Our hospital finished the last year with an inpatient mortality index of 0.54, a fantastic accomplishment. That means that we provide great care and we play the documentation game well....
I’m a doctor. I look for signs and symptoms to diagnose diseases. In the past 4 months, we’ve had 6 really talented women physicians in our department resign and that is a symptom. So, what’s the disease?
If they were accepting academic leadership positions elsewhere or if they were being recruited as educators or researchers then I would see this as a sign of success in our university’s mission to develop medical faculty. But they didn’t; they all went in to private practice. They weren’t brand new academic physicians who realized they had taken a wrong career turn, they were women who were 5 – 15 years in academic medicine who had already committed a quarter to a half of their careers at a teaching hospital and left.
Some physician turnover is good and turnover tends to correlate with economic conditions. In 2009 (during the depth of the recession), annual physician turnover was low at 5.9%. Now that the economy has recovered, turnover has increased to 6.8%, the highest rate since turnover data was first collected in 2005. Many of these 6.8% of physician jobs turned over because of retirement – a lot of older physicians decided to postpone retirement during the recession so there was a backlog of physicians ready for retirement once the economy turned around. A healthy workforce has a relatively predictable percentage of physicians retiring and starting their careers so that the workforce is constantly rejuvenating.
Sometimes, physicians leave in order to take a career advancement or because their spouse is relocating to a different community. Sometimes physicians leave because they weren’t a good fit in your hospital or were not practicing high quality medicine (and often we actively encourage those physicians to leave). Not surprisingly, the highest turnover is in the first 3 years of practice – 5% of physicians leave a practice after one year, 10% leave in year two and 10% leave in year three. That’s a total of 25% turnover in the first three years of practice. And physician turnover is costly: the recruiting costs of replacing a physician is about $40,000 and the indirect costs (of lost revenue, etc.) can range from $250,000 to $1,000,000, depending on the specialty.
Leaving academic medicine for private practice is usually a one-way ticket. It is pretty easy to go from being a university physician to practicing in a community hospital but it is the exceptional physician who goes from private practice into academic practice.
So why do physicians leave a practice?
- Time. Physicians who trained in the 1970’s and 1980’s are the last of the baby boomer generation. During their residencies, every other and every third night call were the norm and they expected to work 70-hour work weeks when they were in practice. For physicians who trained in the 1990’s and 2000’s, work-life balance is a priority and flexibility to adjust work hours during different phases of life is essential to retain them. It’s not just the total hours but it is the predictability of hours, particularly for physicians with children at home. The ability to offer physicians 50%, 70%, or 90% positions during different seasons of their life gives you an employment advantage. For surgeons, guaranteed OR block time is a plus.
- Compensation. Nobody goes into academic medicine expecting to make as much as they would in private practice. Most academic physicians will accept 80% of the going private practice salary in the community to be at a university hospital and they’ll accept 60% if the leadership is charismatic and the work environment is exciting & rewarding. Once you get below 60% of the going private practice salary, physicians will leave for private practice, regardless of how great the work environment is. You can look at national salary benchmarks such as the MGMA but the law of supply and demand works most effectively on a local basis and if you have the only cardiologists trained in MRI interpretation in the region, every other hospital is going to be trying to out-bid the salary you are paying them.
- Equal compensation. According to a recent JAMA article, the average female physician at a public medical school makes $206,641 and the average male physician makes $257,957. In fact, in all specialties except for radiology, men make more than women. Even if you adjust for age, specialty, years of experience, specialty, faculty rank, Medicare payments, and research productivity, women physicians in academic practice make on average 8% less than men physicians. I once had a division director tell me that he had to pay a particular male physician in his division more than a female physician of the same academic rank because the male physician “…was the sole bread-winner of the family and needed to make more because his wife wasn’t working.” Ridiculous.
- Toxic culture. When I wake up in the morning, I’m excited to go to work. That’s not the case with many physicians and if you have a work environment where physicians are constantly trying to undercut each other and there is not a culture of respect and mutual support, then you’re going to lose your physicians. By and large, your physicians are doing wonderful things: they’re diagnosing the diseases that no one else could, operating on the diseases that would otherwise kill their patients, and counseling patients on how to prevent those diseases in the first place. They’re good people doing important things for your patients and your community… and and you need to let them know that you see it.
- Opaqueness. This is the lack of transparency. If your doctors cannot figure out how the finances are flowing or how decisions are made that affect their careers, you can tell them goodby because they will not stay. If a physician sees colleagues seeing fewer patients, leaving the hospital earlier in the day, not handing in their billing cards, not following up on consults, etc. and they don’t get penalized, then that physician is going to assume that no one cares that he/she is working that much harder or is that much more conscientious.
- Bad leaders. No one likes to fire a division director, department chairman, or CEO. But if you keep a poorly functioning leader, then you are in essence firing all of the good people who work underneath them. If one specialty in your hospital has a bad reputation for the physicians being abrasive, being burned out, or providing substandard care, then you need to start by looking at the leader of that specialty.
- Lack of mentorship. Everyone talks about mentorship but not very many people practice it. Establishing a culture of mentorship in your hospital doesn’t happen overnight and it requires mentorship to be a practiced priority for leaders at the highest levels.
- Lack of role models. If you hire a woman physician and she looks around and sees that the division directors, the department chairmen, and the Dean are all men, how long do you really expect that she is going to stay at your institution? For that last sentence, you can also substitute the word “woman” with “race”, “religion”, or any other demographic with the same result. But it is not just that. Even beyond gender, religion, and race, it is whether you identify the leaders as being like you. So for example, I’m a more-or-less caucasian male married to another physician with 4 kids. When I was looking for role models, I didn’t really care about race or gender, I cared about whether my role models were able to be successful and be married to a spouse who worked and still be able to raise normal kids. A leader who had to give up everything that he or she could have had in order to obtain their leadership position is not going to be a role model for most of their physicians.
- Loss of autonomy. Right or wrong, physicians want to work for physicians and not administrators. If they feel they have no control over their lives or are being put into a rat race chasing RVUs then they will feel like they have no real control over their career. And they will become burned out. No physician went through 4 years of college, 4 years of medical school, 3 years of residency, and 3 years of fellowship to become a chess piece on an administrator’s chess board.
- Patient overload. The patients of today are different than the patients of yesterday. Thirty years ago, as an intern or resident, I could manage a service census of 25 patients and still be home by 7 pm; today, the patients are sicker, the treatments we use are more complicated, and the time demands to get them in and out of the hospital are more acute so 25 patients thirty years ago is equivalent to 15 patients today. Similarly, I could see 25 outpatients in a half day clinic in 1996 but in 2016 with the increased complexity of the diseases, the physician documentation demands of electronic medical records, and the changes in patient expectations, I can only now see 15 outpatients in the same time period. The time allocated for a physician to see patients needs to match the time necessary for that physician to practice quality medicine for those patients.
- Inadequate on-boarding. Today’s physicians come out of residency well trained to practice medicine. But they are not necessarily well trained to work in your hospital. There are so many factors to consider including who to consult for what problems, how to efficiently use the electronic medical record, how you transfer a patient to the ICU, what is the blood transfusion policy, etc. If you through your newly hired physicians into practice hoping that they will swim rather than sink, a lot of them are going to sink.
- No opportunities for advancement. Promotion to Associate Professor or to full Professor should be a recognition of excellence and not a recognition of sacrifice. If the only way to get promoted is to give up time with ones family by doing all of the academic work at home in the evenings and weekends that you couldn’t do during the weekdays because you were too busy seeing patients all day, then you will lose good physicians out of frustration. It is unfortunate that in academic medicine, we don’t promote faculty for being excellent, we promote them for talking about (or publishing about) excellence.
So why did our 6 mid-career women leave? I think that in each case the reasons were a little different but I think that what they all had in common was that they did not feel valued. And since I am a hospital medical director, maybe that starts with me. Yesterday, I had back to back meetings from 7:30 AM to 6:00 PM and by the end of the day, after after answering patient phone calls and dealing with angry doctors/nurses/patients/administrators, I was looking to go home. What I should have been doing was looking to find one of those quiet physicians who always get their work done well and on time and asked him or her what is going on in their life and what I can do to help them achieve their own future successes. And maybe remind them of just how good of a job that they are doing.
September 15, 2016