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Weekly UpdatesThe National Physician and Nurse Supply Survey revealed that among hospital CEO respondents, 68 percent view physician shortages as a serious problem that must be addressed (Caldwell 2007). In the last column (Cohn and Harlow 2009), we outlined ways that the recruiting process could differentiate hospitals and alleviate physician shortages. In this column, we address the challenges of physician retention and the strategies to improve the practice environment. Specifically, we discuss physician frustration, workplace burnout, and three elements of a proactive retention strategy. Also, we present the case of a medical group that recognized a physician retention problem and implemented an on-boarding system as a remedy.
PHYSICIAN FRUSTRATION
Physician job satisfaction has decreased because of increased workload, lower reimbursement, and feelings of powerlessness and disenfranchisement. Morrison and Smith (2000) coined the term "hamster health care," writing that physicians feel like hamsters on a treadmill, running faster without getting anywhere.
Physicians' feelings stem largely from their inability to control global trends, including cost/reimbursement pressures, consumerism, aging, migration of care to outpatient settings, and nursing shortages. Thorough medical training has not prepared most physicians to deal with the challenges of working in rapidly changing marketplaces, building consensus, and resolving conflict (Cohn and Peetz 2003). If these feelings are left to simmer without intervention, burnout can ensue.
WORKPLACE BURNOUT
Burnout occurs when work responsibilities or personal demands exceed one's ability to cope, resulting in psychological distress, physical symptoms, and/or clinical errors that lead to patient morbidity and mortality (Cohn, Panasuk, and Holland 2005).
The Maslach Burnout Inventory has three components: emotional exhaustion, depersonalization (decreased empathy), and lack of personal accomplishment (Kash et al. 2000). A study of 382 practicing U.S. surgeons documented that 32 percent of those surveyed suffer emotional exhaustion, 13 percent have feelings of depersonalization, and 4 percent experience feelings of low accomplishment. The study's authors commented that medical residents are taught how to perform surgery but not how to live life as surgeons (Campbell et al. 2001). These factors weigh heavily in determining retention.
The following case demonstrates the journey that the Banner Medical Group undertook to improve physician retention.
CASE STUDY: BANNER HEALTH'S ON-BOARDING PROGRAM
Banner Health, headquartered in Phoenix, Arizona, began employing physicians in 2004 to ensure adequate primary care coverage for its patient population and to provide help with subspecialty call coverage. Banner Health operates ten hospitals in Phoenix and one hospital in northern Arizona, and it owns an employed physicians' organization known as Banner Medical Group (BMG).
When the rate of physician turnover reached 10 percent, BMG's leadership developed and implemented an on-boarding program. The premise was that the more engaged a newly employed physician felt, the lower the risk that the physician would leave prematurely.
The on-boarding program, which has been used to orient approximately 30 physicians into Banner Health, begins on the first day the physician reports to work. It is based on a mentoring approach, whereby the physician is coached by another physician who has more experience with and knowledge of a given environment, process, or system. The only difference from the traditional mentoring relationship is that Banner Health's on-boarding program is not the responsibility of a single person. Rather, the responsibility can be shared among several participants (see the "Co-Mentoring" section later in the article). For example, one veteran physician could introduce the new physician to colleagues at the hospital, while another could coach the new physician on the system and its culture. Banner Health's on-boarding program typically lasts for one year. At the end of this period, the new physician can sign up to become a mentor for another newly hired physician, thereby perpetuating the benefits of the program.
Although several people can mentor newly hired physicians, one physician takes primary accountability to field questions, coach, and provide productivity tips and encouragement. Expectations for the primary mentor include familiarity with clinical guidelines, evidence-based medicine, core measures, process improvement, and leadership/relationship development. The emphasis on the word "relationship" is critical because physician effectiveness and satisfaction depend on interactions with fellow physicians and allied health professionals, over whom the physician has influence but not the authority to hire or fire.
At the beginning of the on-boarding program, BMG's chief medical officer (Bruce Bethancourt) carefully selected the mentors. Also, a consultant (Ken Cohn} was hired to develop a mentors' orientation program a few months before the new cohort of physicians arrived. The orientation for mentors involved several sessions of training, where the consultant provided a briefing on the rationale for the new program and taught co-mentoring, leadership, and communication skills in an interactive setting.
The on-boarding program has three goals:
1. Create and maintain a physician environment that promotes a high level of care, technical competence, patient-staff relationships, and productivity.
2. Retain a high percentage of new physicians by providing an environment conducive to practicing quality, patient-centered medicine.
3. Help physicians and their families feel connected to their communities. (For example, by sharing tips about where to shop, dine, and relax.)
Figure 1 is a flowchart of the various steps in the on-boarding process. The process begins with a general orientation, introducing the new physician to Banner Health's mission and vision; services and programs; locations of Banner's facilities; and the specific layout of the physicians' offices, laboratories, and meeting rooms.
Also, the new hire receives practical information about the institution in which he or she will serve, including details about its daily operations, computer system, compliance and patient safety policies, hospital bylaws, and other medical staff issues.
Results
One year after the on-boarding program was initiated, not a single new physician left BMG, which is a sharp turnaround from the 10 percent loss the group experienced previously. Before the on-boarding program was launched, discontent among the new physician hires was evident within months of the hire date. Since the on-boarding program began, however, everyone who has worked with the new physicians (including allied health professionals) has noted an improvement in physician morale and in the practice environment.
ELEMENTS OF A PROACTIVE RETENTION STRATEGY
Physician retention should be a top priority for senior leaders and should be a focus of performance reviews and incentive compensation. For hospitals to thrive, retention must be every senior leader's business, not just the section chiefs or department chair's responsibility.
A proactive physician retention strategy is critical to preventing attrition as a result of burnout, frustration, and other factors. In this section, we discuss three elements that are fundamental to a successful retention strategy: (1) learn the reasons that physicians leave, (2) seek feedback and input from physician champions who remain with the organization, and (3) encourage physician participation in co-mentoring.
Find Out Why Physicians Leave
Gathering information on why physicians leave unexpectedly is akin to making a diagnosis before instituting a clinical therapy or intervention. A study of more than 1,500 physicians revealed the top three elements that physicians seek in their careers (Wong 2009, 23-26):
1. Meaningful work that makes a difference
2. A sense of community
3. Affirmation of their value by regular, reliable, positive feedback
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Rarely is compensation the primary reason for departure (Atchison and Carlson 2009).
Talking with physicians who have left can identify, in retrospect, the factors that contribute to physician satisfaction, such as the following:
* Clear expectations. Cultural fit is important. A formal compact between the physician and the institution can clarify the reciprocal expectations necessary for a thriving relationship (Shukla, Meyer, and Stingl 2009).
* Ongoing communication. The responsibility for regular communication falls on both the physician and healthcare leaders--effective communication must be two way. Most importantly, communication must begin rather than end with the signing of the physician contract.
* Recognition, appreciation, and respect. As discussed in Wong's (2009) study, meaningful work, a sense of community, and affirmation are key elements of a satisfying long-term physician career.
* Consideration of spouse and family needs. Keeping physicians connected to their respective community means paying attention to their family needs. A spouses network, for example, can be both diagnostic and therapeutic: It is diagnostic in that spouses may bring discontent to the attention of someone who can correct a problem in time and thus keep the physician in town. It is therapeutic in that having someone to talk with can validate concerns and make a person feel affirmed, even if the solutions to a problem are not immediately evident. A spouses network should include men as well as women (Cohn 2009).
* Support and helping hand. Sometimes showing support to a physician may be as simple as asking open-ended questions, such as "Is there anything you need?" or "What can I do to help?"
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