Mitchell Goldstein, MD, MBA, CML, Maha Amr, MD, Mita Shah, MD, Steffi Khurana, MBBS, T. Allen Merritt, MD, Munaf Kadri. MD, Elba Fayard, MD, Ricardo Peverini, MD

The great resignation will go down in history as one of the most significant workplace changes that resulted from the pandemic, social engineering, and governmental policy directed toward moving people away from congregating in the workplace. Although the decrease in numbers has hit hard in other areas, in medicine, in particular, in academic physicians, there has been an unprecedented change in the workforce. Be it the stress induced by the pandemic, inadequate compensation, or a generational shift in expectations from the workplace. Some hospital systems are experiencing physician turnover above 20% per annum. How can this immediate need to transition the workforce be accommodated? What can stem the tide? (1-4)

First, the turnover is expensive. On the low end, it costs $250,000 to onboard a new physician, although some estimates are as high as $1,000,000 (personal communication) over their first several years in practice due to various training, getting used to a new system, and the new hire not having the efficiency of the physician they are replacing. Placement firms have largely taken over recruitment. These services further impact the cost. Hospitals and university systems must figure out better ways to prevent physicians from going to other practices. Even if a physician from Hospital A is hired from Hospital B and vice versa, there is a net loss. Hiring a new physician, even at a much lower salary, will not balance the books when high hiring costs must be overcome. With a larger medical staff, these costs skyrocket. Because of the diversity of specialty and practice, there is no discount for “bulk” hiring.

After much discussion with colleagues from different institutions, those who have left, and those who have stayed, five “Rs” must be reckoned with to retain physicians.

Reputation:

First, reputation is a starting point. Because of their reputation, some institutions will have no problem recruiting physicians. Harvard, Stanford, Yale, and Johns Hopkins have no trouble attracting high-performing physicians to their medical staff. Their reputation helps these physicians establish national reputations and facilitates their grant applications. However, this reputation is a double edge sword. There is ongoing pressure to publish and advance academically. Some physicians cannot handle the stress, and others leave so that they can parlay their institutional-influenced national reputation into a leadership role at another institution. 

Remuneration:

Remuneration is a significant driving force. Most physicians graduate with extensive debt. After four years of college, four years of medical school, three or more years of residency, and potentially more years of fellowship, physicians must pay off their loans, gear up for house purchases, and pay for their children’s college education. There are some unrealistic expectations of physicians early in their careers. They expect to be able to buy a house, have a nice new car, and live the good life too soon. These urges must be postponed. While inflation grips the nation, physician payments have stagnated. Because of changes in RVUs and work valuations, a physician cannot afford to work for what his predecessor did five years ago. Also, the generous deals of the past are gone. 

A physician often starts a job and quickly realizes that the anticipated bonuses and raises will not materialize as hoped. As housing prices increase further and interest rate spikes preclude borrowing, there are places in the US where it is highly doubtful that a primary care practitioner would be able to make enough even to rent an apartment close to the medical center, let alone purchase a small house. Yes, there are programs for loan assistance and repayment, but these are in areas where the particulars of the location make physician retention challenging as well. While there is no good solution to this problem, remuneration cannot be ignored as long as cost of living increases cannot keep up with the economy. 

Rest:

Rest is another criterion. Generational changes have impacted how much time physicians feel they need to be off before taking on their next assignment. Some programs have built-in obligatory respite time or enforced vacation schedules to ensure that their physicians are not overtired. In neonatology, long the home of innumerable three-letter acronyms that describe the most pressing problems, PDA, NEC, RDS, and IVH have been supplanted by WLB (Work-Life-Balance). This piece is undoubtedly essential, but WLB may interfere with the amount of remuneration offered. Moreover, ACGME mandates for training readily translate into expectations for career work. Often these cannot be reconciled with the demands of the job, leading to disenfranchisement and dissatisfaction.

Relaxation:

Relaxation is the other component of this WLB. It is not sufficient to rest, but physicians must feel they have enough resources and backup to enjoy their time off work. This piece is somewhat tricky to define but constitutes the difference between sleeping in one’s bed between calls and being able to participate in family activities, going on vacations, and taking a meaningful part in various CME activities. A Zoom conference does not provide the measure of relaxation that going to a national meeting provides, catching up with one’s colleagues and learning outside the traditional work environment. 

Respect:

Finally, however, respect is most important. In many ways, respect is embodied by the four other areas, but it is the quintessential piece that most physicians identify as lacking in their place of previous employment. It is imperative to note that even the most established physician can be affected if the four previous R’s are aligned and have been for a long time. Often it is a sense that the employer may see them as only a cog in a much larger wheel or someone who is a “worker bee” or a feeling that there is no trajecfor them in terms of professional advancement. A physician may be asked to move their laboratory or workspace many times in a short interval at the cost of productivity. Sometimes the physician feels like a ghost, or in some instances, “constructive termination” seems operational when business cards are delayed, and names and titles do not appear in office space. 

In some cases, re-organization of office space may result in a more seasoned physician losing significant resources or simply not having a dedicated desk space. An experienced physician denied an opportunity to teach or engage with fellows or residents regularly feels marginalized. Exclusion from decision-making activities within the group, whether or not inadvertent, may be translated to a perceived loss of respect for this person’s opinion. Limiting or constraining the practice without a good reason may discourage that physician. In creating opportunities for others, careful attention must be directed towards those who have committed a significant work effort, resources, funding, and even recruitment because even those physicians may feel marginalized by a loss of respect. 

Respect may also be diminished in the presence of a narcissist, especially if this individual has been given oversight of significant programs within a division or department. These individuals initially appear to have excellent people skills, form excellent first impressions, and rise quickly through the ranks in a receptive environment. Narcissist behavior may initially be dismissed as quality focused, competitive, or detail-conscious but is identifiable in its pervasiveness and shifting of targeted individuals. Whole divisions may be marginalized by one bad actor in a position of authority. These behaviors require evaluating every instance as the narcissist solicits support and validation from other unwitting faculty. Blameless individuals are often subject to meaningless inquisitions and begin to conclude that they actually did something wrong. “Gaslighting” of faculty for their “achievements” is never constructive and may result in considerable feelings of less worth. 

What is the solution? In years gone by, tenure was offered to those who were valued in their practice. Although this does not have an analogy in other systems, several of these groups have instituted practices that resemble tenure (e.g., Kaiser Permanente Group) while paying physicians more than an academic model. Indeed, in some private practices, a partnership offers job security and economic advantage that can exceed that offered by tenure. In academic practices, tenure was increasingly considered a high-end luxury item that was not in line with workplace productivity. But is it? Suppose a senior physician has put in twenty to thirty years of high-impact academic performance in an academic setting and appears poised to continue that effort for the foreseeable future. Is there really a risk associated with honoring that individual’s commitment to the institution? Arguably, the cost of replacing that individual would be manyfold greater than that of replacing a physician who has been out of training for two to three years. (5-6) 

Further, with the rapid turnover, retention of senior faculty may be more important than those just looking to pass their boards and then “look for a real job.” Ultimately, again, it is about respect. With a turnover of greater than 20% in some practices and high costs to recruit and re-establish new faculty, prioritizing a budget and strategy for retention may be more practical and economical in the long run. 

References:

1. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2015;175(4): 1877-1883. doi:10.1001/archinternmed.2015.6161. PMID: 26322826.
2. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374(9702):1714- 1721. doi:10.1016/S0140-6736(09)61424-0. PMID: 19880021.
3. Dyrbye LN, Shanafelt TD. Physician burnout: a potential threat to successful health care reform. JAMA. 2011;305(19):2009- 2010. doi:10.1001/jama.2011.652. PMID: 21586713.
4. Linzer M, Poplau S, Grossman E, et al. A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) Study. J Gen Intern Med. 2015;30(8):1105-1111. doi:10.1007/s11606-015-3341-4. PMID: 25893486.
5. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576. doi:10.1370/afm.1713. PMID: 25384822.
6. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613. doi:10.1016/j.mayocp.2015.08.023. PMID: 26653297.

Disclosures: There are no reported disclosures