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Recruiting? Make sure you hire right

Strategies to help you avoid less-than-ideal hires

September 2021

AS HOSPITALIST GROUPS try to emerge from the pandemic, recruiting is again heating up.

According to a presentation at this year’s Society of Hospital Medicine (SHM) meeting, hiring the right hospitalist—that was the name of the session—is like putting together an elaborate puzzle. You want someone who will be a great team player, but you also want candidates to complement the strengths and skill sets that your group members already have.

“It’s ultimately about fit,” said Rachel Cyrus, MD, one of three session presenters. “I don’t mean how similar candidates are to your group, but rather how they might complement and contribute to your mission.”

Plan ahead
According to the latest SHM survey data, one in 10 hospitalist positions each year goes unfilled. That mirrors the annual turnover rate of 11% for hospitalist groups that treat adults.

“It’s ultimately about fit.”

Rachel Cyrus, MD

~ Rachel Cyrus, MD
Northwestern University Feinberg School of Medicine

As Dr. Cyrus, a hospitalist with Chicago’s Northwestern University Feinberg School of Medicine pointed out, “this turnover is predictable. But we always seem surprised that we’re short-staffed.” And when you don’t plan ahead to address that turnover, “you end up in a vicious cycle of turnover amplification. Someone leaves, so the rest work harder—and then they all start to leave.” Your colleagues burn out, hospitals suffer financial losses and you settle for less-than-ideal hires because you’re desperate to fill uncovered shifts.

To avoid all that, Dr. Cyrus urged groups to get out in front of their staffing needs. For several years now, her program has hired what she called “a buffer,” a hire (or hires) that put her group slightly ahead of its predicted staffing needs. (See “Building in a staffing cushion.”)

Her co-presenter Hardik Vora, MD, MPH, said he tries to anticipate staffing shortages through frank and open discussions with each hospitalist in his group during annual reviews.

“It’s important to identify your at-risk individuals,” said Dr. Vora, medical director of hospital medicine for Riverside Health System in Newport News, Va. “I put them each into a green, yellow or red category based on how likely they are to stay for the next two years.” Plus, the members of his group are credentialed across all the facilities in their health system. “That’s very helpful when you have unmet and unexpected needs.”

Presenter Paul Helgerson, MD, vice chair of medicine at University of Virginia Health in Charlottesville, noted that cultivating a group of part-time clinicians as well as community physicians who may want to get back into academia can help augment staffing as well.

“You want some body who will lead with the positive.”

Paul Helgerson, MD

~ Paul Helgerson, MD
University of Virginia Health

“They’re not as beholden to the July swap,” Dr. Helgerson said, “so they’re better able to buttress staffing at other times of the year.”

Know your strengths and weaknesses
Even before you meet with potential recruits, figure out your group’s strengths and weaknesses. According to Dr. Helgerson, one strength of his academic program is the diversity of its clinical roles.

“We tend to win on quality and education,” he said, “but we’re weaker on written scholarship. You can turn some weaknesses into recruiting points by making them directions you want the group to grow.”

Dr. Cyrus’ program stays on top of what group members love about their job (and what they don’t) through annual workplace surveys. She shares those insights with potential candidates.

“I also do exit interviews with people who are leaving,” she said. And she finds it helpful to ask candidates who both accept and turn down offers what influenced their decision to either join or go elsewhere. Another do-ahead item: Make sure any offer you make will be competitive.

“You need to know the local and national market,” said Dr. Cyrus. That includes not only compensation and workload benchmarks, but finer points as well: How much of the salary is guaranteed vs. part of an incentive? How much clinical support can hospitalists draw on from advanced practice providers and/or nurses? And how much protected, nonclinical time can physicians in academic programs expect?

“We actually reach out to local practice and program directors who are our competition,” Dr. Cyrus pointed out. “We ask them to share some of their data, and in return we share some of ours.” That’s proved useful not only in hiring but in negotiations with her own hospital.

Early red flags
UVA’s Dr. Helgerson said he has abandoned the notion of recruitment as an annual cycle. “I think of it as a continual process,” he explained. To ensure a good pipeline of potential candidates, he urged groups to actively cultivate local relationships with residency programs.

“It’s OK to ask candidates for the references you feel you need if they’re not providing them.”

Hardik Vora, MD,

~ Hardik Vora, MD,
MPH Riverside Health System

His program has also realized the value of maintaining a greater Web and social media presence. “That’s something we don’t have a lot of experience with,” he noted. “But it’s helpful when recruiting outside your region.” Social media is great to highlight group members’ scholarship and success stories.

As for screening candidates, that’s impossible for just one person to do. “Pull in a broader group of successful hospitalists to look at each applicant,” Dr. Helgerson said. “They’re going to identify different strengths.” When first reaching out to potential recruits, “explore their expectations. How well does that match up with what your program is good at?” Even in the initial stages, watch out for red flags. One, he said, is candidates who take a “shotgun approach.”

“When I see a cover letter that talks about how excited the candidate is to interview at Wake Forest when I’m here at UVA, that tells me she or he filled out 20 of these and is just circulating them,” Dr. Helgerson said. “I see a handful of those every year.” Also concerning is when candidates’ written communication is a mess.

“That generally shows a lack of preparation,” he said. “Anybody can find friends to help tighten up what they write.” And most concerning: “Someone who’s running from a program rather than to one. You want somebody who will lead with the positive.”

Getting the most from the interview
When candidates make it through screening and arrange an interview, make sure everyone on your side is organized. Can they “speak to a unified vision of what the program is and where we’re headed strategically?” Dr. Helgerson pointed out.

Take advantage of multiple interviewers, and have each take a particular focus. “I might go deeper into what draws a candidate to this area or hospital,” he said. “One of my colleagues might focus on what the candidate wants from a mentoring relationship or an academic focus.”

As for favorite questions, Dr. Vora said he asks all candidates how they think hospitalists add value to their organization. He also asks about what would make their work day stressful or what one thing they would change about where they work now.

As for Dr. Helgerson, one of his favorites isn’t really a question. Instead, during interviews he’ll bring up a clinical dilemma he and his group are facing. “With one candidate,” he recalled, “I mentioned the debate we were having in orthopedic comanagement over whose job DVT prophylaxis was, the orthopedist’s or the hospitalist’s.” Such a discussion can give you insight into a candidate’s ability to collaborate.

Be sure to build informal get-togethers into the day as well as formal interviews. “In addition to the five interviews we’ll do, we want the candidate to have an informal lunch with more junior hospitalists,” he said. Dr. Helgerson will get feedback on the candidate from those who meet with him or her informally—and from the nonphysician staff.

“One big alarm is when staff aren’t treated with the same respect as the rest of the group,” he said.

During interviews, Dr. Helgerson is put off by what he called “an overly transactional approach” from someone who up-front wants to negotiate shift numbers or census figures. “Those can shift over time and lead to unhappiness,” he noted. “Our group tends to focus instead on more long-term career development.”

He also looks for transparency in terms of career plans. “I’ve no problem with a candidate who wants to stay only one or two years,” he said, “as long as it’s transparent and I know what to expect. That’s an agreement we can enter into with a mutual understanding.”

Don’t stint on reference checks
In many groups, checking references tends to be rote, “just a check-the-box part of the recruitment process,” said Dr. Vora. He thinks that’s a big mistake. Information he’s gleaned from speaking with references—and he always prefers to call and speak with them in person, not via e-mail or letter—has changed his hiring decisions.

Some reference questions always crop up. Who, for instance, should be contacting references? “Group leaders should always be involved in that process,” he said. “I’d also suggest bringing in recruitment committee members and nonclinical administrative partners, if needed.”

How many references do you need? “There’s really no magic number,” said Dr. Vora. “Stop checking when you get the information you’re looking for.” He wants a variety of references who can collectively provide a comprehensive view of a candidate. “If the references are too similar, more is not helpful.”

As for the quality of references, he insists on speaking to program directors when considering candidates right out of residency or to a hospital medicine group leader when considering an experienced hospitalist.

And “it’s OK to ask candidates for the references you feel you need if they’re not providing them,” he pointed out. He’s alarmed when candidates give only friends or other residents or fellows as references, or all the references come from candidates’ previous positions, not their current one.

Dr. Helgerson mentioned another reference red flag that crops up: having to spend too long tracking a reference down. “Yes, we’re all busy,” he said. “But if I’m really struggling to connect with a reference, I start wondering if they’re taking the time to figure out how to portray that person in a positive light.”

Key reference questions
When speaking with references, Dr. Vora relies on the following questions: How is performance measured at the candidate’s hospital or program, and how did the candidate do on those metrics? What nonclinical area would a candidate be most likely to succeed in? Where does the candidate have room for improvement? And when was the last time a program director had to sit down with the candidate to talk about clinical or interpersonal concerns?

That last question, he said, can be very revealing. One candidate he was considering was coming from a prestigious residency and interviewed very well.

“But when I asked the program director about clinical and interpersonal skills, I heard that the candidate had been put on a performance improvement program,” he said. “The program director finally admitted that she wouldn’t hire that candidate for her own program.”

On the other hand, another candidate who Dr. Vora’s group was considering hadn’t made a great first impression. She had, through a comedy of errors, missed her interview breakfast, and her reference list had some typos.

“But her references were outstanding, and we hired her on the basis of them,” said Dr. Vora. “She’s one of the best hires I’ve made in a long time.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Building in a staffing cushion

CHANCES ARE, you have a good idea how many members of your group take family leave every year or go off to pursue a fellowship. But too often, programs make the mistake of not anticipating such staffing shortfalls and not hiring in advance against them.

At a session on hiring at this year’s Society of Hospital Medicine meeting, presenter Rachel Cyrus, MD, pointed out that her group at Chicago’s Northwestern University has relied for several years on what she called “a game-changer”: hiring a “buffer,” a hire (or hires) that put the group slightly ahead of their predicted staffing needs.

Buffers allow you to respond to the losses you know you’re going to have. “You’re just hiring them earlier to avoid the gap,” said Dr. Cyrus. Having that new hire already on board helps reduce the stress of turnover and being understaffed. It also allows your group to expand its bandwidth and work on added value projects.

“And you can be picky,” she said. “You’re hiring at the time you want to hire.” Even with buffers, “we still always need moonlighters,” which is a boon for group members who want to pull extra shifts.

But there are risks to such hiring, she admitted. For one, RVUs per FTE with buffers can be decreased, “at least for a period of time.” And buffer hospitalists can be tricky to schedule. But the fear that early hires will go unused has never materialized.

“Try to quantify your biggest staffing shifts per year and decide if that number of FTEs is consistent from year to year,” Dr. Cyrus said. “Then, bake it in.”

Published in the September/October 2021 issue of Today’s Hospitalist

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