Curbside Consult with Dr. Jayne 11/6/17

I did some work earlier this year with a small hospital that was having trouble recruiting and retaining physicians. Smaller facilities can have challenges, depending on geography and community demographics. This particular organization is a little over an hour drive from a major metropolitan area that has plenty of universities, professional sports, and cultural attractions. Depending on your willingness to commute, it would be entirely possible to live in the city or its suburbs and drive to work. There is also plenty of desirable housing in the growing semi-rural community, so the hospital leadership has been somewhat stumped at why they are having so much difficulty with recruiting and retention. I was initially brought in to do an analysis of their physician compensation strategy.

Looking at the physician salary piece is fairly straightforward. There’s good data available from practice management organizations along with specialty societies and various independent analysts. They were paying a little less than I would have expected, with some student loan repayments being offered that are largely irrelevant to mid-career physicians. Their benefits were a little below average, with relocation allowances and healthcare benefits on the less-generous end of the spectrum. They did offer a couple of more unusual benefits such as pet insurance, and disability coverage was solid. In presenting my findings, I asked if they had done any exit interviews with departing physicians and was surprised to learn that they had not. I offered to broaden my work with them to dig into this and they agreed.

I’ve not done many exit interviews as such. In my past life, our human resources department handled them and simply presented data and summaries to the hiring manager when an employee departed. However, I’ve done many stakeholder analysis projects and decided to use that approach when reaching out to physicians and other providers who had departed over the last year.

For those readers who may not be familiar with a stakeholder analysis, it’s in the realm of qualitative research. Participants are interviewed using a standard set of questions, with their narrative responses recorded and analyzed. Since everyone is asked about the same issues in the same way, response trends can be used to identify areas where an organization may have some work to do. Although some consultants will have a second observer attend the interview and assist with analysis of the responses to reduce potential bias, I’m usually a one-consultant show, so I record the interviews with permission. The results are transcribed and then I can more easily perform the analysis and group parallel responses to create the final anonymized summary.

Several interviewees referenced concerns about the commute after deciding to live closer to the metropolitan area for access to what they felt were better schools. Others wanted to live closer to the city to be closer to religious institutions that weren’t present in the community around the hospital. There were some common themes around the hospital not seeming to value diversity and physicians having difficulty fitting in, with several respondents referring to an “old boys’ network.” As people are interviewed, they tend to be more reserved with their responses, then become a little more free as they begin to trust the interviewer. These interviews kept that pattern, with people becoming less guarded as we chatted. I was glad that I was recording the discussions because some of them were pretty entertaining.

One leader was specifically cited multiple times as being a challenge to work with, largely because of what interviewees described as an obsessive focus on sports. It seems most of his conversations contained sports analogies that may not have been fully understood by colleagues who were not of a semi-rural American background. Attempts to gain market share were discussed as playing offense and defense, with plenty of stories about his time coaching his children’s various sports teams. There were also some perceived sexist remarks, with stories about fathers helping coach the teams and mothers being there to bring the Popsicles.

Others described a culture where medical staff meetings felt like a Three Stooges movie, with slapstick antics and inside jokes. Another described departmental meetings which habitually started late, with the pre-meeting downtime being filled by stories of colleagues going together on hunting and fishing trips, which was not only boorish behavior towards those who weren’t part of the trips, but also offensive to those who had religious or personal beliefs around those pastimes. A few alluded to some potentially offensive remarks around ethnic or racial backgrounds, but weren’t comfortable providing specifics because of concerns they might be individually identified.

As the interviewer, you have to stay objective and not indicate that you’ve heard those comments before. It would have been great to be able to say, “No worries, this is about the tenth time I’ve heard this, so you’re not going to be identified,” but you can’t. Stakeholder analysis is challenging, because when you hear about a specific individual multiple times, it’s hard not to start developing a mental picture of that person that can impact future interactions. Sometimes people start to sound like someone you’d want to sit and have a drink with, where others begin to feel like someone you’d never want to be stuck next to at a meeting.

After the interviews were done and I sat reviewing the transcripts, I couldn’t help but reflecting on some of the common themes. Unfortunately, they weren’t unique to this hospital or part of the country, but are things I see more often than I’d like during my travels. I have a habit of capturing some of the more bizarre things I hear in meetings, using a specific phrase in my notes to make them searchable. I looked back at some calls I’ve been on over the last year and found many of the same concepts cited by my exit interview participants. In addition, there were analogies about gambling in general, betting on horse races, and the Vietnam War, which I’m sure weren’t well received by their respective audiences. (Pro tip: probably not a great idea to use gambling analogies when you’re speaking to a group at a faith-based health system that isn’t on board with it.) Other stories in my files included a rambling speech from an executive who took more than a month off to follow a European sports competition, which probably didn’t resonate well with the hourly employees he was speaking to who will never have that luxury.

As I prepared my report, I did some serious thinking about how much to summarize the results vs. how many specifics to include. It’s hard to make meaningful change when you don’t have specific examples to use when coaching people and over-generalizations aren’t helpful. But I had a genuine sense that the people who were the most inappropriate during some of these physician interactions weren’t intentionally trying to offend, but that they didn’t seem to know better ways to interact with their colleagues or that they were creating a culture where people felt unwelcome. As leaders in the organization, I knew they woul’d receive my report and would see themselves, which would be difficult. They would also face challenges in trying to understand how much the cultural factors cited in the stakeholder interviews could be modified given the current state of the organization and its leadership.

I delivered the executive summary of the report in person, then walked through it in detail for a core group of leaders. Fortunately, they received the report in the intended spirit, which was to help identify factors that could impact physician retention and recruiting. There was some good-natured ribbing during the discussion, as leaders identified themselves and their hobbies from the report. They seemed willing to want to understand how to better work with colleagues from different backgrounds along with strategies to reduce misunderstandings when using personal stories and analogies in conversations. I referred them to a colleague who is much more adept at that kind of work and hope that the individuals most cited in the interviews can learn more about themselves and how they interact with others. I also made some recommendations on salary and benefits that I hope make a difference.

One of the reasons I enjoy working in healthcare IT is the great diversity of people with whom I interact. We have an increasingly mobile workforce and it’s a tremendous opportunity to learn about cultural practices from across the country and around the world. It’s also a challenge to think about ways that we can be more inclusive in how we conduct ourselves and in working with colleagues from different backgrounds. It’s also an opportunity for organizations to empower their members to speak up when inappropriate remarks or behavior occur. This organization not only lost some great physicians, but the turnover they experienced had a negative financial impact as they re-recruited for the same positions multiple times.

During the executive briefing, one of the physician leaders asked me about guidelines to determine when someone is crossing the line. I told them my general rule of thinking whether they’d want to say the same thing in front of their supervisor, spouse / partner, or their mother. If it doesn’t pass those tests, it’s probably better left unsaid or for a non-business conversation. I also put in a plug for effective meetings, because when you have an agenda, start on time, and stick to published topics, you’re less likely to go astray.

I recently ran into the leadership and cultural competency consultant that I had recommended to them and was pleased to hear that they’ve been working together for some time. It sounds like they’re progressing and have not only made some strides with a more welcoming environment, but also have seen a decline in physician turnover. It’s hard to know whether those elements are related, but I was glad to hear that the organization is doing well.

What strategies does your organization use to embrace diversity? Leave a comment or email me.

Email Dr. Jayne.