Experience vs. expectation

Dr. Janet Chipman worked for more than a decade in a busy surgery practice she owned with three other physicians, treating patients and sharing the responsibility of running a multimillion-dollar business. She says she valued the autonomy of private practice, which was a common career path among her peers and one she sought when she finished her training.

But nearly three years ago, Chipman and her colleagues signed an employment contract with Baptist Health, a Kentucky hospital operator that has doubled its number of employed doctors to 485 in the past three years. They felt that joining a sizable health system would boost their negotiating leverage with health insurers and make it easier to recruit surgeons into the practice. They'd also have more bargaining clout with vendors. And it would be more viable to participate in one of the new alternative payment and delivery models, such as an accountable care organization.

Even so, Chipman had plenty of doubts before signing the deal. “The decision was incredibly hard for me personally,” she said. “I came from the culture of having your own practice and your independence.”

Not so for Dr. Nicole Lee. The first-year fellow in maternal and fetal health at the University of Mississippi will enter the workforce in two years. She expects to go directly into hospital employment. That's because working for a large health system likely will mean less on-call duty, allowing her to balance work and personal life. “If I have a family, they will definitely be my priority,” Lee said. “Being on call every other week is not feasible to me.”

Physician recruiters increasingly face this gap in physicians' professional outlook as health systems continue their doctor hiring binge. But the chasm in experience and expectations also brings a potential source of workplace tension, as doctors accustomed to managing their own business and putting in very long hours work side-by-side with doctors who want to work eight- to 10-hour days and have time for family, friends and other pursuits.

Doctors moving from independent practice to employment may be more autonomous, business-savvy and likely to prioritize work over other obligations. But they also may chafe under bosses and rules. “They're used to setting the rules,” said Dr. T. Clifford Deveny, Catholic Health Initiatives' senior vice president for physician services and clinical integration. “One of the things you give up is that complete independence.”

Younger doctors may have no experience with or desire to take on demanding call schedules or leadership roles. “They're looking for lifestyle,” said Danise Cooper, manager of physician recruiting specialists for Cejka Search and one of the recruiting agency's senior search consultants. “Lifestyle means less call.”

Thrown together, once-independent physicians and younger doctors may clash over how to share the workload and rotation duties. In addition, physicians may differ in how they respond to their employer's invitation to participate in quality improvement or strategic efforts. And since physicians may treat one another's patients, some doctors may worry about how their colleagues' work ethic and attitudes and accessibility to patients may reflect on them and influence their patients' satisfaction.

Cultural discord among doctors can lead to costly turnover. Culture conflict ranked in the top five reasons for turnover among doctors in the most recent retention survey by the American Medical Group Association and Cejka Search. Hospitals lose revenue when doctors depart and incur the cost of recruiting replacements. In 2012, physician turnover edged upward to 6.8% from 6.5% the prior year and 6.1% in 2010, the survey found.

“Turnover is terrible for everybody,” said Dr. Les Mathers, senior vice president for physician recruitment at Peoria, Ill.-based OSF HealthCare. The system operates eight hospitals across its home state and one in Michigan. Between September 2011 and the end of last year, the hospital hired 89 doctors to bring its total of employed physicians to 505.

Twenty percent of U.S. doctors worked for a hospital in 2012, according to the American Medical Association. That figure rises to 26% if you include doctors in a medical practice partly owned by a hospital. Six years earlier, 16% of doctors were hospital employees.

The hiring spree is taking place at large and small hospitals across the country. Catholic Health Initiatives, which operates 87 hospitals in 17 states, has doubled its number of employed physicians—to 2,000—since 2011. Excela Health, a Greensburg, Pa.-based system with three Pennsylvania hospitals, has hired 44 physicians in the past year to bring its total to 160 employed doctors.

The growth in direct hospital employment of physicians has accelerated for a variety of reasons, including new payment models offered by public and private insurers that bundle payments for hospitals and doctors for entire episodes of care or establish financial incentives for providers to coordinate care and achieve better outcomes and lower costs. These new models require closer collaboration between hospitals, physicians and other providers, and may be easier to achieve when physician practices are more closely integrated with health systems.

Hospitals' recent hiring spree has coincided with a demographic shift in the physician workforce. More women are entering medicine. Thirty years ago, women accounted for 1 of 5 U.S. doctors. Now, 1 in every 3 doctors is female, though that varies by state.

A cultural shift has followed the demographic one, researchers say. Women tend to stress work-life balance, reporting greater concern about having enough time away from work. Studies of physician career satisfaction find women more frequently worry about how relationships may suffer from too much time spent at work. Women doctors are more than twice as likely as men to work part-time, according to the latest American Medical Group Association and Cejka Search physician retention survey.

“When they're coming out of the gates now, they want to both work and play,” said Dr. David Richards, executive director of the medical group at Excela Health, a three-hospital system based in Greensburg, Pa. “They don't want to build a practice.”

Experts say hospital employers must recruit carefully, clearly articulate expectations and enlist the help of strong physician leaders to minimize turnover and conflict among physicians. Recruiting efforts should seek out doctors with skills and interests suitable to the job. Formerly independent doctors are strong candidates for openings where hospital employers hope to establish or expand a practice or specialty and need doctors to cultivate business and raise the practice's visibility. That's because those who come out of independent practice often are keenly entrepreneurial.

Tommy Bohannon, divisional vice president of Merritt Hawkins, a physician recruiting firm that's a subsidiary of AMN Healthcare, said many independent doctors think of themselves as small business owners whose business just happens to be helping people with their health.

Younger graduates often are better matched to jobs with fewer entrepreneurial demands and more team-based care. New graduates also are more comfortable with information technology, including electronic health records and social media tools, recruiters say.

To successfully match candidates and vacancies, recruiters and job-seekers must speak frankly about expectations, schedules and other job requirements. “What I think is most important is to try to make sure that expectations are clear on both sides,” Mathers said.

Doctors in leadership roles in health systems can play a significant part in communicating clearly with potential future colleagues. At Baptist Health, Janet Chipman and her colleagues speak frankly to newly recruited surgeons about the group's shared accountability and high expectations for each other, she said. Patient satisfaction and the group's reputation rest on the performance of all its physicians. “There has to be someone we trust to take care of our patients,” she said.

Compensation models also are important in making sure doctors with different work attitudes are paid equitably and motivated to be productive. Excela relies on compensation incentives to drive productivity, Richards said. About 90% of the system's compensation incentives are tied to productivity, though that may change as insurers shift away from fee-for-service to paying for value and patient outcomes. About 37% of doctors who work for hospitals reported that some of their compensation was tied to productivity in 2012, American Medical Association data show. Nearly 8 out of 10 reported their compensation included a base salary.

Health system employers say they value both physicians with strong leadership skills and good team players who can work well with mid-level professionals to coordinate patient care. Formerly self-employed doctors often can find opportunities to participate in leadership and governance. Demand for doctors able and willing to lead will increase as new delivery and financing models such as ACOs and patient-centered medical homes proliferate, said Dr. Timothy Jahn, Baptist Health's chief clinical officer.

Those continuing opportunities for leadership-oriented doctors are a good thing, because the old model of private practice medicine is shrinking. “There are many factors that make it much more difficult to go out on your own and hang a shingle,” Jahn said.

Follow Melanie Evans on Twitter: @MHmevans