Keeping the group together: What spells success?

If you're part of the management of your practice, you may have heard colleagues leaving for a new position say: "I feel undervalued."

"There's not enough support."

"The pressure is too great."

In some situations, it might not be so bad to see that physician go. Perhaps he or she resisted the established culture, didn't meet the group's productivity expectations. Or, the issue could be outside the practice, such as a spouse who didn't like the community.

But it also could mean that your group didn't put enough effort into retention.

In all the talk about landing the right candidate, the concept of retaining that physician sometimes gets lost. The two ideas are interconnected, but with the daily pressures of running a practice, it's sometimes easy to forget that the sales effort doesn't end when the physician takes the job.

Consultants and group leaders say it takes honest, targeted recruiting and responsive leadership to retain your best doctors. In the interest of both harmony and fiscal responsibility, less turnover should be a goal of every practice; after all, losing candidates a couple of years after you hire them is certainly a more costly mistake than not being able to hire them in the first place.

"Most groups have a strong compensation and benefits package, but it takes a lot more to keep people long term," said Marc Greenwald, MD, chief medical officer and a critical care internist at Fallon Clinic, a 240-physician multispecialty group based in Worcester, Mass. "They look for that warm and fuzzy sense of belonging. That can occur by accident or by design."

The design, however, is not as common as you might think, according to a recent survey conducted by Cejka Search, a St. Louis-based health care search firm, and the American Medical Group Assn.

According to the survey, which compiled responses from 67 groups of different sizes from around the country, 73% of the practices had some method of tracking turnover, but only 27% had a formal, written retention plan. The average turnover rate was 9%, though smaller groups reported a rate of less than 5%.

The survey also reported that more than half the physicians who leave their groups do so in the first five years of joining, and many make their decision to leave in the first few months. Practice issues was the leading reason for voluntary separation, at 31%, followed by compensation at 20% and location at 13%.

Whatever the reason, the group is left having to spend an average of $3,000 per candidate -- including the cost of travel and entertainment for the spouse -- to fill the open position, according to estimates by Cejka Search.

"If they feel dissatisfaction, they feel it early," said Carol Westfall, Cejka president. "The conclusion that comes to mind for me is there might have been a selection problem, or maybe there's a problem at the orientation stage. Perhaps they're not set up well enough for success."

Getting off on the right foot

Nearly all of the groups surveyed reported having an orientation program for new physicians. But that concept could have many different definitions, from handing the physician a policy handbook to having him or her spend time with each department in the office to learn how the group operates.

For Fallon Clinic, the orientation begins as soon as the physician accepts an offer, Dr. Greenwald said. The group's retention plan calls for regular contact with the new doctor between the hire and start dates, as well as a detailed orientation program that teaches the operational basics of the clinic, he said.

The group also has a shadow program, where every new physician follows eight "role model" physicians -- three primary care doctors and five specialists -- over half-day periods to learn more about these colleagues and how they work.

"It's a chance to bond with the individual, so you get a higher level of attachment," Dr. Greenwald said.

In smaller groups, such an extensive program might not be possible, but leaders still can accomplish the same goal of attachment through regular contact and making sure the physician has the necessary tools to succeed.

"A lot of retention is based on physician satisfaction stuff," Westfall said. "It means a lot of communication with the physician in the first month, the third month, and so on, from key people. The conversation is built around 'Have we delivered on what we've promised?' and 'Anything we haven't come through on?' "

In a typical practice, any partner or shareholder can take on that role, and as more physicians take the time to check on a new colleague, it shows that the physician won't be forgotten or lost in the crowd.

Michael Scharf, MD, an orthopedic surgeon and president of Jacksonville (Fla.) Orthopaedic Institute, a 23-physician group, said the partners make a point of welcoming new physicians and offering them assistance.

"Depending on what site [the new physician] is at, there's always people around to help them," he said. "That's done by everybody."

Jacksonville Orthopaedic has never had a physician leave on his or her own volition, Dr. Scharf said. Out of the 23 physicians, 20 are partners in the group, while the other three will have the opportunity to buy in after two years.

"We only recruit what we need," Dr. Scharf said. "So from day one, they're busy."

Honest expectations

During the recruitment process, there's a natural tendency for both the candidate and the group to put their best feet forward.

For the physician, it might mean professing to love that particular region of the country or claiming not to mind the call schedule. For the practice, it could mean making overly optimistic revenue projections or painting a picture of the local managed care market that's brighter than reality.

While it's tempting to offer all sorts of concessions and make grand statements about the group, honest expectations of a doctor's performance and projections of the development of his or her practice are the best ways to ensure a solid relationship from the start, group leaders said.

If a physician comes into a group with lofty expectations that aren't met, then he or she might feel disappointed and begin to regret taking the job, said Kurt Scott, associate vice president in the Dept. of Professional Staffing for Geisinger Health System, a largely rural network of 42 clinics and several hospitals across northeastern Pennsylvania. If one physician leaves, it can create a snowball effect, he said.

"It causes other physicians to think, 'Maybe I should leave, too,' " Scott said. "It boils down to leadership, if you drill down to the most simplistic level. If you're not getting the support you need, you don't have good leaders."

Geisinger uses some of its best leaders to make up its senior search committee, which interviews candidates and presents the health system at the same time.

"You've created a committee that becomes expert in assessing candidates and selling the organization," Scott said, "so you can attract the people you want."

A thorough hiring process, including background and reference checks, can help separate the mere job-seekers from the doctors who are dedicated to finding the right fit. Interviews become lengthy events that are far more involved than a few hours in the conference room. Many groups also ask, if not insist, to meet the physician's spouse as well, knowing how vital a happy family is to a physician's decision to move and to stay.

Geisinger Health System uses a formal retention plan that includes a spousal recruiting committee, where other physicians' spouses spend time with the wives and husbands of candidates to help them get comfortable with the area. The system takes that concept a step further once the candidate accepts the job.

"A real critical time is the first year to two years, when the doctor first comes, when he makes the decision if he made the right choice," Scott said. "A critical piece is how the family gets acclimated, so we set up social events. This summer, we'll have a barbecue for families. We need to get these folks together."

Jacksonville Orthopaedic Institute pays close attention to a candidate's roots when trying to fill a position. While Florida is a desirable practice location for many physicians, climate will often lose to family ties when it comes to making a decision. The group also connects the new doctors with a real estate agent who knows the area and can help them comfortably choose a home from a distance.

"A lot of people we've extended an offer to have family ties to the area," said Patrick Hinton, executive director of the group. "That probably helps with retention as well."

Whatever the tactic, the groups that pay attention to the nuances of physician retention can help protect the practice financially and help maintain its culture. "Any extra attention helps," Westfall said. "The senior leaders should have visible contact with the new hire, so the new hire knows they're known."