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Leaving so soon?

The impact of the "starter job" syndrome

October 2011

Published in the October 2011 issue of Today’s Hospitalist

When Jason J. Ham, MD, finished his training in 2003, he knew he wanted a permanent job near his family in Michigan. He found the perfect position at a hospital where he would spend half his time as a hospitalist and half as an emergency room doctor. (He had trained in a joint internal medicine/emergency medicine residency.)

“I thought it would be my job until I retired,” says Dr. Ham, reminiscing eight years “and four jobs “later. But his “perfect” job collapsed after only a year when the hospital replaced the private group he was part of with its own in-house hospitalists. An airtight noncompete meant that he had to start looking all over again.

Like starter marriages or starter homes, the “starter jobs” phenomenon exists throughout America. But in hospital medicine, it is almost the norm.

“It’s misunderstood during residency, how much a person’s life can change in the early attending years.”

ham~Jason J. Ham, MD, University of Michigan at Ann Arbor

According to some veteran hospitalists, many early career hospitalists are all too eager to jump ship. Their unwillingness to work through the kinds of difficulties that are nearly universal for young professionals in new jobs, these physicians say, endangers their professional growth.

The first year or two of practice, explains Mitchell Wilson, MD, chief medical officer with Eagle Hospital Physicians and a hospitalist for 14 years, “is probably the most critical years of practice. That’s when you learn how to truly practice out from underneath the watchful eye of an attending.”

But veteran hospitalists like Dr. Wilson also say that the job-hopping so common in hospital medicine is a threat to the stability of the specialty. Sticking with a first job for three to five years instead of bailing after only one can benefit both physicians and hospitalist groups.

“If we are to represent ourselves as physicians with specialized expertise, it’s important for us to create bonds within the medical community,” Dr. Wilson says. “That’s not something you do by moving around year after year.”

The upside of starter jobs
According to recruiters, as many as 70% of physicians across all specialties change jobs within their first two years, and hospitalists are at the top end of the range. That high turnover rate is a big reason many established practices don’t consider hiring newly minted doctors “and why recruiters tend to shy away from placing early career hospitalists in groups with which they have long-term relationships.

Certainly, working as a hospitalist for only a year or two is an option for new graduates who may still be deciding on fellowships or waiting for spouses or partners to finish training. Hospitals fan those flames by depending on short-term workers to step in when patient volumes surge.

Even Dr. Ham, who wanted to keep his first job, feels good about most of the subsequent jobs he took. “I found many opportunities that were short-lived but that broadened my experience,” says Dr. Ham, who now runs the medical observation service at University of Michigan at Ann Arbor.

Besides, even if he had found the “perfect” job straight out of residency, there’s no guarantee that it would have given him the work-life balance he needs, now that he’s married and has children. “It’s misunderstood during residency,” Dr. Ham points out, “how much a person’s life can change in the early attending years.”

New rules
But a big part of the starter job syndrome in hospital medicine is frequently due to some major mismatch.

Often, that mismatch relates to lifestyle, particularly for international medical graduates who end up in communities that aren’t culturally diverse. As a result, everything from grocery shopping to religious worship can be a struggle.

Or administrators have aggressive financial, productivity or clinical targets, which can be daunting for experienced hospitalists, let alone just-trained physicians in the post-residency reform era.

“A lot of folks coming out of residency find it a real shock to switch from a rules-governed training program “where you can work only X amount of time and take care of only Y number of patients “to the private sector, where there are no rules,” says Dr. Wilson. They “blame the position or the site for the stressors that the work itself creates,” and they don’t give themselves time to figure it all out.

That response may be even more pronounced now that young physicians have even less knowledge about the business of medicine than trainees of years past.

According to Tommy Bohannon, vice president of hospital-based recruiting with the Irving, Texas-based search firm Merritt Hawkins: “Due to increasing constraints on time and other resources, we see training programs having less time to prepare residents to properly evaluate a job.” That makes it even harder for them to assess a prospective practice’s schedule and business demands.

Date for a while
Darina Stankeyeva, MD, a hospitalist with Eagle Hospital Physicians who’s currently in her first job at Southern Regional Medical Center in Riverdale, Ga., readily admits that she didn’t know what business or financial questions to ask during her job search.

Instead, she based her decision on something much less tangible: what she perceived as collegiality within the group. “It is very hard to assess what a group is like,” says Dr. Stankeyeva, who began that first job in 2010, “but you have to trust your gut on that.”

While she’s happy with her decision, she notes that several friends from residency are already bailing on their first jobs. One friend who wanted to pay off debt quickly took a job that paid a lot but wasn’t a good fit. Others discovered that working in hospital medicine wasn’t what they expected and are now looking for office-based jobs.

At the same time, hospital medicine benefits from doctors who are looking to jump ship from outpatient positions. Steven Youngblood, MD, a hospitalist at East Jefferson General Hospital in Metairie, La., ran the risk of being seriously burned in his starter job, which was as an outpatient physician in Houma, La. While he realized quickly that the practice was a bad fit personality-wise, he had a contract that required him to pay back salary guarantees “for five years.

Dr. Youngblood was able to slip out from under that obligation by quitting the primary care group and starting a hospitalist service for the same hospital that had guaranteed his salary. That served as his introduction to hospital medicine.

His advice for doctors just starting out: “Beg, borrow or steal money to get a lawyer to look at your contract.” He also advises young physicians to embrace the “dating” nature of first jobs, particularly if they don’t have a solid idea of what they want in a practice.

“Work locums for a few years,” says Dr. Youngblood. “You can try a few places out and they can try you out.”

The grass is greener?
Both mismatches in lifestyle and in work expectations tend to be exacerbated by another fact of life in hospital medicine: Groups that experienced physicians often avoid “those just starting up or in transition, or those in smaller, remote locations “may be top-heavy with newbies. Those are precisely the programs that tend to be more chaotic.

“Younger doctors get frustrated and are often disillusioned because they don’t know what they are getting into. They quickly conclude, ‘This is not what I signed on for,’ ” explains O’Neil J. Pyke, MD, chief medical officer for Medicus Healthcare and a hospitalist for 12 years. “They think it must be the job, because they know that hospital medicine is beautiful.”

The problem, says Dr. Pyke, is that the grass isn’t usually greener. Just as a job applicant is always on his or her best behavior when interviewing, the hiring program will also always put its best foot forward. According to Dr. Pyke, it may be better for a young physician to try to make his or her current situation more tenable than to cut and run. Hospitalists need to make every effort to work with their current group to try to improve its performance, he says, instead of seeking that perfect job.

For one, Dr. Pyke points out, being tagged as a “job-hopper”can be detrimental to future job searches. “In our overall assessment of hospitalists, we absolutely look at someone who has two or three one-year jobs in a negative way,” he says. “Don’t tell me you left because you didn’t like the job. It’s your duty to make sure that the program works. You are not a spectator. I want to hear that a person took ownership of a job. If you give a job less than a year or two, you did not give it a chance, in my eyes.”

And paradoxically, Dr. Pyke adds, jumping ship in a year or two may doom you to working another job that’s just as chaotic.

Tier 1 positions that are readily available to newly trained physicians may be in start-ups or transitioning programs, Dr. Pyke explains. Tier 2 jobs, on the other hand, are available for physicians with more experience, while tier 3 jobs are open to only those with the most experience, particularly in attractive markets where hospitalist programs have matured.

Doctors who are quick to leave may be considered only for another tier 1 position, Dr. Pyke says. “If you were to leave after a couple more years,” he explains, “you would have a stronger resume and command better starting compensation.”

Incentives and penalties
The fact that it’s so easy to jump ship, veteran hospitalists say, is serving neither the young hospitalists who need time to mature into skilled physicians nor the groups that are forced to adjust to constant turnover.

In practices she has managed, says Kimberly A. Bell, MD, regional medical director with EmCare Inpatient Services, a national hospitalist management company, and a hospitalist for 15 years, “I have had people join and quit and join and quit, and I think we need to get away from that.”

Dr. Bell adds that she’s all for “golden handcuffs” that can convince doctors to stay, at least beyond their first anniversary in the job.

“I think there should be a significant financial penalty for quitting in the first year to year and a half,” she says. “Before people sign on the dotted line, they need to think about whether they really want the job. They need to look at it as they are stuck here.”

Carrots that can improve retention include bonuses that kick in after a set period of time, extra paid vacation or continuing medical education allowances, or ownership possibilities. Sticks that discourage leaving include noncompetes in employment contracts, requirements that expire after two or three years for paying back signing bonuses, and long periods “120 days or six months “for giving notice. (See “Rehabbing that contract.”)

Sticking it out
In the end, a big reason to carry on in a first job is the same reason why a couple may try saving a marriage before calling it quits: The basis for the initial attraction may still be there.

For Vineet Chopra, MD, sticking with his first job for three years “instead of bailing his first year, like two other doctors who were hired at the same time ” ended up convincing him that not only was hospital medicine the right career for him, but that he had real leadership skills. He was aware of neither when he joined a start-up program in Hot Springs, Ark., after finishing his residency at Mt. Sinai in New York.

“The first year, I was very unhappy. I felt I was promised the world, and it all fell apart very quickly,” Dr. Chopra says. Even worse, the local medical community didn’t appreciate the group.

But he quickly learned just how fast things can change in hospital medicine. “Within 18 months,” Dr. Chopra says, “it was incredible.” Not only had the group reconstituted itself, but colleagues were referring patients and depending on the hospitalists, and he had been given a leadership role on the hospital’s infection control committee.

“I didn’t understand why someone who had just finished residency was on the infection control committee,” Dr. Chopra recalls, “but it was great.”

Dr. Chopra decided to abandon his plans to return to a cardiology fellowship. And because he was able to make such hay in that first position, his next move “after his wife finished her fellowship three years later “was to take a hospital medicine job at the University of Michigan, where he has been for more than three years.

“The willingness to stick it out is key,” Dr. Chopra says. “Many of my younger colleagues don’t do that often enough. It’s like counseling before divorce: You learn that when you get it wrong, you need to be flexible and be able to adapt and make it right for you.”

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.

What makes for a good fit?

IF YOU WANT TO IMPROVE THE ODDS that your first hospitalist job won’t be merely a starter position, recruiters and veteran hospitalists offer the following tips:

  • Don’t pick a job based on location. “If more candidates would focus on the practice, not the location, they would make far fewer moves,” says Tommy Bohannon, vice president of hospital-based recruiting for Merritt Hawkins. “Upwards of 90% of practicing physicians who call us don’t like XYZ about their job. It’s very rare that someone says they want to leave because they love their job but they hate where they live.”
  • Do your homework. Don’t interview at a practice that doesn’t meet your list of needs. “It’s easy to get blinded by a great site visit and forget about the core problems that would make it a job that really isn’t for you, such as working nights,” says Regina Levison, president of Levison Search Associates in El Dorado, Calif.Ask questions about scheduling, night and ICU work, separate admitting/rounding shifts, information technology and CPOE, subspecialty access, rapid-response involvement, emergency department relationships, and the hospital’s long-term goals for its hospitalists.”The odds of finding a job with all 10 things you think are important to you in one package are pretty slim,” Mr. Bohannon says. “If you find seven or eight, you are probably going to be pretty happy over the long haul.” But when only two or three of your personal goals are being met in a practice, “dissatisfaction starts to creep in.”
  • Understand your ability to withstand chaos. Given how many hospitalist programs that hire new hospitalists are either starting up or undergoing a management shake-up, new hospitalists should expect a “chaotic” situation, says Kimberly A. Bell, MD, regional medical director for the Pacific Northwest Region with EmCare Inpatient Services, a national hospitalist management company.Questions to ask during an interview include: How long has the medical director been with the program? How long has the medical director been a hospitalist? What are the challenges the program is facing?
    “Even though candidates are new,” Dr. Bell says, “they have to understand they should be interviewing the practice just like the practice is interviewing them.”
  • Don’t underestimate the loneliness of relocation. This is especially true if you are single or from a culture that’s under-represented in the community you are moving to, Ms. Levison says. That unhappiness can be magnified by a seven-on/seven-off schedule, when you have nothing to occupy yourself in the off times.
  • Insist on a formal orientation program. The existence of an “onboarding program” is one reason larger groups and management companies often have more stable programs with less turnover, Ms. Levison says. An orientation program should include regularly scheduled reviews and interviews “perhaps at one, two, three, six and 12 months “to make sure new hires are learning to practice appropriately, are on track to earn productivity incentives and are not having problems that could be rectified.Effective onboarding strategies, says Mitchell Wilson, MD, chief medical officer with Eagle Hospital Physicians, also help hospitalists “grow roots” in a community.Without those, says Dr. Wilson, “it is easy to say, ‘I’ve done my tour of duty here. Where is the next place?’ ” Groups create what Dr. Wilson calls “stickiness” by doing everything from hooking doctors up with a place to worship to getting them involved on committees that match their professional interests.