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Hospitalist Nhi Lan Pham, MD, accepted a signing/starting bonus to relocate to Texas after finishing her residency in internal medicine in the Detroit area in 2007. The accompanying relocation expenses helped Dr. Pham begin her career near her family in Austin, and the flexible work schedule she negotiated allowed her to spend time with her family.

Another hospitalist willing to relocate for the right job used the relocation budget to his advantage. Moving to take the right job cost $2,000. The employer had budgeted $5,000 for relocation expenses, and the physician was able to arrange to have the $3,000 difference added to his signing bonus.

Yet another physician, already established as a hospitalist in an underserved area of his state, was attracted to a new position. However, his original acceptance of a loan repayment from the state as an inducement to work in the underserved region precluded his applying for the new position. His arrangement with the state did not prevent his approaching the new hospital to see what might be possible. It was a wise move; the new hospital agreed to increase the hospitalist’s signing bonus by enough to reimburse the state for the loan repayment.

One foreign-born physician secured a commitment from his recruiter that his employer would sponsor him and his family for green cards. Another candidate agreed to a reduced starting salary in return for help in securing a visa.

With a projected need for 30,000 hospitalists by 2010, hospitalists find themselves in the driver’s seat when it comes to weighing offers. Incentives are increasingly enticing as hospitalist recruiters nationwide struggle to lure top talent.

Incentives, Perks

What does this mean in practical terms? It means not only rising salaries but also incentives and extra perks to attract candidates to this fast-growing specialty.

Financial benefits are widespread, including signing and performance bonuses. Many hospitalists can plan on a guaranteed income. Employers may agree to pay off student loans or reimburse tuition. Malpractice insurance and tail coverage are commonly covered. Some employers also allow part-time or temporary employment to give a new hospitalist an opportunity to decide about the future or to accommodate a personal schedule.

“There is often a laundry list of incentives from which to choose, as well as more of a cafeteria plan that a doctor and employer can customize to meet specific needs,” according to Mark Dotson, MD, senior director of recruitment at Brentwood, Tenn.-based Cogent Healthcare. Cogent is a recruiting firm dedicated to building and managing hospitalist programs.

By far, the most appealing incentives are flexibility of scheduling and workload that allow physicians to coordinate their work schedule with their lifestyle. In fact, Dan Polk, MD, chief of the division of hospital-based medicine at Children’s Memorial Hospital in Chicago, considers flexible scheduling the basis of his plan to retain staff and build job satisfaction.

“We support lifestyle choices and respect life situations,” Dr. Polk says. “We foster the idea of joining a great team, and we make the environment attractive enough to encourage people to stay. We try to work within the team to cover those who need help, such as maternity or family leave, and we compensate for extra time at a different rate. We embrace people who want to work part time or share a job. Our goals are to support people and to make them want to get up in the morning to come to work.”

Part of the attractiveness of schedule flexibility is fewer weekend and night hours. In addition, employers may allow hospitalists to limit their caseload. Some hospitalists, for example, request a cap of 15 to 18 patients a day.

While retaining experienced, motivated staff is a goal of hospitals, lower caseloads mean “more doctors to do the work if doctors work fewer hours,” says Rusty Holman, MD, Cogent’s chief operating officer and SHM’s immediate past president. To meet that need, hospitals are turning to community-based physicians, fellows, and residents to work weekends and evenings. This, in turn, offers the perk of part-time work for those who want more personal time in their schedule.

The demand for nocturnists also is growing (The Hospitalist, January 2008, p. 22). Nocturnists work at night and on weekends and usually work shorter hours. These physicians prefer this schedule so they can have their days free for family or other pursuits. They also enjoy higher compensation, fewer workdays per month, and lower productivity expectations.

In addition to the having the options of part-time hours, temporary work, or job sharing, hospitalists also can negotiate other schedule perks. Some request and receive a two-week-on, two-week-off schedule. Many ask about the shift model, which demands nothing beyond the full eight or 12 hours of work. Still other applicants find a swing shift fits their lifestyle. There are even short-term choices: the hospitalist program at the University of California at Irvine offers recent residents the opportunity to work for one year while deciding about their career. With scheduling choices as part of an incentive package, many hospitalists achieve Dr. Polk’s goal of being eager to come to work each morning.

Physicians are not the only beneficiaries of these perks. Cogent, for example, recruits physician assistants and nurse practitioners when forming hospitalist groups. These employees also enjoy incentives, including tuition for continuing education and the same schedule flexibility as hospitalists.

What’s Open for Negotiation

  • Full benefits (health and dental care, retirement options);
  • Competitive salary;
  • Guaranteed income;
  • Malpractice and tail coverage;
  • Signing bonus;
  • Guarantee of longer commitment (e.g., negotiate to extend a typical one-year commitment to two to three years);
  • Performance bonus;
  • Relocation expenses (e.g., negotiate to add relocation expenses to salary if not relocating);
  • Loan payment (e.g., negotiate to buy out contract for working in underserved areas);
  • Tuition reimbursement;
  • Housing allowance (e.g., negotiate for down payment or housing assistance);
  • Flexible hours (e.g., no nights or weekends, part time, individualized schedule; or, negotiate for nocturnist position with flexible schedule);
  • Patient-load cap;
  • Self-management contracting;
  • Support and legal help in immigration matters (e.g., negotiate for Green Card fees);
  • Opportunities for career diversification (e.g., research, teaching, administration; negotiate to enter different tracks in the future)—AK

Seller’s Market

Hospital medicine faces a shortage of qualified applicants. The need for hospitalists far surpasses the supply of physicians, who are in the enviable position of sifting through incentives and perks when selecting a hospitalist job.

This has become a national concern, according to Vikas Parekh, MD, assistant director of the hospitalist program and assistant professor of medicine at the University of Michigan Health Center in Ann Arbor. “We’re not seeing a pool of applicants because top residents are not pursuing hospitalist careers,” Dr. Parekh says.

Alpesh Amin, MD, MBA, a member of SHM’s Board of Directors, concurs but also points out that the number of hospitalist jobs is growing. “The need for a few hundred hospitalists 10 years ago has grown to 20,000 to 30,000 today, thus creating a need much greater than the supply,” says Dr. Amin, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California Irvine.

Why the shortage? First, fewer physicians are choosing to practice general medicine, either as an internist, family practitioner, or hospitalist. A recent study found fewer medical students were planning to concentrate on internal and family medicine, and that those who did planned to go into a subspecialty later.1 Dr. Parekh attributes this to a combination of reasons. “Most internal medicine residents are subspecialty oriented and may have decided their specialty early on,” Dr. Parekh says. “They may choose a subspecialty for financial reasons or prestige,” he continues, “but they may also be unclear about what a hospitalist career really is.”

Second, hospitalist programs have begun to expand from large metropolitan regions to smaller and rural areas. The result is an even greater demand for hospitalists.

Meet the Need

“There are no saturated markets within hospital medicine,” Dr. Holman says. “That is, most groups are always actively recruiting. [Cogent develops] full hospitalist programs, including recruiting, employing, managing, and training for new and existing hospitalist groups.”

Who is being recruited? Many recruiters approach residents who have not chosen a subspecialty to offer a staff position after they finish the residency. Although a recruiting firm may not offer financial aid during the residency, an employer may provide some sort of stipend if the candidate commits to remain on staff for a specified time after residency. “Recruit and retain” is the operative phrase in these cases.

Recruiters also are approaching generalists just entering the market to point out the advantages of avoiding the startup costs of establishing an outpatient practice. Further, many hospitalists are emerging from the ranks of solo practitioners interested in the financial and personal advantages of belonging to hospitalist groups. Not only does that eliminate the practice overhead (including the burden of regulatory compliance), but it also may offer additional administrative and academic opportunities. As Dr. Amin says, “There are more MD-MBA combos out there.”

Are incentives the answer to the shortage? Perhaps for now. With time, hospital medicine’s built-in perks may end the shortage and the need for added incentives. TH

Ann Kepler is a medical writer based in Chicago.

Reference

  1. Croasdale M. Primary care doctors in demand; signing bonuses and higher pay for some. American Medical News. June 19, 2006. Available at www.ama-assn.org/amednews/site/free/prl10619.htm. Last accessed March 19, 2008.

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