Physician retention

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Physician retention is a topic worth considering as an increasing number of dissatisfied physicians and specialists opt for early retirement and non-clinical work. Doctors see their autonomy constrained by large managed care businesses, their incomes limited in certain specialties, their paper work and medical insurance increased, and their relation to their communities diminished. This deep personal dissatisfaction is causing physician turnover, especially among primary care physicians. Research shows that physician turnover results in high replacement costs for health care institutions, dis-enrollment and noncompliance rates among patients, and low quality and substandard care ^[1]. The growing turnover rates and decreasing number of primary care physicians in general is especially alarming due to the impending rush of baby boomers needing medical care in the next ten years and the low number of medical school applicants in recent years ^[2].

Contents 1 Reasons for physician turnover 2 Institutional costs for physician turnover 3 The key to physician retention 4 Physician/hospital partnerships 5 Trends for incoming physicians 6 Summary 7 References and resources

Reasons for physician turnover

Where is this deep dissatisfaction among physicians coming from? After World War II, the golden age of medicine beaconed intelligent young people to join the ranks in a prestigious profession where they enjoyed luxurious incomes, loyal patients, a dedicated staff, and an admiring community. While these perks have not completely disappeared, there has been a growing number of disheartened doctors in the medical community. In recent years, more than one quarter (27%) of employed physicians have considered leaving their practice within two years according to the Career Satisfaction Study Group (CSSG) in Chapel Hill, North Carolina ^[3]. Changes in the work environment have largely impacted relations between the physician and the hospital. Studies indicate that the main factors causing dissatisfaction are managed care’s complicated bureaucracy, dwindling leadership support, difficulty finding and paying for malpractice insurance, the physician’s lack of time, and society’s nearly impossible intrinsic expectations of the doctor.

Medical doctors lose their autonomy under managed care and, while there are relatively few doctors that are employed by HMOs, most doctors are involved with at least one managed care contract and are forced to know all the rules of the HMO directly. Because the HMOs force the physician into an employee status, physicians feel less loyalty to their practice and to the hospital. Thus, this loss of autonomy along with an array of administrative rules and bureaucracy has resulted in a dramatic increase in turnover rates. HMO official procedures also result in physicians feeling pressed for time. While the length of time a doctor spends with a patient has increased since the 1990s ^[4], the wide spectrum of tests, schedules, emails, regulations, insurance and legal issues related to individual patient care has sky-rocketed.

Today’s practice of “defensive medicine” hampers physicians with tedious amounts of paperwork and administrative defenses; they cannot afford not to subject the patient to every type of test, procedure and technology in fear of malpractice lawsuits as well as prosecutions under the Stark Laws. More and more, physicians practice medicine on the insurance agencies' terms and on litigation threats, often forgoing the best interest of the patient ^[5]. In addition to the host of ethical questions shrouding malpractice insurance, the insurance has become difficult to obtain. Medical malpractice premiums have soared to new heights with increases not seen since the 1970s and 1980s.^[6]. Varying by state, physicians have seen a 40-60 percent growth ^[6] in premiums. Along with large educational debts, many physicians are nervous about the financial burdens they carry. If the rise in premiums has no regard to the physician's quality, such insurance will do nothing to prevent physician negligence.

The United States is not the only place where doctors explicitly describe their unhappiness with their profession; it is happening all over the world. In Great Britain, physicians complain about having too many tasks, not enough support, and ostentatious but empty promises of health care reform made by politicians ^[7]. Rather than solely concentrating on patients’ health, physicians also must serve as administrative managers, litigators, accountants, insurance experts, counselors, etc. Because doctors around the world are complaining about similar issues, the problem may be rooted in the expectations of modern medicine^[5]. Physicians do understand the limitations of what they can do; yet, they feel society assumes they have all the answers. In light of these assumptions, physicians still try to maintain such expectations of themselves. Thus, the lifestyle can be an emotionally overwhelming one.

Institutional costs for physician turnover

Physician turnover is expensive in many ways. When a physician leaves, the hospital swallows the cost of the physician's business as well as the cost of training a new one. In addition, the hospital deals with patient dissatisfaction and non-compliance issues, disruption of productivity within the hospital working environment, and basic destabilized flow in the work place. The estimated cost of losing a physician is about $250,000 ^{[3] [8]}.

While psychological reasons largely contribute to the high rate in physician turnover, labor economics also play a part in the turnover rate. HMO administrators complain that physicians are not adequately trained in medical school to work within managed care. Thus, when new doctors finally enter the field, they must be more specifically trained. Once trained, however, the physicians choose to leave for better opportunities that HMOs cannot offer. Thus, the HMOs incur the cost of training new physicians who may decide to leave in just a few years ^[8], and the cycle continues. The few journals that have studied the economic patterns for physician turnover have not found correlations between the physician’s intent to quit and their net income; rather, they have linked the way income is distributed among physicians to the disparity found between productivity and income. They also have found that the early desire to quit is the most pointed marker toward actually quitting ^[8].

The key to physician retention

Retaining the physician in the long run depends on early attention paid to particular conditions met by the medical and economic environment. Why? As previously stated, the physician’s early desire to leave his or her job is the strongest clue that he or she will leave within the next couple of years.

Incentives are often great ways for a facility to keep their doctors, but it’s important to remember that physicians are also motivated by the satisfaction of a job well done; they hold their professions in esteem. Ultimately they want to be good doctors, and a good system allows them to accomplish this in a number of ways. Kaiser Permanente, a non-profit health care provider based in Oakland California, reports ten evidence-based practices for effectively retaining physicians.

1. Realistic job preview and behavioral interviewing: let the physician know what the company looks for and hire according to shared values.
2. Essential startup resources and administrative processes planned and in place
3. Practical, timely, comprehensive orientation program delivered in multiple ways
4. Physician enculturation, socialization, and creating feelings of belonging
5. Mentoring program: have a program in place where a seasoned physician can act as mentor and go-to person to the newly hired.
6. Perceived control over the practice environment: make sure the physician doesn’t feel overwhelmed from the beginning.
7. Accurate, effective, and timely feedback
8. Recognition, rewards, opportunities for advancement and career development
9. Open and trustworthy communication, belief that management listens and acts on suggestions
10. Reduction of stress in the workplace ^[1].

Physician/hospital partnerships

Strong relationships between physicians and their organization support overall performance improvement. A study performed by the health policy department at Thomas Jefferson University found that many physician executives feel that there is little cohesion among medical staff. This lack of solidarity strongly correlates with low physician support of organizational priorities as well as low physician involvement in organizational endeavors ^[9].

The Health Alliance of Syracuse recently established a plan to create a physician-organization partnership that allows for senior management to closely work with and support physicians. The CEO and other senior management are responsible for correcting process failures that the medical team needs fixed and directly contacting the appropriate coordinating committee to make the improvements proposed by physicians. The Syracuse group found that reducing cost per case or length of stay is not enough to motivate physicians to aim for performance improvement. Each project must have personal meaning in order to create buy-in or cultivate physician champions^[10]. From today’s viewpoint, health care’s underlying structure is built on managed care. Thus, hospitals and physicians can only function as cooperating partners with aligned incentives and collaborative initiatives in place. Managed care must work to create successful contracts between hospitals and physicians for the system to find a decent level of functionality.

Trends for incoming physicians

The year 2016 is said to be the peak of the health care crisis. This is when the baby boomers will hit their 70’s and when today’s matriculating classes will be 2016's new doctors. This causes concern because the rate of students entering medical schools is less than the needed number to care for the growing patient population. Recent data shows that the number of medical school applicants had begun to drop in 1995 to an all time low in 2003. For example, from 1997-1998 to 2002-2003 the number of applicants decreased from 21.8% ^[11]. Even with the decline in applicants, medical schools have been forced to make room for more students as they prepare for looming medical shortages in the future. Because this move has reduced competition slightly, more people have begun to apply again. Fortunately, the entering class of 2005 is the largest on record with a major increase in Hispanic, Asian and male enrollment ^[12]; in one way, this is an encouraging indication that as medical demands increase, more people will commit to the medical field.

All over the nation, medical schools urgently try to increase enrollment, yet they are not sure their plans will be sufficient. Even if schools accept more medical students, they must provide residencies that are not easily created. Providing residencies has been difficult for states with quickly growing populations such as Oregon, New Jersey, and Florida. Many states have resorted to adding branches to their state school systems in addition to boosting enrollment in their established schools. Plans for new schools are already underway in at least seven states as well as partnerships between medical schools and large American healthcare systems ^[13]. Yet, these enrollment increases are small even with all the proposed plans. The Director of AAMC’s Center for Workforce Studies reports that “a 30 percent increase will only add about 5,000 new graduates a year (which is about half of one percent of total doctors), when the U.S. population is growing at a more rapid rate annually. To meet the future health care needs of Americans, this recommendation is actually a modest one ^[13].”

The drops and increases of medical school applicants have always been periodic in nature, and today we are seeing another increase in applicants since the drop in 2003 ^{[graph A]}. Also, in a long-term scope, the data does not show doctors retiring earlier or going into non-clinical work at significant rates. In the past 25 years, the rates have stayed the same ^[14]. Perhaps recent data is not a reflection of the medical profession diminishing in the eyes of students but just a function in the natural cycle of the economy and society. While it is comforting to know the data reflects historical fluctuations, it is important to realize that society and its needs are changing drastically. Medical schools must take the responsibility to build the infrastructure needed to prepare doctors to face the shortages of the future.

Summary

High turnover rates among physicians in practice wreaks havoc to the core of health care culture. Losing good doctors costs an institution in ways that lower quality and productivity. Directly, health systems must front the cost of losing and training doctors; indirectly, patients become more non-compliant and agitated, the medical staff’s work-flow is disturbed, and the hospital’s ability to standardize care is threatened.

Modern medicine is wrought with difficulties that have become insurmountable for many physicians. Physicians wrestle with a constant lack of time, malpractice problems, and misalignment between administrators’ goals and their own on account of the bureaucracy behind HMOs. Such conditions result in low physician morale and loyalty which leads to job dissatisfaction. The high rates of turnover can be eased if the problem is viewed through a system wide lens and dealt with at the root of the issue. An early focus on retaining physicians is key and should be done through a strong orientation and mentoring program followed with timely constructive feedback, monetary and project incentives, and opportunities for career advancement. Also, it is important to recognize that today's recent graduates and matriculants of medical school are tomorrow’s doctors and will support the brunt of the baby boomer patient population. Infrastructure should be put into place so that these physicians will be prepared for society’s impending demands.

References and resources

1. ^ King H, Speckart C. Ten evidence-based practices for successful physician retention. The Permanente Journal. 6(3): Summer 2002
2. ^ Barzansky B, Etzel SI. Educational programs in US medical schools, 2004-2005. JAMA. 294 (9): 1068-74 2005 Sept. 7
3. ^ Pathman D. Konrad T. Williams E. Scheckler W. Linzer M. Douglas J. Physician Job Satisfaction, Job Dissatisfaction, and Physician Turnover. The Journal of Family Practice. 51(7) 2002 July
4. ^ Mechanic D, McAlpine DD, Rosenthal M. Are patients’ office visits with physicians getting shorter? N Engl J Med. 344:198-204. 2001
5. ^ Zuger A. Dissatisfaction with medical practice. N Engl J Med. 350 (1):69 –75. 2004 Jan. 1
6. ^ Thorpe K. The medical malpractice ‘crisis’: recent trends and the impact of state tort reforms. Health Affairs: The Policy Journal of the Health Sphere. 2004 January 21
7. ^ Smith R. Why are doctors so unhappy? BMJ 322: 1073-1074. 2001 May 5
8. ^ Buchbinder S. Wilson M, Melick C, Powe N. Estimates of costs of primary care physician turnover. Health Economics. 5(11):1431-1438. 1999 November
9. ^ Bard, M. Buehler M. Epstein A. Nash D. O’Conner J. Strong partnerships make good partners: Insights about physician-hospital relationships from a study of physician executives. Disease Management. 5(3): 137-142 2002 September
10. ^ Hosler FW. Nadle PA. Physician-hospital partnerships: incentive alignment through shared governance within a performance improvement structure. Jt. Comm J Qual Improv. 26(2): 59-73. 2000 February
11. ^ American Association of Medical Colleges Data Warehouse. Applicant matriculation file. (Accessed May 19, 2006 at http://www.aamc.org/members/wim/statistics/stats05/)
12. ^ American Association of Medical Colleges Press Release. Hispanics, Asians and Men Fuel Upsurge in Applicants. (Accessed May 12, 2006 at http://www.aamc.org/newsroom/pressrel/2005/051025.htm)
13. ^ American Association of Medical Association Reporter: April 2006. Medical Schools Work to Expand. (Accessed May 12, 2006 at http://www.aamc.org/newsroom/reporter/april06/expansion.htm)
14. ^ Barzansky B, Etzel SI. Educational programs in US medical schools, 2002-2003. JAMA. 290 (9): 1190-6 2003 Sept. 3