings.
Residents determined to work in a particular metropolitan area, however, should pay close attention to their CVs and make sure they’re offering what programs want to buy. Diane B. Wayne, MD, internal medicine program director at Northwestern, notes that the Chicago market has become tighter, but says there are still opportunities.
“The division of hospital medicine at Northwestern is still growing in a lot of directions, including palliative care and preoperative clinics, so the creative use of hospitalists at our institution continues to increase,” Dr. Wayne explains. “And the quality improvement area is growing for hospitalists in general, so there likely will be more opportunities for residents who have that interest in the future.”
Valery Akopov, MD, associate program director of the internal medicine residency program at Emory, says that doctors willing to move outside of large metropolitan areas are still finding ample opportunities. “Folks who move away from Atlanta aren’t having much difficulty getting a job,” he explains.
Some smaller urban markets illustrate that trend. In the Marshall, Minn., region, for example, which has recently built a new rural hospitalist program, hospitalist jobs are still available, according to Karrie Schipper.
Ms. Schipper recruits for one of the region’s largest health systems, Avera Health, which has facilities in five states. “Most of the residents we’ve talked to in the region who want hospitalist jobs,” she says, “have options to stay vs. moving.”
Sarah Grenat, a physician recruiter at the giant Clarian Health in Indianapolis, points out that while positions have dried up in Clarian’s sites in Indianapolis, “there’s a huge need for hospitalists in all of our rural areas.” She also notes that hospitalist positions in rural hospitals no longer mean being tied to a beeper with non-stop call and losing the lifestyle advantages that hospital medicine has to offer.
Suburban and rural hospitals, she points out, have realized that they need to be flexible to attract physician candidates. “We are seeing a transition of most rural programs to the seven-on/ seven-off model,” says Ms. Grenat, because young physicians find that schedule to be “ideal.”
Typically, hospitals offering seven-on/seven-off schedules with 12-hour shifts don’t expect physicians to take call. Some smaller programs may have physicians taking call from home, she admits.
“But keep in mind that the actual call census in a smaller program would be much lower than in, say, a level 1 trauma center,” Ms. Grenat points out. “Physicians may have more call requirements, but the actual call is minimal.”
Where are the big bonuses?
Programs in smaller markets also have some other distinct advantages, Ms. Grenat adds. One big plus is leadership possibilities.
“Smaller, more rural programs don’t have a large pool of experienced hospitalists to draw from,” she says, “so leadership in these programs can sometimes be handed to doctors with less experience.”
And suburban and rural programs can also offer more in the way of signing and retention bonuses, student loan repayment and heftier relocation packages. But recruiters note that salaries and benefits depend on market forces and program setting.
Many academic programs, for instance, have been hard-hit by cuts in state funding and are reporting salary freezes. Outside of academia, hospitalist compensation is holding steady or posting a slight uptick, most sources says.
But salaries go up the further you go from metropolitan areas. Dr. Fried, for example, says that some physicians coming out of his New York program are taking hospitalist slots that pay a little more than $150,000 in the city and $175,000 outside Manhattan.
HMG, which operates mostly outside of major urban areas, puts its across-the-board compensation at around $200,000, which is also what new hospitalists are earning in the Denver area. In the South, which has historically struggled to attract hospitalists, average compensation even for inexperienced hospitalists may be closer to $250,000, says Ms. Turano of Merritt Hawkins.
“I explain to residents that if they want to be in the big city, they probably will make less money,” Ms. Turano says. “Otherwise, they’re automatically thinking that they’ll make $200,000 or that they’ll be able to negotiate their compensation. But they probably won’t in these market conditions.”
The availability of sign-on bonuses, like salary trends, is also market dependent. In Atlanta, Chicago and New York, such bonuses are rare. But in Texas and many rural markets, candidates might see a $10,000 to $20,000 sign-on bonus or more. The tougher an area is to recruit for, the higher signing bonuses and relocation packages run.
And unlike in years past, recruiters are using salary to try to attract board-certified rather than board-eligible candidates. In addition, timelines for board certification are also changing. While five years might have been tolerated in the past, the requirement now might top out at two years or even at one.
“I have noticed that many groups are setting a salary that’s $5,000 to $10,000 lower for hospitalists who aren’t certified,” Ms. Turano says. “That’s new.”
Bonnie Darves is a freelance health care writer based in Seattle.
The big trends in the job market
HERE’S A QUICK LOOK at how the job market for residents may be changing in hospital medicine, compared to just a few years ago:
- Salaries are flattening, especially in desirable urban markets and in the academic hospitalist sector. In some cases, academic doctors haven’t seen their own earnings increase for a year or longer.
- Rural practice opportunities remain plentiful in most parts of the country, and compensation continues to be higher in rural areas than in most urban centers.
- Sign-on bonuses are still out there, but they’re not as common as a few years ago. Physicians will still see sign-on bonuses as draws to rural areas and smaller communities. In those cases, physicians might see $20,000 or more being offered.
- The timeline to be board certified is tightening in some markets to one to two years maximum post hire. In the past, programs were more lax about that deadline.
- In some markets, salary differentials for board-eligible vs. board-certified can be as much as $25,000.
- Attrition rates in hospitalist programs are lower than they’ve ever been “between 4% and 8%, compared to 10% to 15% a few years ago.
Tips for a successful job search
HOW CAN YOU ENSURE that your job search is both successful and efficient? Here are some tips from recruiters and hospital medicine program directors:
- Take time to consider where and how you want to practice, but be willing to sacrifice some compensation if you hope to practice in a desirable urban market or remain where you trained.
- Start looking early, ideally in the fall, and search broadly. According to Mark Williams, MD, now chief of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago, he already had six highly-qualified residents applying in September for positions starting July 2010.
“Normally,” Dr. Williams says, “this would happen in November or December.” Recruiters also say that residents should have a plan B (and C-E) as far as location and practice setting type.
- Don’t expect every interview to turn into an offer anymore, and be prepared to accept a desired position quickly.
- Be willing to compromise on schedule convenience or earnings to land a spot in a first-choice market.