Article below talking about the pitfalls of poor physician retention (in general, not just milmed focussed). In this humble FP docs opinion, this is about as big a problem as there is in Milmed Primary Care (maybe as big as extreme understaffing).
The lack of continuity, continual replacement with novice staffing, lost productivity with having to reteach the milmed specific aspects of a clinic (AHLTA, C4 schools, etc) and more.
And realize that Milmeds answer to this problem appears to be getting civilian docs to replace the milmed docs. This at first looks like it is better than nothing, untill you realize that these civilian docs have worse retention than the milmed docs, and thus "poor gasoline" on an already "burning-down" clinic.
http://64.233.167.104/search?q=cach...+problems+physician&hl=en&ct=clnk&cd=11&gl=us
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Abstract
It is not just the patients who are sick; so is our healthcare system. Turnover andloss of clinicians is both a manifestation and an etiology of illness. Trends in physicianturnover are examined and juxtaposed with the goal of encouraging clinician retention. Analysis indicates that turnover, by impairing both individual and organizationallearning, is especially detrimental to patient care. A prescription and a treatment plan forturnover are proposed to assist medical care organizations and planners to retainclinicians and thereby improve health care delivery.IntroductionA sad reality of modern medicine is that turnover of physicians and other careproviders is barely noticed. The marginal value of any single individual is consideredminimal. Few medical institutions bother with exit interviews. Care delivery systemssimply accept the loss with a long-suffering sigh as an immutable fact of modern life.But, is it?We challenge the conventional wisdom that physician turnover is inevitable andargue that maximizing physician retention is critically important both to deliver highquality care and to achieve institutional fiscal goals. This paper examines physicianturnover and its consequences, stresses the value of retention, and proposes strategies toenable medical care organizations to retain their clinicians and thereby to improveoutcomes.
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Trends in Clinician TurnoverTurnover and retention problems involving medical practitioners and other careproviders have increased substantially in recent years. [1-3] Turnoverthe loss of anemployee, voluntarily or involuntarily, through terminationis calculated as the totalnumber of terminations per unit of time divided by the average number of employees forthat unit of time.Turnover has important negative consequences in the face of adequate staffing:reduced productivity, increased costs and impaired morale. When turnover occurs inunder-staffed circumstances, as is true of most medical institutions, the ability to providecore services may be compromised. In 2001, Congressional Representative NancyJohnson [1] projected a future shortfall of approximately 600,000 registered and licensedpractical nurses. At skilled and assisted living facilities, annual turnover among nursesranges from 29 to 49 percent. [2] Forty percent of physicians over the age of 50 years areplanning early retirement. [3] Ominously, the number of applications to US medicalschools is falling [4] raising the specter of insufficient or inadequate replacementphysicians. No particular US hospital type or size is immune to these trends, [5] andshortage of care providers is a problem not restricted to the USA. The British HeartJournal published a spate of letters related to the departure of young physicians frompractice. They reported an alarming trend where 20% of recent medical graduatesworking in the NHS regretted becoming a doctor and one-third said they would leavemedicine if possible. [6]More physicians are leaving, they are doing so earlier, there may be insufficientreplacements, and this turnover-shortage problem is not limited to physicians. Though considerable inferential data exists regarding how and why these decisions are made [7-12], a reliable predictive model of turnover behavior eludes health services researchers.There seems little doubt that shortages at all levels negatively impact quality of care. [13,14]In medical care settings, causal factors for turnover have been studied in physicians[3, 6, 15], nurses [16], allied health personnel [17-19], and hospital chief executiveofficers. [20] Job satisfaction, burnout and excessive work are highly associated withturnover [21-23]; however, turnover behavior is too complex and confusing to beassessed by simple bi-variate analysis. [24] Most researchers agree that compensation isonly a minor determinant of job satisfaction compared to work content, autonomy,environment, and training. [11, 25-26]People remain in jobs for reasons that are not the opposite of why others leave. [9,27-28] Therefore, studying the causes of turnover in order to improve retention may havelimited utility. People often stay on a job due to inertia and the balance of positive andnegative aspects of their internal and external work environments. Health care executivesand managers turnover much less frequently than clinicians probably because managershave more organizational influence, i.e., over policies, processes, structure and systems.They may erroneously commit a fundamental attribution error [29] by assuming thatothers in the organization remain as a result of sharing their vision, values andappreciation for the work climate.In coping with voluntary departures by co-workers, staff who remain often useegocentric, ego-defensive and attributive mechanisms [30] to conclude that thosedeparting are different, dissatisfied for unknown reasons, and are better off gone. Some
remaining staff may also cope through withdrawal behavior they give up emotionally,but remain physically on the job doing the minimum to avoid involuntary termination.They eschew innovation or risk-taking and cannot improve because they do not learn. AsFlowers and Hughes wrote [9], We have too many people in our organization who areno longer with us.Retention versus TurnoverRetentiona metric of continued employmentis not the simple inverse ofturnover. [31] Turnover considers a single unit of time whereas retention is ongoing, acontinuous measure. Turnover is a snapshot (giving a single picture) and retention is areal time movie, providing constantly updated images. Retention tracks each person as aunique entity while turnover views groups of people as interchangeable statistics.Retention not only indicates who is leaving and who is staying, but more importantly, itsignifies how long each person stays with an organization. Retention measures what wewant while turnover tracks what we do not want. In sum, retention is a different andvastly superior measure of employee behavior.Mortality can be viewed as a medical analogue of turnover. At steady state, life-versus-death and retention-versus-termination are numerical inverses: together they equal100 percent. Mortality and turnover measure the very thing we do not want the loss of apatient or an employee. Death and turnover are cheaper than life and retention in theshort term, because it is more expensive to provide on-going care (i.e., compared topatients whose death renders care unnecessary) and senior employees who remaintypically command higher salaries (i.e., compared to departing staff who have not attained the upper echelons of the salary continuum). There are, however, important andinstructive flaws in this analogy.Death and termination have no intermediate gradations, but life and retention do. Asa result, death versus life and turnover versus retention, are not completely dichotomous.A person can live as a paraplegic or without sight just as a physician or nurse can remainemployed by an organization as a turn-off [9]. If fiscal impacts are considered over thelong term, death and turnover become more expensive than life or retention. Turnoveroffers a poor fiscal return because physicians and nurses who remain in practice with thesame organization tend to learn, to make fewer errors, and to grow in both efficiency andeffectiveness.Adverse Consequences of TurnoverTurnover is detrimental to organizations because it reduces their ability to add valueto system outputs. Higher costs, lower morale, and organizational disruption lead todiminished efficiency and, in healthcare, to adverse clinical outcomes. Turnover isespecially deleterious in activities, such as medicine, with a high degree of ambiguity anduncertainty. Judgment, adaptability and learningcritical to achieving optimaloutcomesare impeded by turnover.Financial costs associated with turnover have been estimated in many industries. Inhealthcare, turnover costs have primarily been studied among nurses. [32-36] A recentstudy has calculated the cost of turnover for all types of employees in a single health careorganization. [37] The findings are alarming: employee turnover consumed roughly 5percent of a medical centers total annual operating budget. This loss, representing more than double the hospitals profit margin, is hidden: it does not appear on any budgetstatement.In addition to quantifiable costs of turnover, numerous important non-quantifiablecost elements exist. Defensive managementthe analog to defensivemedicinerepresents time invested by managers that adds no value to institutionalobjectives. Loss of productivity is much worse with involuntary termination. Supervisorsinvest large amounts of time developing the case for termination to avoid personal blameand guard against litigation. Opportunity costopportunities foregone due to focusing ondefensive managementis another real, but difficult to quantify dimension of turnover.Though turnover increases costs to the public through higher insurance premiums, acost of greater consequence is in quality and continuity of care. If cliniciansphysicians,nurses, technicians or allied health personnelare constantly leaving a service, churningas it were, it is very difficult to establish cohesive processes that result in self-correctingmechanisms (learning), fewer errors, reduced adverse impacts and optimal quality.The Benefits of RetentionLong-term retention of personnel is critical both to quality care and toorganizational success. Figure 1 displays the downward spiral of outcomes resulting fromlow retention of physicians. When clinicians withdraw, costs escalate as the organizationinvests resources in recruiting, hiring and training new medical staff. New staff is lessproductive than those they replaced, less efficient than they themselves will be, and moreprone to errors. Diminished productivity, coupled with higher operating costs ultimatelylead to budget reductions. In turn, budget decreases lead to terminations and a continuingdownward spiral in outcomes.
In service delivery even more than manufacturing, error rates increase as retentiondecreases. Care delivery teams cannot capitalize on mutual learning experiences theypreviously enjoyed with stable staffing. Consequently, learning recommences at thebaseline level after each physician departs and is finally replaced. With a low retentionrates, it is difficult to achieve learning synergies that are otherwise possible with teams ofprofessionals who understand the practice predilections of colleagues and trust eachother.As clinical staff leave, the error rate rises because gaps in service materialize frominsufficient staffing (i.e., unfilled positions) and when new staff are eventually recruited,they need to acquire the relevant learning curves of local service delivery. No matter howprofessionally proficient physicians are, they ultimately rely on a diverse set of clinicalsupport staff to deliver excellent medicine. Medicine is a team sport. All it takes is oneweak link in the chain to jeopardize service quality and efficiency.As error rates increase, the organization reacts to prevent or minimize adverseoutcomes. Risk avoidance strategies lead clinical rigidity and to greater restrictions onservice delivery. Delegation that formerly was possible because team membersunderstood and trusted each other becomes impossible. In short, employee empowermentdiminishes as efforts are initiated to reduce risk to the organization. Less empowermentlowers morale and increases job tension. When coupled with budget reductions fromincreased costs and subsequent staffing terminations, morale plummets. Declining retention rates are also accompanied by numerous negative consequenceson the input side as shown in Figure 1. Medical care organizations with a reputation forpoor morale are less competitive in the job market place. This reduces the potentialemployee pool as more capable individuals choose employment elsewhere. In the end,the medical care organization must loosen its hiring standards leading to less selectiverecruitment. Hiring less capable staff then contributes to lower efficiency andeffectiveness resulting in higher termination rates, lower retention rates and more adverseimpacts. A notable aspect of Figure 1 is the descending spiral for outcomes. Once thisspiral begins, it is difficult to return to the point of origin and virtually impossible to raisethe bar. Any financial gains are short-lived and disappear with the next round ofterminations.In sum, low retention increases costs, job tension and service errors while loweringself-actualization, learning and morale. The end result is more mistakes and adverseimpacts, reduced quality of care, and higher operating costs.Retention of clinicians can improve outcomes by both removing the negative andaugmenting the positive. While eliminating errors is a good goal and a current focus ofmedical quality activities, error-free health care does not equal good health. Clinicianswant both the removal of unwanted outcomes and the expansion of desired outcomes; wewant to get better, not just stop being bad.A Radical Prescription and Treatment PlanWe recognize the challenge in changing anything, much less a system as complexand dispersed as healthcare. The recommendations below focus on what institutions cando without waiting for action from Washington. The first prescription is to stop the folly of ignoring or accepting clinician turnover, which compromises patient care and costsmoney. The volume of resources currently being wasted by turnover can be diverted toincreasing retention with its attendant productive consequences.Medical care organizations should be pro-active to increase physician retentioninstead of merely trying to stem physician loss. Rather than addressing reasons whymanagers think physicians leave, attention should focus squarely on the reasonsphysicians and other care givers express for leaving, for example through exit interviews.Medical care organizations need to change those policies and procedures that negativelyimpact clinician satisfaction. This will challenge managers thinking about who and whatis important to organizational objectives as well as rethinking the definition of success.Medical care organizations and their managers should make the cultural shift torecognize and support their internal customers. Medical organizations justifiably givesignificant attention to patients and third-party payors. Unfortunately, much less attentionis usually given to staff. Most physicians, nurses and other members of the care deliveryteam feel like fungible commodities: interchangeable, expendable and not valued(forthcoming data).We need to help doctors and nurses BE doctors and nurses. Reduce the non-medicalwork burden that consistently overshadows actual provision of services. Match caregiverauthority with caregiver responsibility at all levels and practice participatory governance.Develop the resource base that the clinicians say they need to deliver optimal health care.(Managers: dont tell the doctors what they need. They are your customers.) Reconcilethe organization structure with the actual value chain. If medical care organizationscommitted a fraction of the attention currently given to patients and insurers as an investment in their own care delivery team members, the return would be impressive.Sears and Southwest Airlines proved this. [38, 39] At present, organizational loyalty is ata nadir. Dr. V.J. Simone [40], former Chief of the Huntsman Cancer Institute,immortalized this idea by stating, [Academic medical] institutions dont love you back.Create redundancy. Overwork and stress are two primary causal factors cliniciansexpress for the high error rate and for leaving practice. Medicine could learn from themilitary in this case. Both share the problem of dealing with the unknown and theunexpected. One of the coping mechanisms used by the armed forces is redundancy:Have duplicates, spares, and more resources than you think you need, because that extra,that excess, will get you through the surprises ahead. From an efficiency standpoint,redundancy increases expenses in the short term. However, if redundancy reducesoverwork, stress and burnout thereby increasing retention, reducing errors, augmentingmorale and improving care, the better longrun outcomes will more than justify thehigher short-run expenses.Building a learning culture will improve clinician retention. Improvement inmedical outcomes such as lower error rates, better health status, and optimal resourceusage are dependent on both individual and organizational learning, which requires timeon the job. Retention is necessary to facilitate learning and thereby make progress indelivering high quality care at lower cost (these are not mutually exclusive).Medical care organizations need to create alignment between their overtly espousedoutcomes and their incentive structure. One reason for job dissatisfaction and turnover isthe current system of confusing and contradictory incentives. Provider organizations andpayors want to serve more patients and collect more premiums while simultaneously they want to provide fewer services in order to keep as much as possible of the revenue.Clinicians want to provide best care, without considering resource constraints. Thoughoften couched in personal adversarial terms, this dichotomy is not good guy versus badguy, but a design flaw in our system: the way to make money is by discouraging,constraining, or restricting the delivery of health care services. While institutions can andshould make internal adjustments, this problem can only be solved at the federal level. Finally, senior, experienced physicians need to re-think their roles as healers solely to the individual patient. They need to apply the same problem solving, evidence-based passion to sickness in the healthcare system as they do to a patient with heart disease ordiabetes.There is no silver bullet, no magic potion that will suddenly heal the physicianturnover crisis. The problem is complex and not amenable to simple solutions. Nonetheless, the treatment plan prescribed above can assist medical organizations andplanners who are willing to initiate change strategies that improve retention. Theresulting cost-benefit ratio is strongly positive: long-run effects of the proposed treatmentplan far outweigh the trauma of change and the short-term financial costs
