Hospital medicine groups depend on camaraderie and expertise to carry them through long days and heavy workloads. Group cohesiveness—often fragile—depends on recruiting and keeping hard-working doctors who pull their weight professionally and boost the group’s chemistry.
In a field with five job openings for every qualified candidate, and average annual turnover at 12%, hospital medicine groups can ill afford a bad hire. Whether that person is a practice killer, a cipher who blends into the wallpaper while collecting a paycheck, or a doctor marking time until a fellowship or something better comes along, the group leader must quickly limit a bad hire’s negative impact.
Recognizing that competition to hire hospitalists is fierce, it may seem that avoiding or axing a bad hire—the physician who either doesn’t mesh with your team, is a professional and/or personal train wreck, or has a blue-ribbon pedigree, but performs poorly—is a luxury hospitalist groups can’t afford.
But as Per Danielsson, MD, medical director of Seattle-based Swedish Medical Center’s adult hospitalist program has learned the hard way: “No doctor is better than the wrong doctor. I don’t sugarcoat the demands of our program with prospects. We’re a seasoned hospitalist program, we work hard, and, if we have a position vacant, we’ll work even harder for short periods of time until we find the right person.”
With a hospitalist group of 25 providers, Dr. Danielsson spends more time than he’d like recruiting and interviewing candidates, but he considers it time well spent. “The CV and interview are important, but I’ve devised a list of 12 personality traits that I consider important,” he says. “I share the list with candidates to see if we have a good fit.”
Chris Nussbaum, MD, CEO of Synergy Medical Group, based in Brandon, Fla., says: “They don’t make doctors the way they used to. I don’t see why some hospitalists think seeing 20 to 25 patients a day is such a big deal. I’ve had several tell me that 20 patients a day is no problem—and then they only last one day.” When that happens, Synergy cuts its losses, not allowing a bad hire to linger.
Dr. Nussbaum didn’t think twice about firing one new hire—a physician with an impressive resume who, while writing chart notes at a nursing station, watched a nurse have a seizure, gathered his notes and left the room. “He expected an endocrinologist standing nearby to help out, but it’s outrageous that any hospitalist wouldn’t respond appropriately,” he says. Such callous behavior would send shock waves through any group, and that physician was fired on the spot.
Another organizational disrupter, briefly employed by IPC-the Hospitalist Company (North Hollywood, Calif.) made inflammatory remarks about a hospital’s pre-eminent specialist and other referring physicians. He was fired. Several hospitalist leaders report hiring physicians with stellar pedigrees whose hands consistently strayed to nurses’ derrieres. Those doctors were quickly shown the door.
Robin Ryan, a career coach from Newcastle, Wash., who has prepared office-based physicians for professional moves to hospitalist careers, says the new career path can be confusing. When a physician and a hospitalist group have made a mistake, Ryan says most groups cut their losses by terminating someone who doesn’t fit. “Contracts often require a hefty severance fee, but it’s often the road that groups take,” she says.
To weed out potential bad hires, employees long have used personality tests. Such tests also help job candidates clarify what matters most to them professionally. The SHM’s Career Satisfaction Task Force has developed a framework for hospitalists to do that. The self-test rests on four pillars of job satisfaction: reward/recognition, workload/schedule, autonomy/control, and community/environment (to view, go to www.hospitalmedicine.org and click “Career Satisfaction White Paper”).
Sylvia McKean, MD, medical director, the Brigham & Women’s Hospital/Faulkner Hospitalist Program in Boston and the task force’s co-chair, urges hospitalists to complete the self-test to maximize a potential job fit.
“All jobs have unpleasant side effects,” says Dr. McKean. “People get sick at bad times. There is high stress and sometimes high error rates. It’s important for a hospitalist to analyze what your needs are and to find an environment that best suits them.”
Dr. McKean also offers wisdom from the other side of desk, having interviewed candidates for coveted spots at Brigham & Women’s hospitalist program. “I’ve interviewed doctors who aren’t interested in hospitalist medicine but view our program as a stepping stone to the job they really want here,’’ she says. “We hired and fired someone who wanted her own way all the time. She left for another prestigious hospital. Then there are others who don’t want to teach, but choose a teaching hospital.”
Dr. McKean hopes SHM’s self-assessment tools will help job candidates focus on what they want from a hospital medicine group and avoid the “pebbles” that erode job satisfaction.
IPC, which employs 600 physicians in 100 practices in 24 markets, tried personality testing then discarded it. IPC hired a psychometric firm to devise a psychological profile of “best” and “worst” performing hospitalists. The testers created a test measuring seven key characteristics relating to temperament, intelligence, and clinical skills.
IPC’s CEO Adam Singer, MD, says: “We tested all candidates but found the test ineffective because nearly everyone, including me, got five or better.” He dropped the test, relying instead on extensive interviews. Dr. Singer reviews 2,500 to 3,000 physician resumes annually and spends significant resources on avoiding bad hires. All that hard work doesn’t avoid the occasional mistake.
“I’ve seen everything—the brilliant doctor who can’t function on a team, aloofness, temper tantrums, rudeness, and always pushing responsibility on someone else,” says Dr. Singer. “When something’s wrong, 90% of the time we terminate them ASAP. The other 10% we salvage by finding what’s stressing them, relieving the pressure, and mentoring them into proper behavior.”
Cynthia Stamer, a Dallas-based attorney at Glast, Phillips & Murray, P.C., works extensively with physicians and hospitals and sees young physicians straight from residency joining hospitalist programs “just looking for a job and not focused on whether or not there’s a good personality fit.” She urges job candidates and hirers to better probe the fit.
Stamer finds good hospitalists to be stress jockeys who thrive on the intensity of hospital work. “I think they’re born and not bred,” she says. “They tend to be bored or disruptive in office practices, and to enjoy a pattern of work hard, play hard. The ability to throw the ‘on’ switch and be intense for block scheduling, then be ‘off’ for a block suits them,” she says.
Not That Bad
In a field where an extra pair of hands can make the difference between taking night call or the freedom to take several days off for emergencies, a mediocre team member might seem better than none. Some hospitalist groups would rather pull a bigger load temporarily than tolerate a laggard; others stomach imperfection.
Spotting problems during the hiring process can turn a bad hire into a proper fit. For example, offering a permanent part-time position to someone with young children who can’t commit to full-time employment avoids potential problems. Or, asking enough probing questions might help you discover a physician has a year before a coveted fellowship begins; tailoring a one-year contract for that person optimizes fit. Eliminating managerial tasks for a pure clinician who eschews the leadership fast track works, too.
What to do with the mediocre performer rather than the egregious misfit? Perhaps she consistently arrives to work late, doesn’t complete her charts, and tries to avoid admissions or challenging assignments. A group leader may salvage the situation through mentoring and tying pay to performance. Dr. Singer says: “Underperformers usually don’t understand their impact on the group. We teach them healthcare economics and the flow of dollars. We train them to get the relationship between pay and performance, and hope for results.”
Stamer urges hospitalist leaders to build termination procedures into employment contracts, to document poor performance, and to give severance pay or buy out a contract with a bad hire. “People get testy around disengagement, but if you can take the heat out of the process, it’s better in the long run,” she concludes.
As hospitalist supply approaches demand, avoiding bad hires should be easier. For now, most groups prefer pulling together and working harder rather than abide an outlier. It comes with the territory. TH
Marlene Piturro is a frequent contributor to The Hospitalist.