Career resources content posted on NEJM CareerCenter is produced by freelance health care writers as an advertising service of NEJM Group, a division of the Massachusetts Medical Society and should not be construed as coming from, or representing the views of, the New England Journal of Medicine, NEJM Group, or the Massachusetts Medical Society
By Thomas Crawford, MBA, FACHE, Faculty, Department of Urology, College of Medicine, Affiliate Faculty, Department of Health Services Research, Management and Policy College of Public Health and Health Professions, University of Florida and Eliana Cardona, Student, University of Florida
The primary reason for physician turnover is poor cultural fit,* and when thinking through this phenomenon, it shouldn’t come as a surprise. On the contrary, first interviews generally last no longer than a day-and-half and second interviews may last two days with a preponderance of the time dedicated to searching for a home. With this stated, this is a relatively short courtship and will not provide you with the time required to fully comprehend what it will be like to “live” within your new working environment. Why is this important? To prepare for a national meeting a few years ago, I had estimated that 22 physicians per business day do not make it through the first year of their contracts. Although this may not be statistically significant, it does emphasize the need to assimilate as quickly as possible. Based on this premise, the purpose of this article is to highlight the common mistakes made within the first year of employment and to provide you with strategies to avoid them.
The most common mistake made by physicians of all specialties is attempting to renegotiate the terms of their contracts immediately after commencing their practices. Contractual language is generally nebulous and difficult to comprehend and, unfortunately, if you don’t seek clarification prior to signing, you will not know how the terms are interpreted until they are applied to you and your practice. For example, your contract may state that you have to take an equitable share of emergency department call. However, what if the call rotation you believed to be shared between four physicians is only shared by two? This occurs when physicians are exempted for tenure as outlined within the medical staff bylaws, there is unanticipated turnover, etc. Nevertheless, the impact is that you are now on call every other day and every other weekend and as a result, you want to meet and negotiate a different, more sustainable, call rotation. Although no one would argue that one in two call isn’t sustainable, attempting to renegotiate the terms of your contract within the first year of employment will not be received favorably and your lack of operational knowledge prior to executing the document could lead to strained relationships with the organization’s leadership.
During the recruitment process, not only do you have to ensure that you perform your due diligence in an effort to mitigate the delta that may exist between your contract language and your practice reality, you will need to recognize that the undivided attention you received during the recruitment process will be diluted after you commence your practice. When interviewing, you are the focal point of the organization’s attention as they put their collective best foot forward in an attempt to acquire your services. However, after you have committed, the attention will be directed at the next pressing need and you may be left to navigate the complexities of the new health environment on your own. Unfortunately, based on this premise, I have seen numerous physicians stumble out of the blocks because they don’t know how to get answers to their questions and, although justified, this can result in frustration and the physician being labeled as difficult.
To ensure that you can begin to integrate yourself into the new cultures (practice and/or hospital) that you’ll be working within, you will need to find a seasoned physician mentor. A physician mentor can explain where to get your questions answered and, more importantly, he or she can help you navigate both the formal and informal institutional power structures and identify any political landmines that you may inadvertently walk across without knowing.
Always remember that it is better to observe for a lengthy period of time before asserting recommendations for changes to processes, etc. This point was underscored to me years ago, at a medical section meeting of the rural hospital that employed me, when a new internist started making lengthy recommendations on how to improve the efficiency of getting patients from the emergency department to the appropriate medical surgical floor after the determination for admission had been made. Although his suggestions would have positively impacted his practice, it would have had a negative impact on his new colleagues who provided services at locations 35 to 45 minutes from the hospital. After his recommendations were made, a pillar of my medical community quietly questioned, “How long has he been in practice?” Without knowing the larger context that the other physicians practiced within, the new physician offered a suggestion that wasn’t implementable, took valuable meeting time that could have been devoted to more pressing issues, and had more than one physician colleague disappointed that this occurred without solid working knowledge of our system of care.
Ensuring that you will be the right cultural fit begins during your interview process. With this stated, make sure you understand how your contract language will impact your practice and continually ask clarifying questions. Once you commence your practice, seek out a respected physician mentor who will answer your questions as they arise and has a firm grasp on the political landscape. Lastly, wait until you have a solid understanding of the cause and effect relationships that anchor the processes or decision-making within your system of care before making recommendations. Leaving your place of employment because you are a poor cultural fit may be avoidable if you create opportunities to understand the culture before and after commencing your employment — this will hedge against the potential of you becoming 1 of the 22 physicians that resigned today.
*Cejka Search. (2009). Retrieved from www.cejkasearch.com