Published in the February 2006 issue of Today’s Hospitalist
Editor’s note: In this two-part series, Today’s Hospitalist takes a snapshot of the recruiting environment from two perspectives. This month, we look at how hospitalist programs are increasing their ranks. Next month, we’ll get the perspective of hospitalists who have recently entered the job market.
It’s late afternoon one day in early January when Brian Bossard, MD, picks up the phone to talk to an internal medicine resident about employment opportunities.
What makes the conversation unusual is that Dr. Bossard, founder of Inpatient Physician Associates in Lincoln, Neb., is talking about a position that will start in August 2007, a year and a half away. In addition, he is making an offer to an internist who’s not even halfway through her training.
“I’ve offered (positions) for 2007 to one physician already, and I’ll probably do that for another one. You get them almost out of the cradle if you can,” says Dr. Bossard with a weary chuckle.
Five years ago, such an approach to physician recruiting might have seemed extreme. In today’s red-hot job market for hospitalists, however, it is an example of how hospitalist programs and recruiters are doing whatever they can to gain an edge.
“Where I had initially identified a six-month period for recruiting,” Dr. Bossard says, “I now consider it 12 months.” To beat the competition, his group is bringing physicians in for site visits “and asking them to sign contracts “earlier and earlier.
Dr. Bossard is quick to note that his prospective recruits aren’t unknowns, but rising stars who have been recommended by other recent hires, including several former chief residents.
“You wouldn’t make offers to people you don’t know, but that’s the sort of thing that has changed since 2002,” he says, alluding to the year he formally started Inpatient Physician Associates with six hospitalists. The group today employs 14 hospitalists at two campuses of BryanLGH Medical Center and plans to grow to 16 by the end of the summer. “It’s been constant, rapid expansion.”
The perils of a buyer’s market
While Dr. Bossard and others recruiting hospitalists face a buyer’s market, they say the term doesn’t fully convey just how much choice physicians have when looking for work.
“There’s been such a proliferation of programs that young doctors have six or seven opportunities, literally, that they can look at,” says Dan Fuller, president and cofounder of Atlanta-based In Compass Health. The group staffs hospitalist programs in 27 hospitals, primarily in the Southeast, and contracts with a half-dozen others. “If you’re a hospitalist with any kind of experience, you’re a very hot commodity.”
To illustrate just how hot the market is, Mr. Fuller recalls that nine years ago, he started two hospitalist programs in North Carolina “one with six physicians and the second with 14 “within 90 days. In today’s market, industry observers agree, it would be almost impossible to find that many physicians that quickly.
“We’ve heard that some programs are taking up to two years to start,” Mr. Fuller says. “It’s a supply-and-demand thing, and it’s off the scale.”
Kurt Mosley, vice president of business development for the national physician recruiting firm Merritt Hawkins & Associates in Irving, Texas, agrees that physicians are calling the shots. “If a hospitalist doesn’t have a malpractice issue,” he says, “there is no such thing in America right now as an unemployed hospitalist. They’re in that much demand.”
Because he regularly speaks about hospitalist recruitment issues, Sanjiv “Ben” Panwala, MD, a nocturnist in Portland, Ore., has an interesting opportunity to see both sides of the issue. “When you talk to residents,” he says, “what you hear is that they’re being so heavily recruited that they’re in the driver’s seat, completely.”
Not surprisingly, hospitalist programs have a different point of view “They’re struggling with hiring,” Dr. Panwala adds, noting that program directors have said that they will “unabashedly” provide any information hospitalists request in the hopes of recruiting them.
Young physicians like Rebecca Nessel, MD, a third-year internal medicine resident at University of California, San Francisco have discovered that they are hot commodities. “I haven’t been looking extensively,” she says, “but it seems that everywhere I look, they’re hiring. Everyone I contact has said, ‘Come visit our program so we can show you what we offer.’ ”
Five years ago, it was relatively easy to identify the sources of demand for hospitalists. In 2001 and 2002, for example, a major growth spurt in the number of hospitalist programs was fueled by hospitals that were building new programs themselves or contracting with companies to do the job for them.
More recently, however, several new trends have increased the demand for hospitalists. One is the expansion of hospital medicine into surgical co-management, with hospitalists taking on everything from bypass cases to hip-replacement patients.
At the same time, mid-sized community hospitals in the suburbs and even rural areas are realizing that the inpatient care model that has proven to be a godsend to large urban centers might benefit them as well. And in some parts of the country, demand for hospitalists today is being exacerbated as long-established programs and relative newcomers alike expand, driven by internal demands and resident duty-hour restrictions.
(While there are no statistics, analysts say that demand for hospitalists appears to be highest in the Midwest and the South, while it seems to have peaked in the Northeast.)
And now, some analysts say they are seeing a second round of interest from urban hospitals. “A few years ago, the demand was coming from the suburban and rural areas, but now it’s increasingly coming from urban areas,” says Mr. Mosley. “We’re seeing some of the largest urban hospitals, especially those that started their programs on the later end, in the hiring mode again.”
Demand from several fronts
David Joyce, president and CEO of Delphi Healthcare Partners in Raleigh, N.C., says that the sheer volume of new or revamped hospitalist services is largely responsible for the current recruiting crunch. He likens it to the 1970s, when recruiters like himself were helping staff new emergency medicine programs.
“The demand for hospitalists now is almost insatiable because of the number of hospitals that have put in programs in the last few years,” Mr. Joyce says.
While Delphi has historically focused on specialties like emergency and critical care medicine, anesthesiology, surgery and ob-gyn, Mr. Joyce says that he now personally receives a few calls a week from program directors or hospital administrators who are at their wit’s end. They’re trying to either expand existing programs or replace contract arrangements with hospital-operated programs, he says, and many tell him they are “getting nowhere fast.”
But analysts say that the growth of hospitalist programs is only one part of the supply and demand equation. As Mr. Mosley from Merritt Hawkins explains, a tight supply of hospital beds is also putting the squeeze on the hospitalist workforce.
A recent Kaiser Family Foundation report, for example, found that in 2003, there were 280 beds for every 100,000 residents, a number that’s about two-thirds the capacity that existed in 1975. Fewer beds translate into higher censuses “and an increased need for inpatient physicians like hospitalists.
“We’ve cut back from about 8,000 U.S. hospitals to 5,800,” Mr. Mosley says, “and hospitals are running full most of the time. In this environment, facilities that have hospitalist programs are better able to deal with the load, especially unassigned patients.”
That, in turn, means that hospitals that haven’t launched hospitalist programs are frantically trying to get them up and running, squeezing the hospitalist workforce even harder.
Bidding wars on the horizon?
That pressure is only exacerbated at programs that have internal problems or inherent “flaws,” according to Martin Buser, MPH, a founding partner of Hospitalist Management Resources LLC, a consulting firm with offices in San Diego and Colorado Springs, Colo.
“We come across groups all the time that say they’ve been advertising for a year and have barely gotten a nibble,” Mr. Buser says. “They ask, ‘What’s wrong with me?’ Often, the problem is that they’re not externally competitive.”
He explains that one of the chief problems is that physicians already working for these groups are earning salaries that fall short of their peers. When the group “puts that in the market, no one responds to it,” explains Mr. Buser, whose firm consults in program development and restructuring.
That revelation only leads to more headaches. “You can’t pay newcomers more than you pay yourself,” he says. “That’s an issue programs have to address if they’re going to recruit successfully.”
How much are hospitalists earning? All of the experts interviewed for this story agreed that hospitalist salaries have risen significantly in the last two years. Informal estimates put those salaries in the $165,000 to $180,000 (or slightly higher) range in non-academic programs. That’s a jump of $10,000 to $15,000 from just a few years ago.
Mr. Mosley from Merritt Hawkins adds that in some markets, hospitalists are earning $20,000 to $30,000 more than their office-based practice counterparts.
And while no one interviewed for this story suggested that the high demand for hospitalists has begun to spark bidding wars, some are already seeing those kinds of tactics.
“We’re seeing more and more signing bonuses “in the $10,000 to $20,000 range “and more generous moving allowances than we’ve seen in the past,” notes Mr. Buser.
Even without bidding wars, says Dr. Bossard from Inpatient Physician Associates, the recruiting bar is being raised all the time. “The hungry programs “and there are many out there “will raise the salaries to silly levels,” he says. “Then others have to either compete or lose out.”
Looking beyond pay
While some hospitalists might respond to the siren call of a big paycheck, more experienced physicians are learning that their clout in the marketplace can translate into better working conditions.
Mr. Buser acknowledges that a poor salary package is only one problem that can raise a red flag among market-savvy hospitalists. He says that hospitalists are also on the lookout for unreasonable workloads, poor leadership and high turnover.
Hospitalists are also increasingly concerned about hospitalist programs’ footing in the hospital and asking about groups’ contracts, as well as the funding and support they receive from the administration.
“If you’re a hospitalist looking for a job right now, you probably have five to 10 offers,” he explains. “Why would you take a position with a group that isn’t solid or a program that’s not well supported by the hospital?”
Other potential problems hospitalists are looking for include a lack of mentors, or rigid compensation structures that don’t allow for merit-based bonuses and don’t offer an ownership or partnership track.
In addition, hospitalists who have heard horror stories from their colleagues about insufficient specialist backup are increasingly looking for evidence that practices have a good ER backup panel, Mr. Buser says. He notes that no one wants to be “left hanging out there” when they need help.
Finally, hospitalists with a few years of experience are increasingly eschewing not only programs that they have heard have problems, but startups in general. “Many hospitalists who’ve been involved with new programs are saying ‘No thanks, I’d rather plug in to an existing one,’ ” Mr. Buser says.
Deal-breakers and deal-makers
Hospitalists have so much leverage when it comes to job hunting, in fact, that what they view as deal-makers and deal-breakers might surprise program heads and hospital administrators.
All other things being relatively equal, Mr. Mosley notes, hospitalists lean toward high-tech features like wireless access to patient information, test results or pharmacy. Voice-activated transcribing is another must have on some hospitalists’ list.
“That’s becoming one of the new negotiating points for hospitalists: Who can provide the most wireless features, and who will pay for my BlackBerry?” Mr. Mosley says.
And while good parking may not seem like a deal breaker, it has been an issue for some physicians. “It may sound strange,” Mr. Mosley acknowledges, “but I have heard of a few hospitals that have lost their hospitalists to a competitor because of parking hassles.”
To increase their competitiveness, programs are responding by finding creative ways to make more efficient use of their limited resources or adopt alternative structures.
Some are using locum tenens physicians to either start a program or get through a difficult expansion, and others are delegating more tasks to nurse practitioners or physician assistants. Others are revising schedules to allow for shorter shifts or beeper “call” only for a portion of a longer shift during historically slow periods of the day.
No relief in sight
Because every bubble must eventually burst, some hospitalist programs may be looking forward to the day that supply begins to meet demand. When asked whether any relief was on the horizon, however, everyone interviewed for this article replied with a resounding “no.”
“I don’t see any relief valve,” says Dr. Bossard. “Internal medicine is not adding folks to the residency programs, and traditional internal medicine is having a hard time recruiting. I see the shortage continuing.”
There is some hope, however, that as the hospitalist field becomes more desirable for economic and lifestyle reasons, community-based internists may move over to inpatient medicine and swell the ranks of hospitalists.
“We’re seeing some of the mid-career doctors move from office practice [to hospitalist work], because they see that they can work fewer hours, make more money and not have the headaches of running a practice,” says Mr. Joyce from Delphi. “The hospitalist field is still primarily a younger physician’s game, but I do think we’ll see more mid-career internists make the move.”
Based on his experience at Merritt Hawkins, Mr. Mosley made a similar assessment. “I think mid-career is a big movement,” he says. “There are a lot of internists who have followed their patients in the hospital who are now saying, ‘Let me go one way or the other’ and are choosing hospitalist work.”
“Still,” Dr. Mosley adds, “hospital medicine is a pretty demanding physical job, so I don’t see a lot of 60ish doctors becoming hospitalists.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.