Keywords

Introduction

In an ambulatory teaching practice, successful retention and recruitment of high-quality teaching faculty are critical. Shifts in care delivery models that now emphasize efficient patient-centered ambulatory care require a large ambulatory faculty workforce capable of both providing and teaching high-value medical care. This chapter highlights the steps to accomplish successful retention and recruitment identified from the literature. Common barriers and ways to overcome them are discussed. This chapter also provides specific steps of recruitment, contract negotiation, onboarding, and retention. Particular attention is given to retention strategies that help to improve the well-being of faculty in their positions and reduce the incidence of attrition.

Outline

  • Background

  • Identifying the challenges to recruitment and retention

  • Successful recruitment

  • Contract negotiation

  • Onboarding

  • Making retention possible

    • Creating a culture of connection and flexibility

    • Optimize clinical work environments

    • Ensuring a mission-based care focus

    • Factors to overcome barriers to faculty recruitment and retention

      • Value teaching

      • Career development

      • Faculty development

      • Faculty mentoring

      • Innovative clinical learning models

      • Develop faculty interests

      • Nonfinancialincentives

  • Conclusion

Background

Recruitment and retention of high-quality clinical educators to internal medicine (IM) residency teaching ambulatory practices have always been an important part of successful leadership. Shifts in care delivery models that now emphasize efficient patient-centered ambulatory care require a large ambulatory faculty workforce capable of both providing and teaching high-value medical care. Even before the pandemic, recruitment and retention of clinical faculty had become increasingly difficult. Data from a 2010 Association of Program Directors in Internal Medicine (APDIM) survey demonstrated that greater than 40% of programs reported difficulty recruiting core ambulatory faculty [1]. In the current environment, the pressures on retaining and recruiting faculty have increased dramatically. Rising rates of physician burnout and effects of “The Great Resignation” of 2021 seen across all sectors of employment, but highly magnified in medicine, have continued to strain the system [2]. Attrition of faculty is costly and time consuming. Specifically, turnover of primary care physicians (PCPs) in the USA has been estimated to add $979 million of excess health care spending in a 2018 study [3]. For an organization, the cost of physician turnover can range from $500,000 to more than $1 million per doctor [4]. This estimate includes recruitment, sign-on bonuses, lost billings, and onboarding costs for replacement physicians. Thus, clinic leadership needs to recognize the critical importance of a strategy to actively recruit and retain a stable core of faculty.

Identifying the Challenges to Recruitment and Retention

Physicians are faced with many stressors that potentially reduce their job satisfaction and lead to increased risk of attrition. Fifty-four percent of physicians leave their practice group within the first 5 years [5]. The Jackson Physician Search and Medical Group Management Association (MGMA) 2021 survey of 181 physicians found that 46% of physicians had considered leaving their current employer for another medical practice and 43% had considered early retirement in the year prior to the survey [6]. In the survey, physicians identified various problems that impacted their job satisfaction: lack of effective two-way communication with management, loss of influence on patient care and scheduling, inadequate support staff and increased administrative burden, loss of meaning and value in their work, fear of instability, being overworked, and lack of recognition.

A 2017 Alliance for Academic Internal Medicine (AAIM)/Society of General Internal Medicine (SGIM) position paper on faculty recruitment, retention, and development identified four problems that are prevalent for faculty in ambulatory teaching clinics [7]: (1) increased workload and stress (driven by increasing clinical volume, lack of time, increasing patient complexity, and workflow modernization), (2) inadequate financial support of teaching, (3) increased demand for ambulatory teaching, and (4) inadequate faculty development.

In the current climate, the effects of the pandemic on the health care workforce cannot be overstated. In a 2020 survey of 20,665 health care workers including 2914 physicians, 1 in 5 physicians reported intention to leave their practice within 2 years [8]. Burnout, fear of exposure, COVID-related anxiety/depression, and workload were found to be the driving factors (see Chap. 38 on burnout). Conversely, physicians who felt highly valued by their organization and who had a strong sense of meaning and purpose in their work were less likely to report intent to leave their jobs.

Successful Recruitment

Recruitment of faculty takes much time, commitment, and attention to detail. The key to success is being able to consistently and effectively communicate the strengths of the program to the right candidates. A program with high levels of retention of faculty will be attractive to potential candidates. Successful recruitment will effectively highlight the program’s strengths and the features that make it an attractive place to work.

The first step of recruitment is assessing the needs for the position and then disseminating the information about the job opening out to appropriate venues. Some of the important components of this communication are clear and informative job descriptions, effective use of good advertisement in the right journals/venues including social media, use of professional organizations and meetings (i.e., regional and national SGIM meeting), and use of word of mouth. Taking the step to recruit in areas where minority candidates are reached is imperative and may help minimize any potential recruitment bias.

Once a candidate is identified, ensure clear and quick communication. Consider having a knowledgeable administrative staff member as well as a clinic faculty leader as point persons assigned to always be responsive to the candidate’s inquiries. Be transparent about the position and the requirements and explicit about details such as relative value unit (RVU) goals, protected teaching or research time, and any other expectations.

Interview time requires putting the best foot forward. Have the candidate interview with faculty that have similar or complementary interest while emphasizing program diversity. Seeing a variety of faculty members supported by leadership to pursue many different academic endeavors will impress candidates.

The details of the interview day highly influence the candidate’s opinion of the position and environment. The applicant’s experience should be optimized from beginning to end. Hotel choice, friendly travel assistance, and shared meals with interested, engaged faculty will be critical. Use video technology when necessary, but prioritize in-person meetings.

Assessing and addressing special needs of candidates’ family members are vital to success and retention.

Contract Negotiation

Once mutually interested, it is important to negotiate an appealing contract for both parties. Knowing the resources and the salary ranges available to offer and amount of protected time that can be supported is paramount prior to the negotiation. Within that context, be as flexible as possible to meet the needs of the candidate. Items such as remote work, flexible schedules, continuing education, and leadership opportunities are important to discuss. The candidate should leave the negotiation meeting feeling welcomed and understanding the expectations of the position itself.

Onboarding

The first few months of a faculty member’s new position are an opportunity to build future success. Clear direction and strong support will help smooth the path for the new faculty member. Commitment, time, and attention to detail are needed in this phase just as they were required during recruitment.

Ensuring that the lines of communication are open will be very important in the first few months. The faculty member should have easy and quick access to the staff who are in charge of administrative tasks of onboarding. Assigning a mentor, such as the clinic medical director or another seasoned clinic faculty member who knows the ropes, will be helpful to ease the transition. A written manual for clinic faculty can be very effective as a way of organizing the information that needs to be relayed to the new member of the team. Such a manual could include items such as the following: lists of websites, phone numbers, and email groups to join; list of teaching/supervising/resident feedback responsibilities; clinical responsibilities when seeing own patients; list of staff/service resources; scheduling rules, processes, and guidelines (i.e., how to make any schedule adjustments); list of resources patients may need outside of clinic; how to use translation services; and how to use the electronic medical record (EMR) most efficiently in the clinic and resources to help, etc.

Other very important steps of the onboarding process are (1) introducing the new faculty member to the whole clinic, including support staff, residents, and faculty; (2) creating a reasonable clinical schedule with a gradual ramp-up to full productivity; (3) making sure that the EMR training is effective and ongoing (general and specific to the clinic); (4) sending an email to the department/division/medical center introducing the new faculty member; (5) introducing candidates to faculty in other clinics/divisions who share interests (work or nonwork related); (6) adding new faculty to critical email lists; and (7) ensuring that the new faculty can physically find their way in the health system.

During the onboarding period, it is the department and clinic leaders’ responsibility to create effective and open lines of communication. Frequent and early check-ins will be the building blocks to success. These check-ins will create strong working relationships, will help identify issues that need attention quickly, and will forge a path towards an engaged and confident faculty member who feels empowered and supported by leadership.

Making Retention Possible

Prioritizing the well-being and satisfaction of the faculty in a teaching clinic will be paramount to increase retention and also enable recruitment. The Jackson Physician Search and Medical Management Association group survey identified the top three drivers of physician satisfaction with their employer as [5] (1) effective two-way communication between physician and management, (2) increased/adequate compensation, and (3) decreased administrative burden.

Sinsky C et al. recommended evidence-based approaches to reducing burnout and a focus on ensuring that each faculty feels valued by their organization as potential ways of retaining physicians and other health care workers [8].

Other key areas of focus to maximize retention and ensure adequate recruitment are (1) creating a culture of connection and flexibility, (2) optimizing the clinical environment, and (3) ensuring a mission-based care focus. These three areas are further described below:

Creating a Culture of Connection and Flexibility

It is imperative that leadership maintains strong effective communication strategies with their faculty. Long after onboarding is completed, frequent check-ins remain necessary. Such meetings will help to recognize burnout and to begin meaningful conversations regarding how to improve a struggling faculty member’s situation. Showing care for the health and well-being of the faculty’s whole family is essential. It is also important to recognize the natural shift in priorities that happens for any employee when their family is challenged by illness or other stressors. Providing flexibility in (1) place of work (practice site home, clinic, hospital); (2) time (part-time, nontraditional work schedules); and (3) job descriptions and career paths will help faculty adjust to challenging situations. If a faculty member does make the difficult decision to step away from work, leadership should try to ensure the stability of their position in the future and make reentry possible once the time arises.

Optimize Clinical Work Environments

Many academic continuity clinics are under-resourced and may not operate efficiently placing significant administrative burden on clinician educator faculty [9]. This can lead to decreased satisfaction and burnout detracting from faculty retention. Focusing specifically on the “quadruple aim” enhancing patient experience, improving population health, and reducing costs, but including work-life balance improvement, can be vital to retention [10]. Advocating for increased administrative and clinical support while involving faculty in quality and efficiency improvement programs may be helpful. Working in a culture which rewards collaborative cooperation amongst faculty (flexible coverage, peer support) creates a positive environment, which can go a long way towards offsetting any financial disincentives that may be inherent in the system. In an analysis of high-functioning primary care practices, the tenets of “Joy in Practice” indicated that optimization of clinical practice can be achieved via focusing on team-based care with distribution of clinical and clerical duties amongst team members, co-location of team members, nonphysician order entry, and enhanced team communication [11].

Ensuring a Mission-Based Care Focus

The sense of participation in a valued mission shared by the faculty as a whole is one of the strongest motivators for many faculty. Whether that be pride in providing the best teaching experience for trainees or, as in many teaching continuity clinics, dedicating the practice to care of vulnerable populations can create an atmosphere of collaboration and support that offsets the challenges of practicing in under-resourced environments. Leaders who identify these core missions and prominently highlight the importance of the mission may often be rewarded by faculty teams who dedicate themselves to providing the highest level of care and education.

Factors to Overcome Barriers to Faculty Recruitment and Retention

The AAIM/SGIM position paper published prior to the pandemic outlined seven factors to consider in order to overcome barriers to faculty recruitment and retention. These seven factors are summarized below [7]:

Value Teaching

One key element in demonstrating institutions placing value on ambulatory teaching is to provide adequate time and compensation for those providing this education. Studies note that teaching during a clinical session adds significant time and complexity to the workday. One study estimated that 30–50 min extra time was spent with learners embedded in an ambulatory clinical session [12]. Additionally, relative value unit (RVU)-based productivity may be compromised during teaching sessions. Clinical educators should not be “penalized” for teaching and should have protected time to teach. Systems which provide “teaching RVUs” to supplement clinical RVUs may be useful in offsetting decreased clinical productivity [13, 14]. Similarly, ramping down the number of patients scheduled per session can enhance teaching performance and highlight the value placed on such educational activity while decompressing clinical pressures. Another mechanism utilized is “mission-based funding,” with specific salary support provided for those faculty regularly precepting learners, thus recognizing the inherent clinical productivity losses necessitated by time spent actively teaching and mentoring trainees. Indeed, paying faculty to teach is positively correlated with better teaching evaluations [15]. Freeing up faculty time by the use of scribes or advanced practice providers are other mechanisms to protect faculty time while demonstrating institutional commitment to support clinical teaching.

Career Development: Promotion and Tenure

Academic faculty with large clinical demands may still face traditional pressures to obtain research grants and publish formal peer-reviewed articles, which may not be feasible for clinicians focused on clinical care of patients and direct teaching of trainees.

Promotion criteria must be updated and upgraded to reflect the work of the teaching faculty, which includes recognizing a faculty member’s support of the educational mission, curriculum development, mentoring, presentations, and completion of learner evaluations. Faculty members who exhibit excellence in teaching should be recognized and rewarded [16].

Faculty Development

Formal faculty development has been widely recognized as vital to the success of clinician educators and requires sufficient protected time for meaningful engagement. For clinical educators, faculty development should focus on teaching as educational skills, as they are often more comfortable with their clinical skills than with the skills required to teach effectively. Furthermore, implementation of measurement of Milestones, Entrusted Professional Activities, and other recent educational competency requirements may require faculty to learn new skills to function successfully in educational settings [17].

Faculty Mentoring

In addition to faculty development workshops, faculty mentorship must be highly developed in order to successfully retain talented faculty. A position paper published by the Association of Program Directors in Internal Medicine in 2010 on the redesign of residency education in internal medicine highlighted the importance of well-qualified clinician educators to mentor and help develop the skills of junior teaching faculty [18]. Components of peer observation and “learning communities” with an emphasis on faculty collaboration appear to be most successful in supporting clinician educators in their work. A systematic review on mentoring programs found that successful programs included mentor engagement, presence of a steering committee, mentor-mentee relationships, formal curricula, regularly scheduled mentoring activities, and dedicated program funding [19].

Innovative Clinical Learning Models

Recruiting and retaining faculty into sites with innovative clinical learning models which can enhance clinical care and education are an appealing mechanism for attracting faculty committed to clinical education. Innovative educational models which add variety to the teaching environment include use of nontraditional venues such as homeless clinics or prison clinics, incorporating medical students into a clinic, and incorporating specialty clinics or other primary care specialties into a clinic. Changing the resident schedules in clinic can also improve the learning environment; for example, clinics utilizing long block curriculum or increasingly popular X + Y block system can enhance continuity and resident satisfaction while decreasing the stress of simultaneous clinic and inpatient duties [20, 21].

Develop Faculty Interests

Faculty members may have specific niche interests that lend themselves well to the development of a specialized sub-clinic within the regular continuity clinic setting. Examples such as women’s health, sports medicine, integrated behavioral care, and high-risk patient or procedure clinics have been reported. Faculty members with a passion in such areas can often spur educational interest amongst trainees and may lead to enhanced faculty satisfaction and retention.

Nonfinancial Incentives

Direct funding for clinician educators as mentioned is important in demonstrating institutional commitment to education. However, other mechanisms of incentivization of the faculty can be employed. Simple interventions such as providing an academic title can assist with career advancement. Providing teaching faculty with extra exam rooms or dedicated parking if possible and other simple recognitions can go a long way to demonstrate appreciation for the work provided. Ambulatory teaching awards, letters of recognition provided to departmental leadership, and certificates of appreciation are all inexpensive but effective interventions, which may enhance faculty satisfaction.

Conclusion

Ambulatory education in the continuity clinic setting is a vital part of medical training. Recruitment and retention of excellent clinician educators can be increasingly difficult. However, focusing on valuing clinician educators as demonstrated by protected teaching time, warding off clinical burnout, educational parity with other academic endeavors, rigorous faculty development, and promotion and tenure advancement, as well as nonfinancial incentives and mission-focused goals can enhance leaders’ ability to recruit and retain the highest quality clinician educators. Excellent communication with faculty and flexibility focused on work-life balance are highly important factors in retaining happy productive faculty.