qualified, dedicated, and satisfied physicians is critical to the
success of Kaiser Permanente. Losing physicians greatly impacts patient
and physician satisfaction, as well as continuity of care. There are
also large costs.1 A recent Colorado Permanente Medical
Group (CPMG) study showed that patients whose Primary Care Physician
(PCP) had left the medical group had significantly more hospital admissions,
emergency and specialty visits, and laboratory and x-ray tests. These
patients also had dramatically reduced satisfaction scores and greater
disenrollment rates.2 Compounding these issues is the difficulty
in recruiting the right replacements from shrinking pools of primary
and specialty care physicians. These are just some of the factors
that combine to make a compelling case for focusing our strategies
on supporting and retaining Permanente physicians. Although we currently
engage in many programs to encourage physicians to remain with the
program, there is more that can be done. This article outlines critical
retention elements cited in the literature and provides several examples
from the medical groups.
Effective Hiring Techniques
has become "militant about
fit," says Simone Ince, MD, Regional Department Chief, Internal
Medicine, and a speaker at the 2002 Permanente Executive Conference.
The first step to a lasting physician relationship, according to Dr
Ince, is hiring physicians who share the values of the CPMG, clearly
spelled out in the CPMG Code of Conduct. By using a cross-functional
team of physicians trained in behavioral interviewing, CPMG asks specific,
standardized questions to determine if the physician will fit in with
the high-quality, patient-focused culture and behavioral norms of
the physicians already in the group. Years of organizational research
backs up their hiring philosophy: "The best predictor of future
behavior is past behavior."3 CPMG interviews focus
on how each candidate has acted in previous situations, such as working
on a high-performing team, disagreeing with a colleague, and going
to extremes for a patient. Of course, says Dr Ince, it is also important
to ask traditional questions regarding the candidate's qualifications
integrated into the CPMG recruitment methodology is honesty about
what a new physician can realistically expect at Kaiser Permanente.
Empirical evidence emphasizes the importance of not only stating the
positives but also the challenges of the position and the organization.
In the literature, this is called a "realistic job preview."4
Jack Cochran, MD, Medical Director, CPMG, says, "We want the
physician candidates to leave the job interview scratching their heads
and thinking, 'is this the right environment for me, does this fit
my values, am I going to be successful here?'" If the candidate
is not given a good idea of exactly what s/he will be doing, what
type of control s/he has over the work environment, and what support
is available, the physician may not get off to a good start with the
organization and is more likely to leave.5
and Startup Resources
suggests that the first few days and weeks of employment are when
the new hire is most open to embracing the organization.5
It's the organization's best time to secure the loyalty of employees,
and many successful organizations seize this opportunity to impress
their new hires. At Mayo Clinic, they are very conscious of welcoming
new physicians and building loyalty through the use of symbolic gestures
that say "you are now one of us" such as nametags, nameplates,
welcome dinners and gifts, and receptions for
new families. New physicians and their families that quickly feel
a part of the medical group community are not only more likely to
stay but are more likely to be fully committed to the organization.6
addition to the symbolic gestures, it is critical to provide the resources
that physicians need to do their jobs.7 In a recent focus-group
survey of new physicians of The Permanente Medical Group (TPMG) in
Northern California, many new physicians complained that they did
not have the "nuts and bolts" to effectively begin serving
members. They lacked lab coats or parking passes in their first days
or weeks on the job, they did not have adequate training on the computer
systems, and some were uncertain about how to perform crucial procedures--like
making a referral or ordering a laboratory test. One physician stated,
"I had no office/desk, no computer, printer or e-mail. In the
days following, when I asked about getting a printer, I was yelled
at by a nurse for asking." Yet this same group of 90 physicians
said they were eager to get up to speed with their jobs as quickly
as possible and were eager to excel but couldn't without the essential
tools and training they needed to do those jobs.
other gift that welcomes a physician to Kaiser Permanente is a slow
start. For new physicians, having time to acclimate to their practice
by being given a lighter load when they first start out is essential.6,7
This tactic gives new physicians time to attend orientation and training
sessions, and to learn about systems on the job. In addition, many
new TPMG physicians felt that they needed extra time in their schedules
for opportunities to network and socialize with colleagues within
their specialty, both within their department and throughout TPMG.
"It is really helpful to have a lighter load when you first start
out. It allows you more time to go through the steps."6
These opportunities effectively acclimate new physicians not only
to the workload but to the medical group community.
Enculturation and Mentoring
addition to having the nuts and bolts supplies and the most basic
training, new PMG physicians need timely orientation to their department,
facility, and region.7 New TPMG physicians surveyed wanted
practical orientation with a tour of the facility and introductions
to chiefs and/or key department contacts within weeks of being brought
on.7 They also wanted practical, department-specific orientation.
Ideally, the department orientation should occur before the physician
starts or very shortly thereafter.6,7 David Shearn, MD,
Director of Physician Education and Development, TPMG, says, "We
must treat our new physicians like we treat our new members and provide
a great care experience for them."
addition, the literature shows that the best orientation programs
go beyond basic introduction to a department and provide an opportunity
to "enculturate" a person into an organization to foster
a feeling of belonging and loyalty.6 Richard Pitts, DO,
Assistant Area Medical Director, Southern California Permanente Medical
Group (SCPMG) in Orange County, has developed an orientation program
entitled "Finding Your Path to a Successful Permanente Partnership."
All new physicians meet together every two weeks for nine months,
beginning in September each year. During these biweekly breakfast
meetings, they are introduced to SCPMG's leadership and managers from
various departments. They learn about Kaiser Permanente's mission,
vision, and social purpose, as well as the SCPMG behavioral norms
and operating principles. The sessions address specific aspects of
Permanente Medicine to help independent-minded physicians adjust to
a collaborative work environment and successfully obtain partnership.
Not only do these physicians gain a clear sense of Kaiser Permanente
and SCPMG, they get a clear picture of what is required of them to
become a Permanente partner while at the same time building organizational
commitment and creating strong bonds with other KP physicians across
specialties and facilities.
new PMG physicians feel a strong need for mentoring--for an accessible
clinician who can answer questions and foster feelings of belonging.7
Research has shown that the ideal mentor role is to provide acceptance,
confirmation, coaching, counseling, friendship, and role-modeling
to the new employee.8 Specifically, physician-mentors help
new physicians to learn the often-complex KP systems, to network with
other physicians, and to answer clinical and operational questions.
In addition, the mentor can help welcome the new physician into the
community.8 Because mentors serve multiple roles, they
must have a clear program, with training, that outlines the role each
facility is asking the mentor to serve, provides time and some funds
for the mentor to get to know the mentee, and provides opportunities
to provide guidance and support. Dr Ron Copeland states, "As
the OPMG (Ohio Permanente Medical Group) Medical Director, I cannot
think of any better investment of our professional time, excluding
direct patient care, than mentoring fellow colleagues."
of Leadership: Setting Expectations, Giving Feedback, Providing Recognition,
way a department or physician chief welcomes a new physician and demonstrates
leadership plays a key role in a new physician's decision to stay
with KP. Physician leaders who not only communicate organizational
and individual goals and expectations, but embody them are more likely
to retain the committed physicians working with them.9
Key leadership behaviors involved in the clear communication of goals
and expectations include listening to new physicians and providing
them guidance, feedback, opportunities, rewards, and recognition.
These behaviors have been shown to increase commitment in our physicians
and to make them feel a part of their new PMG. When physicians clearly
understand how they are doing and what is expected of them, they are
more focused, committed, and willing to stay.10
physicians are hired and oriented, they need accurate, effective,
timely feedback about how well they are or are not meeting expectations.
The literature shows that effective performance feedback increases
performance and satisfaction.11 Physicians cannot improve
if they don't know where they need to improve. Dr Cochran (CPMG) states,
"We will have arrived as a culture when the courageous conversation
is considered a thoughtful, humane gift and when we seek to receive
and seek to give critical constructive feedback." In addition
to feedback on performance problems, recognition must be provided
for things done well.12 This, unfortunately, is not done
nearly often enough. In recent interviews with Kaiser Permanente physicians
regarding the physician work environment, an overwhelming number of
physicians stated that more recognition would be greatly appreciated.13
One physician stated, "I truly think that we don't necessarily
need monetary recognition or gifts. All those things are nice, but
I think it is far better if leadership just walks by you in the hall
and says, 'You are really doing a good job and I appreciate what you
have done.'" Empirical evidence backs this up and suggests that
the most effective recognition is personalized, timely, and one on
not the money or perks but the relationship with one's leadership
that can have the biggest impact in engagement and retention.12
Yet communication is often missing because leadership perceives themselves
as too busy to communicate or only communicates by e-mail and never
in person. Physicians want to be listened to and to see that their
suggestions for improvement are acted upon. If leadership listens
and follows up on physicians' concerns these physicians feel significant
influence and control over their work environment.13 Lack
of perceived control was the most important predictor of burnout among
a study of 1800 HMO physicians.15 Organizational leaders
that listen and involve their physicians with designing service delivery
are likely to have less burnout and more satisfied, happy, and committed
Care Experience Council (CEC)a has been actively studying
the Physician Work Environment for the past two years. In its analysis
of the 2000 and 2001 People Pulse Surveys, the CEC found key drivers
of physician satisfaction across five regions of Kaiser Permanente.13
These drivers correlated with "feeling supported to do what is
necessary to satisfy members," and include influence and involvement
over the work environment; strong leadership and effective communication;
and being valued for diversity and recognized for good work. In the
case of physician retention, if we can ensure that physicians have
what they need to perform their jobs, are involved in decision making
and improvement efforts, are listened to and receive feedback, and
are recognized for their efforts, we will increase the likelihood
of retaining Permanente physicians.
Shearn concludes, "Physician retention is more than keeping physicians
from leaving the organization. It is about retaining the hearts and
minds, commitment, and loyalty of our physicians." There are
many opportunities for the Permanente Medical Groups to hire the right
physicians (be militant about fit), orient and enculturate them, give
them the tools they need to be good physicians including training
and mentoring, and listen to them and recognize them so that they
can provide the best possible care and service to members. In return
for our efforts, we will create a community of highly satisfied and
committed Permanente physicians.
CEC is an interregional group whose charter is to investigate
and validate operational tactics and improvement practices related
to member satisfaction with the care experience at Kaiser Permanente.
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Kaye B, Jordan-Evans S. Retention in tough times. T & D. 2002
Steinbruegge J, Tallman K. MD work environment update: physician
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Graham GH, Unruh J. The motivational impact of non-financial employee
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Linzer M, Konrad TR, Douglas J, et al. Managed care, time pressure
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