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Is the "revolving door" derailing your practice?
Though distinct factors in hospital medicine encourage high turnover, hospitalist programs look to gain greater stability
by Lola Butcher



Published in the February 2007 issue of Today's Hospitalist.

Talk to Harsukh P. Patolia, MD, about his achievements as a hospitalist, and he proudly points to both the longevity and stability of the decade-old program he directs at Lewis- Gale Medical Center in Salem, Va.

Dr. Patolia and four of his colleagues have worked together for more than five years, which is eons in hospital medicine. Perhaps even more importantly, Dr. Patolia feels certain that this core group of physicians will continue to work together for the foreseeable future.

"Even if someone comes and tells my partners, 'I'll pay you $50,000 more per year,' " says Dr. Patolia, "I'm confident that each of them would say 'no.' "

In a specialty known for its high turnover, Dr. Patolia's practice is the envy of many of his peers. Survey data from the Society of Hospital Medicine put the mean annual turnover rate for hospitalist groups at 12%. But the survey also found that 37% of groups reported a whopping turnover rate of 15% or more, a problem that some describe as a "revolving door" of hospitalist recruitment.

So how has Dr. Patolia's group, which is employed by the giant hospital chain HCA, avoided the high turnover so common to hospitalist practices? While Dr. Patolia says he pays careful attention to factors like work schedules and compensation, he is quick to add that those factors by themselves are not enough.

What's really held the core group of physicians in his practice together for five years and counting, he claims, is the camaraderie, loyalty and values that the physicians have come to share over the years. That shared culture both keeps the hospitalists tied to the practice and ensures their job satisfaction, during both good and bad times.

While concepts like culture and camaraderie may seem better suited to a therapy session than a busy hospitalist practice, hospital medicine experts say they're critical in building a stable hospitalist group. Without the right culture, physicians and program administrators say, hospitalist groups will not only lose physicians, but face problems with performance among the doctors they do keep.

Contributing factors
Just how bad is the problem of retention in hospital medicine? Eric M. Siegal, MD, a regional medical director for Cogent Healthcare, which operates hospitalist programs in 15 states, cites one report from a national recruiting firm that suggests a ratio of five open slots for every qualified candidate—a factor that is at least related, he says, to high turnover rates.

Analysts say there are certain factors inherent in hospital medicine that push turnover rates higher than in other specialties. Because hospitalists as a group tend to be young, for example, they may not have the same ties to community—such as children in school—as other physician groups. And a certain number of internists use a hospitalist job to fill the gap before a fellowship or as a stepping stone to another career.

But perhaps more importantly, hospitalists face no financial barriers to switching jobs. "Unlike most traditional medical fields, you don't have to build a practice," says Dr. Siegal. "There's no penalty to leaving."

In fact, the typical physician's strategy for boosting income—building a patient base over time—simply doesn't apply. Instead, hospitalists who want to make more money may be best served by switching to another job with better pay.

Similarly, the prevalence of hospitalists who are employees, rather than investors in their own practice, also tends to keep physicians less tied to any one practice. According to Dr. Siegal, no more than 25% of hospitalist groups are owned by the physicians who work in them.

"When you're a partner in a practice," he points out, "you have a certain degree of investment and buy-in that encourages you to weather storms that you otherwise wouldn't weather."

Impact on groups
While individual hospitalists may benefit from regularly changing jobs, the trend can be crippling to practices. The expense of recruiting a physician, which can run up to $50,000 per person,, is only part of the story. A revolving door can also cause problems with length of stay, efficiency and the introduction of new services.

And high turnover erodes more than revenue streams. "You run into constant credibility problems with specialists and primary care physicians," explains Dr. Siegal. "If your program is a revolving door, even if the people you hire are fabulous, a certain degree of trust gets lost."

Roger Heroux, PhD, of Hospitalist Management Resources LLC and based in Colorado Springs, Colo., says that paying attention to the nuts and bolts of a hospitalist group can head management infrastructure can help improve a group's chances of long-term stability. Without proper planning, he points out, "there are no clear goals or objectives that can be measured, so no feedback to let hospitalists know if they're doing a good job."

Workload and scheduling are other critical areas. What's the ideal physician-patient ratio? According to Dr. Heroux, it's one hospitalist for every 15 inpatients. Any more patients, he says, and hospitalists risk burnout and start looking at other options.

To address surging patient volume, physicians in one of Dr. Siegal's former positions used a "jeopardy" system, which assigned a back-up physician to help whenever a hospitalist's census rose above 20 patients.

That solution not only recognizes that hospitalist schedules will go awry, but helps forge bonds among physicians. According to Lewis-Gale's Dr. Patolia, his group has frequently been short-staffed, with members for years working longer hours than they might have wished. Yet they haven't burned out or jumped ship, something he attributes largely to their mutual commitment.

"I can ask any of my partners to take over my patients and I will not hear a 'no' from anybody," he says. "We depend on each other."

Building a culture
While some may say that Dr. Patolia has been fortunate to find a group of physicians that just clicks, he notes that the group has gone to great pains to bring together physicians who have a common vision-and to let go of physicians who were not a good fit.

Over the years, for example, the group has dismissed three physicians because they didn't fit in, says Dr. Patolia. In each case, other group members decided that if they did not trust a physician's expertise or enjoy a good working relationship, it was better to reduce staff size-even when that meant working longer hours.

"They could be disruptive to the morale of the group, which plays a very important role in keeping us together," he says.

Cultural factors, which include expectations about workload and income, are critical factors in creating a cohesive group. In Tampa, Fla., for instance, Chris Nussbaum, MD, the founder and chief executive officer of Synergy Medical Group, an independent hospitalist group, says he makes sure he doesn't "sugarcoat the workload" when meeting with prospective recruits.

"If upfront there is any hesitancy about that," Dr. Nussbaum says, "then we won't go any further." Physicians he hires are also drawn to the group's productivity-based profit-sharing and the offer of a partnership at the end of two years.

At Lewis-Gale, compensation based on productivity is a big part of the shared culture. Such a model, Dr. Patolia says, makes long work hours more palatable. While this type of compensation may not appeal to everyone, it does appeal to all the physicians who have been successful in the group.

That said, the exact opposite culture may boost stability in other practices. Dr. Siegal recalls working in a program in Denver where doctors who were highly motivated by money did not mesh well with the group.

Given the choice between lifestyle and money, we would pick lifestyle any time," he says. "They couldn't understand why we would pass up opportunities to make more money."

Autonomy and decision-making
While a group's internal culture is important for retaining physicians, so is its relationship with the rest of the hospital. While Dr. Patolia's group is owned by HCA, the hospital does not employ the hospitalists directly. Instead, the hospitalists work through a multi-year contract with the hospital and interact directly with the hospital CEO.

"We can talk to him, but he's not a boss to us," explains Dr. Patolia, who says another factor in group stability is respect for-and from-hospital administration. Still other factors include autonomy and physicians' ability to make clinical and quality decisions.

According to Dr. Siegal, good internists are "control freaks" by nature who thrive in an environment with as much independence as possible. "If you treat them like any other group of employees, you're going to lose them," he says. "Physicians frequently have their antennae up for exactly that issue. They have to have the ability to make decisions."

Lola Butcher is a health care business writer who is based in Springfield, Mo.


The high points and the downsides of changing jobs

When Jose Gude, MD, first entered hospital medicine in 1996, he didn't expect to have four jobs in the next decade. But he started his fourth position last September, making him a poster physician for the revolving door.

He made his first job switch for personal reasons, as he and his wife wanted to relocate to the Pacific Northwest. But within two years, he was burned out.

"It was a really high pressure job due to a high census and poor or delayed administrative response to group needs," he says. "I was just getting exhausted."

Dr. Gude stayed four years, then moved again, this time for the opportunity to be a nocturnist at Seattle's Swedish Medical Center. The new job offers him more time off with his family and, because of the nighttime shift, the possibility of a less stressful workload.

"If you want to make this a career, you can't really see 18 to 20 patients and be pressured every day," he says. "It's going to get to you."

Job switch pros and cons
Danielle B. Scheurer, MD, a hospitalist at Brigham and Women's Hospital in Boston, is now in her third hospitalist position in five years, although all her moves have been for personal reasons rather than dissatisfaction. She relocated once to fulfill her professional goal of working in academic medicine rather than private practice and once to accommodate her husband's medical training.

Dr. Scheurer thinks the lure of higher pay is less responsible for high turnover than difficult working conditions.

"It's hard to change jobs," she says, "and it would probably have to be a pretty significant wage increase to warrant switching."

On the plus side, both Drs. Gude and Scheurer point to benefits they've gained from changing jobs. In his new position as a nocturnist, for instance, Dr. Gude now has more time off to champion the new electronic medical record the medical center is about to implement.

And Dr. Scheurer says that she appreciates the exposure to new clinical techniques, colleague ideas and networking opportunities that a new position can bring.

But "there's a steep curve to learning a new system, and you have to start at the bottom as far as scheduling," she says. You also have to deal with re-credentialing hassles and with having to work to gain respect among new colleagues and staff.

How many is too many?
Physicians may also want to be wary of racking up too many lines on their vitaes.

"A lot of people frankly would be very hesitant to hire someone if they knew they were only going to be around for a year or two," Dr. Scheurer points out. "You would really have some explaining to do because it is a huge investment on so many levels to bring someone into the practice."

But according to Eric M. Siegal, MD, a regional medical director for Cogent Healthcare, the job market for hospitalists is just too hot to penalize even physicians who have performance problems, let alone ones who make a habit of changing jobs.

He recalls having problems with one physician recently who failed to show up for work and didn't get along with colleagues.

"We warned her that this kind of behavior would taint her reputation and make it difficult for her to get a job elsewhere," says Dr. Siegal.

But that warning, he adds, turned out to be completely wrong. "She had another job lined up at a good program even before she left us," he says. "Her new employer never even called us for a reference check."


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