Finding the Right Fit: The Bottom Line in Physician Recruitment.

Published by the Renal Physicians Association, January 2008

For nephrology practices bringing a new physician on board and physicians searching for a practice, success ultimately is measured in terms of establishing a long-term relationship that meets the most critical needs of all involved and results in a seamless integration of new clinical staff. Getting to that finish line, however, is time-intensive and should be guided by both parties' raw understanding of their specific needs and expectations of each other.

"Everyone needs to think long-term because mistakes can be very costly in many ways," explains Martin Osinski, a nephrology-focused physician recruiter and President of Nephrology USA^®. "Keeping retention in mind is key because it will cost so much more to bring someone on, have them leave, and have to replace them - in terms of goodwill with your patients and the community, time, and the cost of the recruitment process itself."

Logistically, physician recruitment takes on average a year to complete, from the beginning of the process until that person actually walks into the practice to see patients. The process ultimately has very high stakes that impact the business of the practice, patients, clinical and office staff, and the lives of the incoming physician and family. The foundation for the recruitment and search relies on both sides' honest expectations.

The Practice
Practice managers and recruiters agree: understanding their practice's needs, philosophy, personalities, expectations of staff, and their community sets the stage for effective physician recruitment.

"We made one recruitment mistake," said Cynthia DeSoi, M.D., President of Nephrology Associates of Central Maine in Lewiston. "It was six years of wearing shoes that didn't fit. And in the end, it was painful for everyone. And we've learned."

Avoiding those mistakes, according to Osinski, depends on a few vital points of clarity. "The practice needs to start by knowing why it is bringing a new person on, and how far they are willing to go financially because you don't make money on a new physician for the first year or two. And what are your expectations in terms of work ethic, and how do you plan to distribute the workload? If you understand those elements, you're better suited to identify the right type of individual."

The recruiting practices must lay out clearly their expectations for the candidate, including compensation, workings of the partnership as well as day-to-day operations, sharing in additional revenue streams, ability to generate production, and work ethic.
Amy Barkley, Practice Manager of Advanced Kidney Care Medical Associates in Pittsburgh, focuses on three key elements. "I want to know that you're clinically competent, and that your personality fits with our physician-owner," she explained.

"The other piece, which is also personality, is how they view and treat staff. Do you see them as a tool to be used or as a valuable member of the team? We want someone who can stay long term, so we really need to marry all of these things together for it to work for everyone."

Logistically, the recruitment process can be boiled down to 10 defined steps, many of which involve several strategies and tasks. The on-site interviews, in particular, can be an intense piece of the recruitment. "It's very difficult to assess someone in a short amount of time," said Mikki Collett, Practice Administrator of Memorial Nephrology in Olympia, Washington. "In one very full day, they tour a dialysis unit, meet with me in the office, round with one of our doctors in the office, tour and have lunch at the hospital where they also might take the lead on rounds, and then they might finish up by rounding through the office again or the dialysis unit with another one of our doctors."

That tight process is designed to give the candidates a feel for people, the practice, and the clinical sites. For the practice, the day offers insight into a candidate's bedside manner, long-term thoughts on the practice, personality, and level of assertion both in clinical and business approach. Usually involving one and a half days initially with a possible second visit for finalists, the visit also must include a way to present real estate options to the candidate and/or spouse. Helping the candidate (and spouse) understand a region's culture, differences in school systems, and the feel of the community can be just as important as clinical philosophy and compensation.

Finally, all parties must be realistic about the length of time involved for state licensure, which ranges from six weeks to 10 months, plus two-to-three months' credenrialing time.

The Candidate
Given the fact that there are twice as many open positions for nephrologists* as there are renal fellows entering nephrology, physicians searching for positions may have a wide range of options. Finding the right fit, however, will involve time and careful assessments to understand which physician or groups of physicians, in which type of practice, and in which location, will be in sync with that individual's professional expectations, lifestyle, and spouse and family needs. Physicians just entering practice also may have young families, or may be planning to start families, and need to consider carefully how far they want to live from grandparents and extended family, a long-term personal issue that may not become evident for several years.

"The key element from the candidate's perspective is to think, 'Is this situation going to meet my needs professionally and personally long term?' said Mr. Osinski. "Look at whether the balance between work and lifestyle is going to make sense for you, and realize how important a spouse is in the long-term aspects. If the community and your set-up in the practice won't allow your family to be comfortable, or if the community's not a good fit professionally or personally for your spouse, the situation will not work out for you."

Candidates must ask questions about the range of clinical expectations and responsibilities, as well as issues surrounding the physician's integration into the practice, compensation, and governance, and be sure they get as specific answers as possible. Mr. Osinski listed several overarching topics and some baseline questions.
Compensation: What is the starting compensation? What is the time to parmership? What are the practice's additional revenue streams and what are the financial prospects?
Introduction to Community: Does the practice have a set plan to introduce you to the community for business development? Will they introduce you to referral sources and community leaders? Is there a mentor-physician to guide you?

Clinical Responsibilities: Will you practice nephrology only, or is there any primary care? What about management of transplant recipients? What's the call schedule? How is the call schedule shared?

Business Growth: What is the long-term direction of the practice? What are expansion plans in terms of clinical staff, patient load, and ancillary business?
Partner Buy-In: How is the practice governed? Is it shared management among partners, or does one person make the decisions? How are costs calculated? What is involved in becoming a partner, and what are the benefits?

"You need to be direct in asking questions about compensation, your role within the practice, your expectations, time to partnership, and governance," Mr. Osinski said.
For Sundar Venkatesh, MD, the search for a posidon lasted four months, and he joined the staff of Nephrology Associates in Nashville, Tennessee six months later. He worked several avenues to find the best match for himself, including physician job websites (RPA, New England Journal of Medicine, American Society of Nephrology) as well as a recruiter, who could identify positions that might not have been advertised.

Dr. Venkatesh approached his search knowing his priorities: a location close to Atlanta, a nephrology-only position, and a large group practice setting. "The key factor in my decision to come to Nephrology Associates is that in spite of this being a large group practice, it was physician-managed," he said. "I think the bottom line was that 1 felt comfortable that I would be able to communicate freely with the senior partner who manages the practice."

The Fit
Throughout the recruitment process, both sides must be as up-front as possible, Mr. Osinski, warned. "If either side hides something, it will come out eventually, which is very unproductive."

The year-long investment in recruitment sometimes boils down to interpersonal chemistry. "The major issue comes down to compatibility from a lot of perspectives," said Dr. DeSoi. "The person has to have a passion for what they're doing, want to live in a pretty rural place, and fits in with us. In reality, you spend more rime with the people in the practice than you do your own spouse, so we'd better get along!"

And the right fit for all parties results in the health and efficiency of the practice, which ultimately impacts patient care. "The practice can't run without everyone, from the front desk staff, to the billers, to the physicians all working together," said Ms. Barkley, "so compatibility, competence, and valuing every member of the team all must come together for the entire staff to work well."

*Physician workforce: Coming up short by Martin Osinski, MBA and Jay Wish, MD.