Hiring, engaging and retaining the A-team.

The young head endocrinologist at Mother Frances Hospital is on David Teedgarden's A-list.

"She always walks around with the biggest smile," says Teegarden, a physician who's president and chief medical officer of Trinity Mother Frances Health System in Tyler, Texas. "Patients love her and the staff love her. She's another stellar physician."

She was so talented that the University of Texas Health System began courting her to head up a prestigious fellowship program. Recently divorced, she was uncertain about her future as a single woman in Tyler, a community of 100,000 where social life, notes Teegarden, revolves around family, work, church and outdoor activities.

A colleague mentioned to Teegarden that she was about to leave. "If I hadn't heard it through the grapevine," says Teegarden, "it would have caught me by complete surprise."

Teegarden snapped into action. "Boy, when I found out she might be leaving," he says, "I just swarmed her with about as much love as I could!"

The result?

"She's going to stay," he says. "Yeah, she's staying."

Lesson learned: "We don't spend enough time on our happy, productive doctors," Teegarden says. "No, I don't think we do. I'm going to make that one of my goals this year ... We need to celebrate success more."

Stay or go?

At the Fallon Clinic, in Worcester, Mass., chief medical officer Marc Greenwald, MD, jokes, "We like to think we're like Lake Wobegon."

In humorist Garrison Keillor's mythical Minnesota Greenwald of that name, "all the children are above average." But in truth, admits Greenwald, his 240-doctor multispecialty group has its share of problem children. And cleaning up their messes can, he says, easily become a preoccupation for harried executives.

At Fallon, he says, "We try to target our investments. When you know a stock is going to be a loser, you sell the stock. We learned from Donald Trump. We don't fire people very often, but when we do, the most usual reason is, 'It's just not working.'"

About one in eight physicians who leave a group practice do so against their will. That's according to a 2004 Physician Retention Survey by Cejka Search and the American Group Management Association. Mid-size groups (51-150 physicians) recorded the most involuntary separations--16 percent. Small groups and large groups (more than 150 physicians) attributed 7 and 9 percent of turnover respectively to firings last year.

So although they're infrequent, rancorous partings can't quite be written off as rare. And considering that those kicked out are by far the most problematic of a group's doctors, a fair portion of leadership time is obviously being spent dealing with the problem physicians.

"Any organization that is fairly large," says Teegarden, "just by nature has some A-players and maybe some B and C. Our organization strives to have an A-team."

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And that, he says, starts by defining very clearly what the Trinity Clinic considers to be the characteristics of an A-player. The expectations are detailed in the group's "Principles of Practice," in which are specified the group's "Partner Profile" and "Physician Covenant." (See sidebar pg 8.)

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Nevertheless, as every professional sports franchise has discovered in recent years, the difficulty in signing potential star players is exceeded only by the difficulty in keeping them on the roster--given cut-throat competitive enticements, intra-squad rivalries, sensitive egos, organizational upheavals, family vicissitudes and more.

Indeed, in a 2002 survey of 1,939 practicing physicians across the United States funded by the Agency for Healthcare Research and Quality and reported in the Family Practice journal, more than one in four respondents--27 percent--confessed to a likelihood ("moderate to definite") that they'd be gone from their current practice within two years.

As it stands, according to the Cejka-AMGA survey, actual annual turnover for medical groups nation-wide averaged 9 percent last year. Mid-size groups lost the most doctors, small groups the fewest. For more than half the groups, though, turnover was below 5 percent annually. (Take into account, however, that more than a quarter of the groups counted in the survey did not track turnover among their physicians at all. Almost one in five large groups numbered among that ignorance-is-bliss cohort.)

Doctors are most likely to exit a group practice within two years of joining, the survey found. But close to half the defectors had notched at least six years when they decided to walk.

To be sure, the deciding factor for 2 percent was non-negotiable: death. And 15 percent had reached retirement age. But most were doctors in their prime--healthy, experienced, known and accepted by their colleagues.

Among them were many of the most productive and valuable contributors to the organization--potentially, if not actually. And yet, a festering dissatisfaction finally prodded the A-team players to seek greener pastures.

What might be done to keep those A-players in the uniform of the home team?

Turnover costs

One large multispecialty group practice of nearly 1,000 physicians in Pennsylvania calculated a few years ago that for every primary care doctor who decamped:

* At least $20,000 had to be spent to recruit a replacement

* Between $300,000 and $400,000 was lost in annual gross billings

* The affiliated hospital took a ding of $300,000 to $500,000 in lost inpatient revenue

* Additional, unspecified losses were suffered by the group's specialists in referral income

Turnover of doctors hurts patients, too. A 2001 study by Kaiser's Colorado Permanente Medical Group found that the patients of primary care physicians who left the group required significantly more hospital admissions, laboratory tests, X-rays, emergency and specialty visits, their satisfaction scores were dramatically lower and their disenrollment rates were much higher than average.

From this perspective, then, failure to track physician turnover--let alone ponder its causes and work hard to alleviate them--is not only fiscally irresponsible, it's professionally negligent.

So what does make good physicians quit an organization?

Not surprisingly, money plays a role. Inadequate income was cited as the leading reason for forsaking a group of 50 or fewer physicians, the Cejka-AMGA surveyors found. (Forty-five percent of doctors in that category listed "compensation" as their main gripe.)

But on the whole, money is not the primary issue in physician turnover. Only one in five physicians who walked out voluntarily last year fingered economics as the precipitating factor.

Indeed, physician leaders of several of the nation's largest, most prestigious and most stable group practices make it a point of pride that they do not pay doctors top dollar. And yet their turnover rates are consistently in the low single digits.

"Most of our surgeons could make twice as much or more on the outside," declares Robert Kay, MD, chief of staff of the Ohio-based Cleveland Clinic. "Money for us is not the factor. We need to be competitive but we never lead the market. What we do is we allow physicians to achieve professional satisfaction at the highest level."

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That seems to be an effective formula. Among the Cleveland Clinic's 1,700-plus physicians, turnover is less than 3 percent, Kay notes. And, on the left coast, Sharon Levine, MD, associate executive director of Kaiser's flagship Permanente Medical Group, in Oakland, Calif., uses the same equation.

"When you strip everything away," she asserts, "retaining the best physicians comes down to providing a professional environment. Pride is the best driver of performance. To the extent that physicians are proud of their organization, and feel its values are congruent with their own, that's what drives them to over-achieve and to care."

Levine acknowledges that "you need table stakes, as it were. Our starting salaries are market-based. But I don't think you make people happy with money. Although you can make them unhappy."

In Northern California, Permanente offers a salary of $150,000 a year on average to a general internist just out of residency--but with perks like retirement benefits worth an additional 30 percent and substantial bonuses distributed among high performers. The measures are quality of care (outcomes), service (patient satisfaction), workload and group contribution (coming to department meetings, willingness to take a fair share of five-o'clock walk-ins ...) just basic group citizenship, Levine explains.

"Our goal is to keep a physician for a 30-year career," she says. And despite being the country's biggest group practice, with some 5,500 doctors on the payroll, annual turnover at Permanente, according to Levine, declines from a modest 5 percent in the first year to 4 percent in the second and third and to less than 2 percent thereafter. (She herself is rounding on her 29th year in the organization.)

Permanente doctors are eligible for election to partnership--becoming shareholders in the group--after three years of probation. The event is celebrated each spring with a retreat where all the new partners and their families gather at two adjacent hotels in Monterey for an unbuttoned weekend with the board of directors, faculty and medical leadership.

The centerpiece of this getaway is a big-picture presentation: the group's place in the nation's medical care system, its tactical and strategic plans and the panorama of possibilities Kaiser promises each of its A-players. These include broad opportunities for clinical advancement, teaching, medical research and administrative leadership, Levine says.

"We essentially grow our own leaders," she adds. "We rarely hire a chief and never a senior executive from outside the group. Many of our physicians move in and out of leadership roles--maybe serving one or two five-year terms as a department chief, then going back strictly to practice."

The new-partner retreat is also designed to connect families and infuse them with the team spirit. "We have more children there than senior leaders," laughs Levine, "and we have lots of activities for them. We want them to feel connected--to have a sense of where their mother or father is spending their time. It's a great event!"

Family matters

Family alienation, in fact, accounts for more than a quarter of the breakups between physicians and their organizations, points out Carol Westfall, president of Cejka Search.

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Her firm's survey for AMGA used separate headings--"location" (somewhat ambiguous in that "often a physician is satisfied professionally but his family isn't happy in the community," Westfall observes), "spouse's career" and the catch-all "spouse's dissatisfaction"--in teasing out causes of voluntary separations.

While individually these categories represented only 13 percent, 10 percent and 4 percent respectively of reasons given for quitting, they're interrelated and together add up to 27 percent. And that, she emphasizes, would rank as the second-most frequent reason a doctor chooses to walk out on a practice.

"When I think about retention," says Westfall, "I think about: What are the things you can control and what are the things you can't?"

Lack of a local symphony orchestra or university or major cultural scene is pretty much beyond the corrective power of a medical group. But taking pains to assure that a physician appreciates, and is eager and likely to fit into the community as it exists--and just as important, that his or her family members share the enthusiasm--is within a group's control during the recruitment process. Here, during the earliest courtship phase, Westfall stresses, is where disappointment down the road can best be circumvented.

"Selling the community is as important as selling the clinic," agrees Teegarden. As a result, spouses, significant others and/or children all get red carpet treatment when Trinity is wooing a doctor. They're brought to Tyler for a preview of homes available, schools, amenities.

Teegarden recalls an A-team recruit from Chicago whose wife had grown up in East Texas and was elated at the prospect of returning, but worried that their 12-year-old son would be disappointed.

"I flew Jake [the son] down and asked him what he was interested in," says Teegarden. "One of the things was baseball, so I took him to a Little League game and introduced him to the coach. He was also interested in acting, so I hooked him up with a couple of thespian groups."

Jake became an eager lobbyist for Dad to make the move and that sealed the deal.

Which points up a thread that runs through almost every article and every interview about how to keep an A-team. It starts with the recruitment of A-players--meaning not just those with great stats and great ability. It means those who also possess the character and temperament necessary to mesh with teammates and help the squad function at the top of its unique game.

"A tidbit that often gets missed," suggests Westfall, "is that an organization can improve its interviewing skills. I know of one, for example, that assigns two of its senior executives to interview candidates just for cultural fit.

"Some groups," she explains, "are very touchy-feely. They want their physicians to socialize, be active in the community, participate in cultural and health care events. Others are very businesslike, it's all about watching the numbers. Neither is bad. But if the fit is wrong, there'll eventually be a clash."

The salaried model exemplified by the Cleveland Clinic and the Kaiser Permanente Medical Group has become a strong attraction for many physicians in the current health care environment. The latter has hired more than 500 physicians in the past year alone, and can choose among eight applicants for every opening.

Nevertheless, notes Levine, "There are physicians who just can't operate in a group like ours--for whom an unlimited degree of freedom is part of their need, who have trouble surrendering total autonomy. You just can't fit a square peg into a round hole."

"Practice issues," in fact, account for almost a third of voluntary separations from medical groups, according to the Cejka-AMGA survey. And this purposely nebulous category ("we didn't want to narrow or limit responses," explains Westfall) is responsible for fully 41 percent of fallings-out in large group practices.

Some "practice issues," of course, evolve over time: "A feeling of instability in the group," Westfall says. "A sense of insecurity that referral patterns aren't quite right, that the business is not being run right, that employees are unhappy, that there's too much turnover. Or that there's poor management of billing or of the office. Or it can be simply internal politics."

Other issues surface abruptly as functions of a rapidly changing health care landscape. That's what happened at Fallon, says Greenwald. A practice that had been "almost a staff-model HMO," in which doctors served only one payer, was suddenly spun off to survive as a "multispecialty, multi-payer, fee-for-service model--what I call 'the real world.'"

The shift was attended by an exodus of "people not comfortable with a model of practice they weren't used to."

Greenwald, who's only been at Fallon for a year, has worked hard to help his players--especially those who're struggling--learn to adjust to the curveball and the change-up. There's a very rigorous orientation process. Every doctor gets a personal coach who may or may not be the department chair.

There are feedback sessions, lectures and courses on subjects from ethics to leadership. There's a program for integrating families and a "long-range Welcome Wagon." There are special rewards for star performers over and above the regular CME allowance. There are flex-time and part-time options, because "the reality is, not everyone wants to work full-time," he says.

But, adds Greenberg, "I wouldn't want to give away all our secrets."

He does allow, though, that he brought in consultants to counsel all clinicians on how to improve in this critical arena. About 20 percent of a Fallon physician's compensation is tied to performance--judged in terms of quality, patient satisfaction and group participation. So for those who scored lowest in patient satisfaction, Greenberg assigned a coach to shadow and offer real-time tips and follow-up. And he promised a full retroactive payout to those who could boost their scores to a certain level next time around.

One-third achieved the goal, he reports. And fully three-quarters registered an improvement.

Most often, though, suggests Greenberg, "practice issues" can be traced to "lack of shared expectations. We've said something--or you've heard something--that's different from the way things are."

Once again, agree the physician leaders interviewed as well as the human resources literature, retention of A-team players begins on Day One of recruiting. Clear, thorough and honest discussions of what the candidate seeks and can bring to the organization, and what the organization seeks and can offer the candidate and his family, are the essential foundation stones of a lasting relationship. Don't exaggerate. And be prepared to follow through.

Allen Roberts, MD, an emergency physician in Fort Worth, Texas, boils it down to a simple premise: "Under-promise, over-deliver, and everybody's happy. Yeah, it's a cliche, but I think that's better than the alternative."

One size doesn't fit all

There are, of course, many emoluments that can help cement an A-player's loyalty to the team.

But, as Roberts points out, "This is the enigma of leadership: what seems to be a pretty homogenous group, let's say EM docs in the same ED, would be lazily presumed to have the same concerns and motivators, and that couldn't be more wrong. Every single one has to be approached for concerns and comments, and each needs to be treated equitably and professionally.

"For instance," he continues, "while income might motivate some physicians, and therefore an RVU-based reimbursement scheme would make them happy, others would be much happier slowing down, spending time in administrative duties, et cetera. One size definitely doesn't fit all."

Teegarden's of the same mind.

"I'm a big believer in face-to-face time," he says. "For instance, at noon I'm taking three doctors to lunch. They can be cantankerous, and I know I'm setting myself up to get slapped around. But at the end of the day, they're not disruptive, they bring definite value to the community--they're very bright people, a great resource. And unless I get to know 'em on a personal level, how am I gonna be sure I'm not missing out on some great idea to improve care?"

Cejka's Westfall places "communication, early and often," as "number one" in retention. "I'm not so sure it's what you do but how you do it. You've got to have senior leaders who make retention a goal."

Westfall was surprised at how few organizations responding to the 2004 survey lacked a formal retention plan. "If it's not in writing, with someone owning accountability," she warns, "it doesn't become real. There should be somebody reporting to the board on a monthly basis--how new hires are doing, how they're doing at 90 days, at one year ... if anybody's at risk ... what the year-to-date turnover is ... interviews upcoming.... Then retention becomes a concrete goal of the organization."

David Ollier Weber is a freelance health writer and frequent contributor to this journal. He can be reached by e-mail in Mendocino, Calif., at [e-mail]

RELATED ARTICLE: Trinity Clinic Physician Covenant

As a Trinity Clinic physician my obligations are:

* To provide excellent medical service to all patients under my care

* To work collegially with all physicians, non-physician providers, staff and administration

* To work toward the accomplishment of Clinic and System mission goals of clinical quality, customer service, financial performance and growth

* To practice at the highest of ethical standards

As a Trinity Clinic physician I can expect:

* A high quality clinical practice environment

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* An integrated business and clinical system of care for my patients

* A competitive compensation system, which rewards both clinical excellence and productivity

* Inclusion as a full member in a medical organization, which consistently strives to achieve the highest standards of clinical quality, customer service and technological innovation

Approved by the Trinity Clinic Board of Directors October 19, 1999

RELATED ARTICLE: Physician Tenure at Time of Separation

The majority of physician departures (54%) were reported to occur within the first five years of joining a group. Hospital-owned groups most often lost physicians between three and five years of employment, while physician-owned groups tended to lose physicians most often after the six-year mark.

Smaller groups tended to lose physicians with two or less years of experience at a significantly greater rate (44%) than medium-sized or large groups (28% and 24% respectively).

                                 Group Size            Region
                 All Groups  3-50  51-15-  >150  West  Central  East

Tenure (years)
2 years or less     29%      44%    28%    24%   22%    29%     34%
3-5 years           25%      12%    26%    28%   29%    26%     20%
6 years or more     46%      44%    46%    48%   49%    45%     46%

                    Population     Group
                    Served         Ownership
                 100K  >500K    Physician  Hospital
                 500K           Owned      Owned

Tenure (years)
2 years or less  29%    28%      32%       24%
3-5 years        20%    32%      15%       47%
6 years or more  51%    40%      53%       29%

2004 Cejka Search and AMGA Physician Retention Survey