Over the past 10 years, hospitals across the United States have increasingly adopted a hospitalist model of care.1 The field of pediatric hospital medicine is now the fastest growing pediatric specialty, with ∼3000 pediatric hospitalists currently practicing in the United States.2 Most programs are young and expanding. A survey of 112 pediatric hospitalist leaders by Freed et al3 in 2007 found that 55% of programs had been in existence for ≤ 5 years, and 48% reported some turnover in their pediatric hospitalist workforce over the preceding 2 years. Because demand currently exceeds supply, program leaders have been advised to “never stop recruiting” because a “hospitalist programs’ biggest challenge is accommodating growth.”4 These recruiting efforts apply for both career-committed hospitalists as well as people who may be more transient, such as those headed eventually for fellowships or residency graduates who have not yet decided on a permanent career path.
When queried about how they hire a new hospitalist, leaders of other pediatric hospitalist programs usually recite a familiar story; there may (or may not) be a job posting, there may (or may not) be a detailed job description, and a determination is made as to whom to invite for interviews based on their curriculum vitae (CV) and cover letter. The interviews are conducted over a 1- or 2-day period, and candidates meet with various individuals who may have a connection with the applicant’s clinical or research interest or personal background (“She’s from Colorado, just like you!”). There is usually a dinner or two, and the people who are involved in this process have an opportunity to get a feel for how they like the individual. Of course, they probably review the candidate’s CV ahead of time, and they may have a rich discussion about the possibilities for clinical care, teaching, or research that may lure the candidate to the institution. At the end of the chat, the interviewer then usually completes an evaluation form that rates the candidate on several items such as “qualities as a teacher,” “ability to secure extramural funding,” or some other standard that is deemed important to the group. If multiple candidates are interested in the job, there may be a search committee tasked with selecting the best candidate. Ideally, after this process, the top candidate is identified, references are called, and the candidate is offered the position. He or she then (presumably) accepts the offer and starts some months later.
So what is wrong with this approach? Many great physicians have been hired this way and, to be honest, this method of hiring physicians can work. The main disadvantage with this approach, however, is that it does not allow the group to gauge with much certainty if the fit between candidate and job is the correct one. Consistent, objective standards on which to base hiring decisions are lacking.
Only after the candidate has been in the position for a few months can the group know whether the fit between the new hospitalist and the position is the right one. Fortunately, much of the time, things work out fine.
But what happens when the fit is suboptimal? Poor career fit, especially in academic medicine, has been associated with development of burnout,5 low job satisfaction,6 and turnover.7 Anyone who has witnessed, or been a part of, an incorrect hiring decision knows how costly it can be, both in human and financial terms. There can be large negative effects on clinical performance, patient satisfaction, physician morale, and in some situations, these decisions may lead to physician turnover. Some estimate the costs associated with 1 physician’s departure from a practice at >$200 0008 due in large part to lost productivity, hiring expenses for a replacement physician, and the ramp-up and adjustment in clinical performance and billing immediately after a new hire. Surveys of physicians who have voluntarily left their positions indicate that the number 1 reason for leaving is related to “poor cultural fit with the practice.”8 If program leaders were to view hiring performance of their group members like they do clinical or teaching performance, perhaps we would have a more satisfied workforce and fewer turnovers in the competitive pediatric hospitalist market.
As a pediatric hospitalist program leader, I am involved with hiring additional members of our group. Before beginning the process for a recent hire, I sought to optimize the chances that a potential candidate’s qualities and previous experiences would fit with the needs of our group and the demands of the job. Looking to the literature regarding best practices in hiring physicians,8–16 I was struck by a key recurring theme; the best predictor of future behavior is past behavior. Taking a vastly different approach to filling our open position, we embarked on a 10-step, goal-oriented process that was much more structured than in the past, with excellent results.
The 10-Step Process for Effective Physician Hiring
Develop and post a detailed job description. This description allows the group to clarify its needs, and it also allows potential candidates to understand some aspects of the job and the group’s values. It is important to specify the types of duties expected for the position (clinical, teaching, and/or research) and explicitly state any preferred qualities or experience of the successful applicant. Taking time to do this initially saves time in the long run for all parties. With a detailed job description to review, candidates will be better able to determine their level of interest in the position before they apply. This may help reduce the number of applicants who are not a good fit for the position because they choose not to apply in the first place.
Develop a standard set of behavioral-based questions (Table 1) to be used in the telephone interview, with 3 goals in mind. Those goals are: to learn if you want to invite the candidate for an in-person interview, to learn if you want to work with the candidate as a colleague in your group, and to hear specific examples of the candidate’s experience and past accomplishments and how they were achieved. It is important to avoid posing hypothetical questions to the candidate (eg, “We have a lot of complex, technology-dependent patients on our service. How do you feel you’ll do with that?”) because these types of questions can be answered affirmatively without gaining a true understanding of the candidate’s experiences. A better question would be, “Tell me about a recent time when you cared for a complex, technology-dependent child on your service who required a large amount of care coordination. What were the clinical circumstances, and what was the outcome? What did you learn from the experience?”
Conduct uniform telephone interviews based on these ∼10 to 15 questions. Answers the candidates provide to the questions can be scored by the interviewer on a set scale from 1 (unacceptable) to 5 (outstanding). The best results will be obtained when recruitment leaders define ahead of time what an “unacceptable” or “outstanding” answer might be to aid in scoring. The telephone interview portion of the hiring process is relatively “low stakes.” If candidates are found to be misaligned with position requirements at this stage, the most you have lost is ∼30 minutes of your time. You may thus choose to conduct telephone interviews with all candidates who have applied for the position, assuming they meet a few standard educational qualifications, such as graduating from a residency program with pediatric training. A few guidelines for the telephone interviews can help:
Do not lead the candidate. He or she should be doing most (?80%) of the talking.
Start the telephone interview with an introductory statement that clearly directs the conversation to achieve the goal at hand. “I have a handful of questions to ask you, and then I’ll be happy to answer all your questions at the end.” This wording does not tell the candidate how many questions you will be asking, which allows you to cut short an interview that is clearly not going well, maximizing efficiency of the process for both parties.
The candidate’s questions about the job details can be answered at the end, after you have asked your questions. Doing this allows you to achieve your goals efficiently. Remember: the point of the telephone interview is to determine whether there is an empirical basis on which to extend an invitation for an in-person interview.
After explaining the format of the interview, start by asking, “Have you had an opportunity to review the job posting and description?” The answer should be a quick “yes”; failure to have reviewed the posted job description is a red flag. This question can be followed by, “What interests you most about the position?” Both of these questions help determine if this person is a serious candidate for the job.
The telephone interviewer may want to preface questions with, “At our hospital, we have _______” and then follow with a question asking the candidate about his or her experience.
Narrow the field of candidates based on the scores achieved. The costs related to bringing candidates to your institution for in-person interviews can be significant, so it is prudent to be selective and invite only those candidates who have the highest likelihood for optimal fit with the group and the needs of the position. If a candidate’s experiences or past accomplishments do not align well with the open position, it is less likely he or she will be successful in that role. Given a choice between different candidates, it is preferable to offer in-person interviews only to those who have the interest, background, and likelihood of greatest fit for the job.
Engage a dedicated interdisciplinary hiring team. This step may be the most dramatic deviation from past traditional practices. Physicians, nurses, ancillary staff, and administrators are all part of the hospitalist team; using these individuals as key members of your core hiring team will lead to a more robust and accurate hiring decision. For our hiring process, in addition to existing group hospitalists and our division chief, we engaged a pediatric intensivist, family medicine and emergency department physicians, a nurse case manager, and a transfer center operator. We chose these individuals based on the large amount of contact we have with them and their colleagues on a daily basis. We were interested in their unique perspectives regarding a variety of competencies. Because of previously established trust and collegiality, these individuals could be counted on to provide accurate and honest assessments of each candidate’s qualifications, experience, and likelihood of optimal fit with our program. Before participating, each core hiring team member was oriented to the process and guided as to what his or her role would be and what to look for in each candidate. In addition to members of the core hiring team, several other faculty provided input to the process with brief interviews or conversing with the candidate in a social setting (ie, at lunch or dinner). All individuals who have had this type of contact with a candidate should be given a simple evaluation that allows free-form comments with a 3-tiered final assessment: excellent, satisfactory, or red flag. These simple evaluations can often confirm impressions made by the core hiring team members.
Develop specific interview questions for use by members of the core hiring team within several category competencies that are known to be essential for the position (Table 2). We devised 5 areas that best represented the essential attributes for our position: clinical, teaching, personal qualities, commitment to quality improvement, and developing an academic career. Individuals on the core hiring team with expertise in the various areas were given a designated category. Each person was assigned a few (2–3) specific, behavioral-based questions to help rank candidates with the best fit for each category during the interview.
Score all candidates’ responses and overall interview on a set scale. Similar to the scoring for the telephone interviews, having a scale from 1 (unacceptable) to 5 (outstanding) allows the interviewer to compare the responses given to the standard questions in an objective manner. An interviewer for a specific category should be instructed to ask all applicants the same standard questions to ensure consistency and ease of comparison between candidates. Not all of the interview questions need to be structured, however, and this will allow the discussion to be free-flowing and conversational. The interviewer’s overall rating can incorporate both the structured (scored) and unstructured portions of the interview.
Conduct group meeting of hiring team members to discuss and reach consensus. Once all the in-person interviews are completed, there are several benefits to a final group meeting. It allows every member of the hiring team to fully participate in the discussion and to evaluate the information gathered from the interviews. In addition, all core hiring team members should be given an opportunity to voice their opinions and any reservations. By the end of the group meeting, ideally all candidates are ranked in order of priority (in the event your top candidate rejects the offer). The goal of this meeting should be to prioritize the candidates in descending order of best fit for the position.
Check references. This crucial step verifies the information provided by the candidates on their CVs and in the interviews. Candidates should be asked to provide the names of at least 3 people who have worked directly with them in the recent past. Ideally, you are able to call the candidate’s current group leader. However, this may not be possible if the candidates have not disclosed to their current employer or leader that they are seeking another job. However, all candidates should be able to provide the name of someone in their present work environment to talk with (eg, a physician partner, a colleague in another department or area of practice, administrative leader.) As with the telephone and in-person interviews, it is best to ask behavioral-based questions such as, “Tell me about a time when you observed the candidate ____.” You should ask the person providing the reference specific questions about their observations of the candidate’s performance and actual accomplishments. In doing so, you will be able to compare your impressions and the answers given by the candidate during the interview with another source. One of the most important questions to ask every person who provides a reference is, “Would you have any hesitation about re-hiring this individual if the circumstance arose?” If the answer is “yes,” this is an immediate red flag and should be given serious weight in the decision whether to proceed with hiring.
Offer and subsequent on-boarding. Once it is clear who would be the best fit for the position and you are satisfied after querying at least 3 references, the group leader should call and offer the candidate the position. Salary and benefit negotiations can be time-consuming and lengthy if not discussed during the interview with the group or departmental leader. The group leader should be well versed in details such as signing bonuses and relocation expenses. Depending on your institution, once the candidate has verbally accepted the position, an official offer letter can be drafted, and this letter, along with a contract, can be mailed to the candidate for signature. The on-boarding process usually entails many steps put into motion by personnel in human resources for the department and the institution, all of which ensure proper state licensure and hospital credentialing. It is important for the group leader to inquire about the needs of the physician’s partner/family and to be able to refer them to realtors, provide resources for schools and neighborhoods, and identify any issues surrounding partners’ employment needs. These offers of assistance will demonstrate your desire to minimize the adjustment of a new position for both the candidate and his or her family. Once the candidate has officially accepted the position and has a signed contract, he or she should be welcomed into the group immediately, even before the start date. Keeping them informed of significant changes affecting the group and involving them in group decisions will allow a seamless start and will foster teamwork and good will.
Hiring the right person to join your hospitalist group practice takes time, but the effort you put into the hiring process will pay immeasurable dividends in improved career fit, which is a win–win situation for patients, the successful hospitalist, and the group practice. We successfully piloted this process for our recent hire, with excellent results. This structured process uses individual evaluations that combine more objective scoring and relevant comments to allow assessment of all the essential attributes for the position. Assigning targeted, behavioral-based questions to interdisciplinary interviewers, including nonphysician partners, with expertise in various attributes can ensure that applicants are compared in a standardized fashion. This process allows better determination of fit for the position compared with the unstructured process typical in academic medical centers and more accurately identifies the candidate whose experience, skills, and characteristics best matches the needs of the program. Structuring the hiring process in this manner will afford an effective method to hire a new pediatric hospitalist.
The author thanks Ms. Kelly Reeser, transition executive and former board member of Peak to Peak Charter School, for her expert review of the manuscript.
FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.
- curriculum vitae
- Freed GL,
- Brzoznowski K,
- Neighbors K,
- Lakhani I
- Butterfield S
- Kurtz ME
- Dye CF
- Copyright © 2012 by the American Academy of Pediatrics