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T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
AOA Critical Issues Hiring Your Next Partner AOA Critical Issues R. Dale Blasier, MD, FRCS(C), MBA, Michael R. Gagnon, MBA, Joseph P. Iannotti, MD, PhD, and Sandra Jarvis-Selinger, PhD
Hiring a new partner into an orthopaedic department or group can be a daunting task. A recent American Orthopedic Association symposium sought to address three major aspects of hiring that affect orthopaedic leaders: (1) when to hire—the chairperson’s role; (2) generational issues that affect hiring; and (3) the development of an initial compensation package. How does the chairperson recruit new physicians? Hiring a new partner into the academic setting requires a good deal of foresight. There must be an established game plan. Advertising and interviews need to be orchestrated. Chairpersons can find information about candidates from many unique sources. Fit within the department and community is important and must be cultivated. Spouses and families need special attention. Research candidates have individual needs. Perhaps the most important aspect of recruitment is the development of a realistic business plan. This paper provides an overview of factors to consider in managing a new hire. Generational issues are intriguing. Should they affect our hiring practices? It seems clear to established physicians that the new generation of graduates is different from their predecessors. Is this really true? Most everyone is familiar with the terms ‘‘Silent Generation,’’ ‘‘Baby Boomers,’’ ‘‘Generation X,’’ and ‘‘Generation Y.’’ Is there anything to be gained by categorizing an applicant? Is it important to hire a replica of one’s self? This paper provides a thoughtful overview of generational issues as they apply to hiring new partners. continued
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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Most department chairpersons are not trained as negotiators. Some preparation and experience are helpful in guiding the process of making an initial offer to a candidate. It is not all about pay. The package includes the guarantee period, expectations for the new hire, mentorship, and resources. How much should new orthopaedic academic hires be paid? Recent benchmark data from the Academic Orthopaedic Consortium suggest a mean income of $282,667 for physicians who have just finished a fellowship. New hires are concerned about call frequency and available time free from work. How much work should be expected from an academic surgeon? Recent survey data from the American Orthopaedic Consortium suggest a mean of 9200 relative value units per year. This article offers some guidelines for the chairperson who needs to formulate an initial offer for a new hire. There is a lot involved in hiring a new partner, as times are changing. This paper offers considerable food for thought about hiring.
Hiring a new partner into an orthopaedic department or group can be a daunting task. There are financial, leadership, and management aspects that must be considered. Many leaders of such groups are excellent clinicians but struggle with the business aspects. At a recent American Orthopaedic Association (AOA) symposium, three major aspects of hiring that affect orthopaedic leaders were addressed: (1) when to hire—the chairperson’s role; (2) generational issues that affect hiring; and (3) the development of an initial compensation package1. Hiring a New Partner—the Chairperson’s Role The first step requires defining the need for a new partner and considering the opportunities and benefits that will result from hiring a new partner. A partner may be hired because another partner is leaving, because the practice is growing, or because an additional partner is needed to staff a new location of the practice. Additional reasons include improvement in patient access and patient satisfaction or development of a new subspecialty area. Recruitment may also present an opportunity for development of research or educational capabilities within the department. At the earliest stages of recruiting any new hire, it is important to assess the resources of the practice and to define the financial feasibility of hiring a new partner. In some manner, the position must be advertised or posted. Posting in a societal journal is common, but many positions are advertised by word of mouth. Before the interview, it is important to define which attributes would be desired in a candidate and to clearly communicate these goals to all who will interview the candidates. After the first interview, it is important to estimate the level of interest that the candidate has in accepting the position as well as the level of interest that the interviewers have in hiring the applicant. It is important to obtain permission to contact references for the purpose of defining the prior performance of the applicant. Public information regarding malpractice history, conduct or licensing issues, and Hospital Care Assurance Program (HCAP) scores can be obtained from national databases. Hospital administrators may provide insight regarding candidates being considered for an important leadership position in your organization. Long-term success requires ensuring that the hire would be a good fit within the group practice, department, institution,
and community. The candidate’s motivation and goals to integrate into the department are important. It is important to consider the candidate’s short-term and long-term goals for joining the practice. The needs and motivation of the spouse and family with regard to a move are important. In some cases, the spouse may require additional professional recruitment. When recruiting for research faculty, it is important to define both the candidate’s expectations and his or her needs for support and resources. This includes salary support, space and equipment, and support personnel. The department must define measures of success and the consequences of not meeting these expectations. Recruitment within an academic center requires defining the individual’s academic rank and disclosure of the process for appointment and promotion. The candidate should be reviewed by the committee on appointments and promotions to define the possibilities for academic rank with this appointment. The hiring chairperson should expect to both convey expectation for rank and promotion (and describe the various tracks) to the candidate and to make recommendations to the committee regarding the candidate’s qualifications for a recommended track. On-call coverage is important; the frequency, scope of responsibility, and locations for call should be spelled out. Making an exception to departmental guidelines often results in ill feelings within the group practice and should be avoided. It is important to define a business plan before advertising a position. The plan should consider support personnel, space and equipment, and protected time for research, educational, or administrative activities. The business plan will also define the expected case volume, relative value unit (RVU) productivity, net revenue, and overhead cost. Transparency of the financial aspects of the practice and of the expectation for performance generally leads to a healthy level of trust within the organization. Recruitment is facilitated by partnering with other stakeholders to share in the risk and opportunity of the recruitment. These stakeholders may include the hospital, ambulatory surgery center, medical school, or other academic departments. Partnerships within the hospital are an important consideration in the development of a business plan.
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TABLE I The Named Generations
Generation
Characteristics and Work Attitudes
Population
% of Active Physicians
Silent Generation (1925 to 1945)
The Silent Generation are traditionalists, loyal, hard-working, and optimistic. Great team players, they get along well with others and often have only one employer their whole lives. They are less tech-savvy than subsequent generations.
30 Million
10%
Baby Boomers (1946 to 1962)
Baby Boomers are loyal, work-centric, and cynical. They value responsibility, perks, praise, and challenges and often equate salaries and long hours with success.
77 Million
55%
Generation X (1963 to 1981)
Members of Generation X are ambitious and thrive on diversity, challenge, responsibility, and creative input. They are hard-working but place a high value on work-life balance (leisure).
45 Million
30%
Generation Y (1982 to 2000)
Members of Generation Y are creative, optimistic, and achievement-oriented. They are excellent multitaskers and very tech-savvy; they ‘‘demand’’ a life-work balance (leisure).
75 Million
5%
It may be appropriate to include a restrictive covenant in the final offer letter or contract. In many institutions, reappointment requires an annual professional review with defined criteria for reappointment. Some contracts define terms of severance. It is important to build support within the practice environment to execute a job offer. Engaged members of the practice can help with the recruitment of the new member as well as the candidate’s spouse and family. This should include a recruitment agenda for the spouse and children; such an agenda might include meeting with local community groups and realtors as well as touring the city, community, and schools. The final steps in recruitment include defining movingexpense support, start times, and requirements for licensure and accreditation before beginning a clinical practice. Throughout the recruitment process, it is important to detail all important issues in writing and have an attorney on each side review the contract. Having a checklist and standard operating procedure is important for the recruitment process. Despite an organized approach, the department chairperson will still have difficulty in predicting the ability of the new hire to perform surgery, to interact well with coworkers, and to be flexible and reliable. Generational Issues: A Great Divide? What is it about generations? When we talk with our colleagues, regardless of their age, we all seem to have the same sentiment toward those entering the workforce—that is, ‘‘the kids these days. . .’’ From twenty-two to eighty-two years of age, people tell stories about ‘‘how they weren’t like this when they were entering the workforce’’; ‘‘how the new generation doesn’t value this or doesn’t understand that’’—and this sentiment is not relegated to those exiting the workforce. We have seen this from individuals who have only been in their careers for a few years. Medical education is not immune to this perspective.
Who Are We? An Overview of the Generations Most everyone is familiar with the terms: ‘‘Silent Generation,’’ ‘‘Baby Boomers,’’ ‘‘Generation X,’’ and ‘‘Generation Y.’’ The categorical manifestations are everywhere, and clear date lines are drawn between the generations. So who are we and what has been written and studied about these generational categories? Table I details the date lines for these generations, their most common traits and attitudes toward work, their population numbers, and the percentage of working physicians (for the year 2007). Implications Twenge conducted time-lag studies to discover how generational differences specifically relate to work attitudes and to shed some light on the differences2. Twenge’s findings suggest some trends when looking across the generations. These trends include (1) work centrality and work ethic have steadily declined since the Silent Generation, (2) there is no difference in either altruistic or intrinsic values across generations, (3) extrinsic values peak for Generation X, (4) leisure values have steadily increased from the beginning of the Baby Boomer generation until the time of Generation Y, and (5) job satisfaction has increased between Generations X and Y. Overall, research has shown that individualistic traits have increased steadily from the period of the Silent Generation and are continuing to increase for Generation Y (and possibly beyond)3,4. So what does this mean relative to hiring your next partner? Most importantly, you’re not hiring a replica of yourself. As Twenge comments in her book, Generation Me, ‘‘...asking young people today to adopt the personality and attitudes of a previous time is like asking an adult American to instantly become Chinese.’’5 Recognize that the person whom you are hiring may have a very different set of values than the ones held by you and your current partners. Remember that these values may not be better or worse, just different; therefore, expectations must not be left as mutual assumptions. Discussing and understanding each other’s perspectives, and coming to an agreement, are important for the
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avoidance of future conflict and misunderstanding. Because individualistic traits are peaking with the current generation, it is fine to tell applicants ‘‘what’s in it for them,’’ but be sure to balance that with what they are expected to contribute. Also understand that ‘‘the kids these days’’ perception may have been a reality for those who were hiring you, too. Each successive generation may look at other generations as having ‘‘misplaced values,’’ and such stereotypes may create an unintended divide. In the most positive sense, stereotypes can help streamline complex information by being an energy-saving device, but we also know the negative aspects of stereotyping. So put your ‘‘the kids these days’’ perception aside and judge the individual, not the generational stereotype. Finally, remember that ‘‘your next partner’’ is also still learning how to be a doctor during this critical transition from a guided, structured training environment to a workplace setting that involves heightened responsibility and none of the previous restrictions. During this critical period, it is important that those who are doing the hiring also mentor and support the individual. By doing this, you can find a way to incorporate the value system of your new partner into the values of your group and, ultimately, the profession. This will aid in building a positive enduring orthopaedic culture across the generations of current practitioners and set a strong foundation for those future generations who will appear at the door.
unusual, especially if the new hire is coming from an existing practice (as opposed to directly from fellowship). It may be possible to minimize this deficit by having the new hire work at least part-time at the local Veterans Administration Hospital, where compensation is fixed and does not depend on productivity. Another way to address such a deficit is to approach the affiliated hospital or health system for support. In a 2011 survey conducted by the Academic Orthopaedic Consortium, 66% of academic orthopaedic departments that negotiated this backstop received some level of support from their hospital, health system, or practice plan. It is important to remember that the compensation is just one single slice of getting to ‘‘yes.’’ There are other, nonmonetary elements of the offer that may be just as important as the pay that is outlined in the offer. The prospective hire’s perceptions of the considerations below weigh heavily:
The Initial Compensation Package One of the most important functions of the orthopaedic chairperson is the hiring of new faculty. The ability of the chairperson to hire is strongly correlated to the compensation package that is offered. Many noncompensatory elements—of both a financial and a nonfinancial nature—are being considered by the prospective hire and being weighed in his or her final decision. This summary is meant to provide insight into the development of the overall compensation package that must be addressed in a successful negotiation with a prospective hire. Starting from the Beginning It is important to understand the financial requirements that are involved in supporting a new faculty hire. One approach is to develop a three-year pro forma that associates all projected expenses and revenues of a startup faculty hire over the course of his or her first three years. This is ideally modeled on a mature practice within the group in the relevant subspecialty and prorated, as initial revenues will be expected to be much less than those of a mature practice. As a rule of thumb, it is appropriate to estimate first-year production to be 33% of that of a mature practice. By end of year three, it is safe to estimate that production will be 75% of that of a mature practice. At this stage, the hire should be at or near the break-even point, especially if the practice owns its ancillaries. Mature-state production benchmarks (i.e., work RVUs) are available to members of the Medical Group Management Association and Association of American Medical Colleges and are valuable as additional benchmark data points. Deficits for the first three years of a new hire are significant. For academics, a three-year total deficit up to $400,000 is not
Viability of the practice (e.g., overall financial health, patient demand to support the new practice, and local market dominance) Likeability of the partners and perceived social ‘‘fit’’ Quality of the hospital and operating room Transparency around the compensation plan and the practice finances Work hours and call obligations Timetable for career advancement opportunities
Lastly, the decision to accept or not accept an offer is often strongly influenced and/or driven by where the spouse wants to live. Five Critical Inclusions in a Solid Offer Letter The offer letter encapsulates the main components being offered to the hire and should also include the expectations for the hire in return. These are ‘‘five critical inclusions’’ that should be outlined within the offer letter: 1. The Pay
This should spell out base pay, benefits, and bonus potential. 2. The Guarantee Period
This speaks to the duration of the compensation that is being guaranteed—typically, two to three years. 3. Expectations of the New Hire
Case volume or work RVUs per year (based on existing faculty production) Number of clinics or clinic visits per year Practice and hospital locations, including outreach location Participation in call schedule Teaching, publications, and other academic production Participation in societies and associations
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4. Mentorship Assignment(s) (Very Important to ‘‘New Generation’’ Hires)
Detail the kind of help and support the hire can expect from more senior partners. 5. Resources Provided to the New Hire
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Operating-room block time Clinical resource (e.g., nurses and certified medical assistants) Continuing medical education (CME) allowance Secretarial assistance Office, computer, smartphone, and supplies Relocation expense reimbursement Startup package and sign-on bonus (if applicable)
There are ways to make an offer more attractive without increasing the costs. As an example, if the assumption is that the new hire will receive $270,000 base pay and $30,000 bonus pay in the first year, the following alternative plans could be considered:
Other nonfinancial perks include:
Other Optional Items
Non-compete agreement Partnership provisions (private practice) Academic and/or appointment title(s) (clinical appointments).
Starting Compensation for Hires Directly Out of Fellowship
Compensation packages (base and bonus) for hires who are coming directly out of fellowship are guided primarily by two or three factors: 1. What the local and/or regional competition is paying 2. Established benchmarks 3. Most importantly, what the hiring department can afford, balanced with internal equity Traditional benchmarks (e.g., benchmarks of the Medical Group Management Association and Association of American Medical Colleges) have no orthopaedic data points that can be referenced for starting compensation. However, the Academic Orthopaedic Consortium encompasses these data within its annual survey among seventy distinct academic orthopaedic programs nationally to isolate physician compensation, clinical productivity, and the flow of funding from external sources that serves to enable academic orthopaedic departmental operations. This information is released through the Physician Collaboration Network platform (https://forMD.com) to all of the member executive directors for further distribution to their department faculty and leadership. In 2011, the benchmark data compiled by the Academic Orthopaedic Consortium revealed that the mean base starting compensation for new academic hires directly out of fellowship was $282,667, with a range of $220,000 to $375,000. For hires directly out of fellowship, compensation packages during the guarantee period typically include base and bonus compensation elements (e.g., $270,000 base plus $30,000 bonus). The bonus element is typically 10% to 15% of the base salary. The trigger for the bonus may be subjective, such as being a ‘‘good citizen and working hard,’’ or it may be tied to such metrics as work RVUs (most common), case numbers, charges, or collections.
Allowing the $30,000 bonus to be paid up front rather than at the end of the first year Allowing a salary of $300,000 and no bonus Allowing the new hire to transition from a guaranteed salary model to one based on productivity (e.g., based on work RVUs) if it pays more prior to the end of the guarantee period
Conferring a title or leadership post Offering a preferred operating-room time or practice location
Maintaining Perspective It is not wise to be the ‘‘highest bidder,’’ but the salary offer will generally need to be at least in the ‘‘middle of the pack’’ among competitors. All things considered, new hires want the starting salary to be ‘‘in the ballpark’’ of other offers (outliers excluded). Hires who have just finished a fellowship often have considerable debt and look favorably upon packages that offer high cash flow early rather than later. Although the starting salary is important, prospective hires are often interested in future earning potential beyond the period of guarantee. Projecting a range of future production levels and associated (projected) compensation levels not only provides the candidate with the potential for future earnings but also forces the practice to project the potential market for these services and transparency about what they would project to pay for that production. Starting Compensation for Hires Coming from Another Practice Established physicians are generally unwilling to take a substantial pay cut (i.e., >10%) during a guarantee period without the expectation of recouping it in the future. It may be important to look at the candidate’s most recent production figures to see if this would support the future desired compensation. The practice weighs what it can afford against the urgency of need and how this would impact internal equity. It is not wise to offer a new hire more in base compensation than that earned in total compensation by existing mature-state faculty in the same subspecialty. Financial losses are steeper for new hires that come in at a high salary that must be reduced over time, since their starting compensation is always higher. Use of Benchmarks—the Medical Group Management Association and the Association of American Medical Colleges For paying members, the Medical Group Management Association and the Association of American Medical Colleges are useful in providing numerous compensation and productivity
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benchmarks (associated with mature-state practices [i.e., established practices that have stopped growing]). The data published are also categorized according to geographic area and setting (academic or private practice). Having said this, the data also have some limitations, with representative examples shown below: There may not be data for certain orthopaedic subspecialties. The total number of survey data for a particular subspecialty may be extremely small. The national benchmark average may not be applicable as it is too broad. There are no starting salary benchmarks for orthopaedic surgeons.
Regardless of the criticisms, these benchmarks can be valuable and are often referenced by physicians and administrators, especially in relation to physician compensation and clinical productivity. Accordingly, it is imperative to be able to explain any major variance in comparison with these benchmarks. Approach to ‘‘Closing the Deal’’ The approach to closing the deal should be more of a conversation than a negotiation. It is appropriate to take inventory of mutually shared goals and to determine if there are enough of these to warrant a future together. Getting the prospective hire to talk about his or her goals, vision of the future, special needs, and concerns is valuable in determining ‘‘strength of fit.’’ It is important, especially at this stage, for the parties to
talk openly about the opportunity, goals, and possible conflicting goals associated with the position to avoid a poor fit that results in subsequent disconnect or worse (a decision to leave the practice). In the spirit of partnership, it can be helpful to share a draft of the offer letter with the prospective hire and ask him or her to take two weeks to consider it and return it with any suggestions for change. This ties both sides to the process of identifying areas of possible contention, and it allows negotiation and maintains communication during the progress. The timeline helps to ensure that the process moves forward. Academic Orthopaedic Consortium The Academic Orthopaedic Consortium was established in 2005 by a handful of executive directors at the top academic programs in the country. This consortium was formed largely out of necessity since there was no overarching society or association that existed solely for academic orthopaedic programs. The purpose of the Academic Orthopaedic Consortium is to provide a network that, through the collective wisdom of community, could educate, empower, and enable administrators in academic orthopaedics. Today there are executive directors from more than seventy U.S. academic orthopaedic programs who participate as members. Membership in the Academic Orthopaedic Consortium is free and is open to executive directors of all academicaffiliated orthopaedic programs. A prospective member must have a profile to participate, as all of the executive directors connect and share by utilizing the for[MD] platform. Information
Fig. 1
Table showing representative data from the Academic Orthopaedic Consortium survey of 2011. FY 09 = fiscal year 2009, FY 11 = fiscal year 2011, WRVUs = work relative value units, and RETMNT = retirement.
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regarding membership in the Academic Orthopaedic Consortium or with regard to the for[MD] platform can be obtained from [email protected]. The collective body of the Academic Orthopaedic Consortium is committed to providing national-level analysis, benchmarking, and organized discussion that will improve the national academic orthopaedic community as it tries to understand its environment and, accordingly, as it processes how it should evolve. The 2011 Academic Orthopaedic Consortium survey on ‘‘Physician Compensation, Clinical Productivity, and External Support’’ across U.S. academic orthopaedic departments was released in December 2011 and contains a snapshot of helpful information relative to compensation for academic orthopaedic surgeons (Fig. 1).
spondents described themselves as being born between 1946 and 1962, and 39% described themselves as being born between 1963 and 1981. Seventy-one percent of those born between 1946 and 1962 and 65% of those born between 1963 and 1981 believed that the current generation of graduating residents does not have the same level of commitment to the profession as did the respondent. Work ethic is perceived to be changing over time. It is clear that the experienced chairperson’s perspective, recognition of generational issues, and a reasonable initial compensation package will be key in hiring your next partner. n
Conclusions Hiring a next partner requires a good deal of diligence and preplanning. Financial, generational, and social issues are important. Hiring into an academic organization requires some additional consideration above and beyond that of a private practice setting. In particular, academic rank, teaching responsibilities, faculty development, and opportunities for research become important. Attendants at this actual AOA symposium were polled regarding several questions relevant to hiring. The majority (58%) of respondents felt that the most common reason for a member of a practice to be asked to resign from a group was poor fit within the practice environment or culture. The most common (48%) perceived reason for a member to voluntarily leave a practice was poor fit with the practice environment or culture. It is clear that a good fit between the hire and the practice is key to successful retention within a group. With regard to compensation, most respondents (89%) believed that the proper level of compensation for a new hire should be guided by market rate but that the level ultimately must be a balance between what the department can afford and the impact that the rate will have on departmental internal equity. Generational issues seem to matter. At the symposium, 48% of re-
R. Dale Blasier, MD, FRCS(C), MBA Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 3 Children’s Way, Little Rock, AR 72202. E-mail address: [email protected] Michael R. Gagnon, MBA Department of Orthopaedic Surgery, Duke University, 4709 Creekstone Drive, #227, Durham, NC 27703. E-mail address: [email protected] Joseph P. Iannotti, MD, PhD Department of Orthopaedic Surgery, A41, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address for J.P. Iannotti: [email protected] Sandra Jarvis-Selinger, PhD eHealth Strategy Office, University of British Columbia, 855 West 10th Avenue, Vancouver, BC V5Z 1L7 Canada. E-mail address: [email protected]
References 1. Blasier RD. Hiring your next partner. Presented as a symposium at the 125th Annual Meeting of the American Orthopaedic Association; 2012 June 28; National Harbor, Maryland. Symposium no. 1. 2. Twenge JM. A review of the empirical evidence on generational differences in work attitudes. J Bus Psychol. 2010 Feb 18;25(2):201-10. 3. Walsh DS. Mind the gap : generational differences in medicine. Northeast Florida Med. 2011;62(4):12-5.
4. Coupland D. Generation X: tales for an accelerated culture. New York: Martin’s Press; 1991. http://familiesandwork.org/ downloads/GenerationandGender.pdf. Accessed 2014 Apr 17. 5. Twenge JM. Generation me: why today’s young American’s are more confident, assertive, entitled—and more miserable than ever. New York: Simon and Schuster; 2006.
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BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
AOA Critical Issues Hiring Your Next Partner AOA Critical Issues R. Dale Blasier, MD, FRCS(C), MBA, Michael R. Gagnon, MBA, Joseph P. Iannotti, MD, PhD, and Sandra Jarvis-Selinger, PhD
Hiring a new partner into an orthopaedic department or group can be a daunting task. A recent American Orthopedic Association symposium sought to address three major aspects of hiring that affect orthopaedic leaders: (1) when to hire—the chairperson’s role; (2) generational issues that affect hiring; and (3) the development of an initial compensation package. How does the chairperson recruit new physicians? Hiring a new partner into the academic setting requires a good deal of foresight. There must be an established game plan. Advertising and interviews need to be orchestrated. Chairpersons can find information about candidates from many unique sources. Fit within the department and community is important and must be cultivated. Spouses and families need special attention. Research candidates have individual needs. Perhaps the most important aspect of recruitment is the development of a realistic business plan. This paper provides an overview of factors to consider in managing a new hire. Generational issues are intriguing. Should they affect our hiring practices? It seems clear to established physicians that the new generation of graduates is different from their predecessors. Is this really true? Most everyone is familiar with the terms ‘‘Silent Generation,’’ ‘‘Baby Boomers,’’ ‘‘Generation X,’’ and ‘‘Generation Y.’’ Is there anything to be gained by categorizing an applicant? Is it important to hire a replica of one’s self? This paper provides a thoughtful overview of generational issues as they apply to hiring new partners. continued
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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Most department chairpersons are not trained as negotiators. Some preparation and experience are helpful in guiding the process of making an initial offer to a candidate. It is not all about pay. The package includes the guarantee period, expectations for the new hire, mentorship, and resources. How much should new orthopaedic academic hires be paid? Recent benchmark data from the Academic Orthopaedic Consortium suggest a mean income of $282,667 for physicians who have just finished a fellowship. New hires are concerned about call frequency and available time free from work. How much work should be expected from an academic surgeon? Recent survey data from the American Orthopaedic Consortium suggest a mean of 9200 relative value units per year. This article offers some guidelines for the chairperson who needs to formulate an initial offer for a new hire. There is a lot involved in hiring a new partner, as times are changing. This paper offers considerable food for thought about hiring.
Hiring a new partner into an orthopaedic department or group can be a daunting task. There are financial, leadership, and management aspects that must be considered. Many leaders of such groups are excellent clinicians but struggle with the business aspects. At a recent American Orthopaedic Association (AOA) symposium, three major aspects of hiring that affect orthopaedic leaders were addressed: (1) when to hire—the chairperson’s role; (2) generational issues that affect hiring; and (3) the development of an initial compensation package1. Hiring a New Partner—the Chairperson’s Role The first step requires defining the need for a new partner and considering the opportunities and benefits that will result from hiring a new partner. A partner may be hired because another partner is leaving, because the practice is growing, or because an additional partner is needed to staff a new location of the practice. Additional reasons include improvement in patient access and patient satisfaction or development of a new subspecialty area. Recruitment may also present an opportunity for development of research or educational capabilities within the department. At the earliest stages of recruiting any new hire, it is important to assess the resources of the practice and to define the financial feasibility of hiring a new partner. In some manner, the position must be advertised or posted. Posting in a societal journal is common, but many positions are advertised by word of mouth. Before the interview, it is important to define which attributes would be desired in a candidate and to clearly communicate these goals to all who will interview the candidates. After the first interview, it is important to estimate the level of interest that the candidate has in accepting the position as well as the level of interest that the interviewers have in hiring the applicant. It is important to obtain permission to contact references for the purpose of defining the prior performance of the applicant. Public information regarding malpractice history, conduct or licensing issues, and Hospital Care Assurance Program (HCAP) scores can be obtained from national databases. Hospital administrators may provide insight regarding candidates being considered for an important leadership position in your organization. Long-term success requires ensuring that the hire would be a good fit within the group practice, department, institution,
and community. The candidate’s motivation and goals to integrate into the department are important. It is important to consider the candidate’s short-term and long-term goals for joining the practice. The needs and motivation of the spouse and family with regard to a move are important. In some cases, the spouse may require additional professional recruitment. When recruiting for research faculty, it is important to define both the candidate’s expectations and his or her needs for support and resources. This includes salary support, space and equipment, and support personnel. The department must define measures of success and the consequences of not meeting these expectations. Recruitment within an academic center requires defining the individual’s academic rank and disclosure of the process for appointment and promotion. The candidate should be reviewed by the committee on appointments and promotions to define the possibilities for academic rank with this appointment. The hiring chairperson should expect to both convey expectation for rank and promotion (and describe the various tracks) to the candidate and to make recommendations to the committee regarding the candidate’s qualifications for a recommended track. On-call coverage is important; the frequency, scope of responsibility, and locations for call should be spelled out. Making an exception to departmental guidelines often results in ill feelings within the group practice and should be avoided. It is important to define a business plan before advertising a position. The plan should consider support personnel, space and equipment, and protected time for research, educational, or administrative activities. The business plan will also define the expected case volume, relative value unit (RVU) productivity, net revenue, and overhead cost. Transparency of the financial aspects of the practice and of the expectation for performance generally leads to a healthy level of trust within the organization. Recruitment is facilitated by partnering with other stakeholders to share in the risk and opportunity of the recruitment. These stakeholders may include the hospital, ambulatory surgery center, medical school, or other academic departments. Partnerships within the hospital are an important consideration in the development of a business plan.
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TABLE I The Named Generations
Generation
Characteristics and Work Attitudes
Population
% of Active Physicians
Silent Generation (1925 to 1945)
The Silent Generation are traditionalists, loyal, hard-working, and optimistic. Great team players, they get along well with others and often have only one employer their whole lives. They are less tech-savvy than subsequent generations.
30 Million
10%
Baby Boomers (1946 to 1962)
Baby Boomers are loyal, work-centric, and cynical. They value responsibility, perks, praise, and challenges and often equate salaries and long hours with success.
77 Million
55%
Generation X (1963 to 1981)
Members of Generation X are ambitious and thrive on diversity, challenge, responsibility, and creative input. They are hard-working but place a high value on work-life balance (leisure).
45 Million
30%
Generation Y (1982 to 2000)
Members of Generation Y are creative, optimistic, and achievement-oriented. They are excellent multitaskers and very tech-savvy; they ‘‘demand’’ a life-work balance (leisure).
75 Million
5%
It may be appropriate to include a restrictive covenant in the final offer letter or contract. In many institutions, reappointment requires an annual professional review with defined criteria for reappointment. Some contracts define terms of severance. It is important to build support within the practice environment to execute a job offer. Engaged members of the practice can help with the recruitment of the new member as well as the candidate’s spouse and family. This should include a recruitment agenda for the spouse and children; such an agenda might include meeting with local community groups and realtors as well as touring the city, community, and schools. The final steps in recruitment include defining movingexpense support, start times, and requirements for licensure and accreditation before beginning a clinical practice. Throughout the recruitment process, it is important to detail all important issues in writing and have an attorney on each side review the contract. Having a checklist and standard operating procedure is important for the recruitment process. Despite an organized approach, the department chairperson will still have difficulty in predicting the ability of the new hire to perform surgery, to interact well with coworkers, and to be flexible and reliable. Generational Issues: A Great Divide? What is it about generations? When we talk with our colleagues, regardless of their age, we all seem to have the same sentiment toward those entering the workforce—that is, ‘‘the kids these days. . .’’ From twenty-two to eighty-two years of age, people tell stories about ‘‘how they weren’t like this when they were entering the workforce’’; ‘‘how the new generation doesn’t value this or doesn’t understand that’’—and this sentiment is not relegated to those exiting the workforce. We have seen this from individuals who have only been in their careers for a few years. Medical education is not immune to this perspective.
Who Are We? An Overview of the Generations Most everyone is familiar with the terms: ‘‘Silent Generation,’’ ‘‘Baby Boomers,’’ ‘‘Generation X,’’ and ‘‘Generation Y.’’ The categorical manifestations are everywhere, and clear date lines are drawn between the generations. So who are we and what has been written and studied about these generational categories? Table I details the date lines for these generations, their most common traits and attitudes toward work, their population numbers, and the percentage of working physicians (for the year 2007). Implications Twenge conducted time-lag studies to discover how generational differences specifically relate to work attitudes and to shed some light on the differences2. Twenge’s findings suggest some trends when looking across the generations. These trends include (1) work centrality and work ethic have steadily declined since the Silent Generation, (2) there is no difference in either altruistic or intrinsic values across generations, (3) extrinsic values peak for Generation X, (4) leisure values have steadily increased from the beginning of the Baby Boomer generation until the time of Generation Y, and (5) job satisfaction has increased between Generations X and Y. Overall, research has shown that individualistic traits have increased steadily from the period of the Silent Generation and are continuing to increase for Generation Y (and possibly beyond)3,4. So what does this mean relative to hiring your next partner? Most importantly, you’re not hiring a replica of yourself. As Twenge comments in her book, Generation Me, ‘‘...asking young people today to adopt the personality and attitudes of a previous time is like asking an adult American to instantly become Chinese.’’5 Recognize that the person whom you are hiring may have a very different set of values than the ones held by you and your current partners. Remember that these values may not be better or worse, just different; therefore, expectations must not be left as mutual assumptions. Discussing and understanding each other’s perspectives, and coming to an agreement, are important for the
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avoidance of future conflict and misunderstanding. Because individualistic traits are peaking with the current generation, it is fine to tell applicants ‘‘what’s in it for them,’’ but be sure to balance that with what they are expected to contribute. Also understand that ‘‘the kids these days’’ perception may have been a reality for those who were hiring you, too. Each successive generation may look at other generations as having ‘‘misplaced values,’’ and such stereotypes may create an unintended divide. In the most positive sense, stereotypes can help streamline complex information by being an energy-saving device, but we also know the negative aspects of stereotyping. So put your ‘‘the kids these days’’ perception aside and judge the individual, not the generational stereotype. Finally, remember that ‘‘your next partner’’ is also still learning how to be a doctor during this critical transition from a guided, structured training environment to a workplace setting that involves heightened responsibility and none of the previous restrictions. During this critical period, it is important that those who are doing the hiring also mentor and support the individual. By doing this, you can find a way to incorporate the value system of your new partner into the values of your group and, ultimately, the profession. This will aid in building a positive enduring orthopaedic culture across the generations of current practitioners and set a strong foundation for those future generations who will appear at the door.
unusual, especially if the new hire is coming from an existing practice (as opposed to directly from fellowship). It may be possible to minimize this deficit by having the new hire work at least part-time at the local Veterans Administration Hospital, where compensation is fixed and does not depend on productivity. Another way to address such a deficit is to approach the affiliated hospital or health system for support. In a 2011 survey conducted by the Academic Orthopaedic Consortium, 66% of academic orthopaedic departments that negotiated this backstop received some level of support from their hospital, health system, or practice plan. It is important to remember that the compensation is just one single slice of getting to ‘‘yes.’’ There are other, nonmonetary elements of the offer that may be just as important as the pay that is outlined in the offer. The prospective hire’s perceptions of the considerations below weigh heavily:
The Initial Compensation Package One of the most important functions of the orthopaedic chairperson is the hiring of new faculty. The ability of the chairperson to hire is strongly correlated to the compensation package that is offered. Many noncompensatory elements—of both a financial and a nonfinancial nature—are being considered by the prospective hire and being weighed in his or her final decision. This summary is meant to provide insight into the development of the overall compensation package that must be addressed in a successful negotiation with a prospective hire. Starting from the Beginning It is important to understand the financial requirements that are involved in supporting a new faculty hire. One approach is to develop a three-year pro forma that associates all projected expenses and revenues of a startup faculty hire over the course of his or her first three years. This is ideally modeled on a mature practice within the group in the relevant subspecialty and prorated, as initial revenues will be expected to be much less than those of a mature practice. As a rule of thumb, it is appropriate to estimate first-year production to be 33% of that of a mature practice. By end of year three, it is safe to estimate that production will be 75% of that of a mature practice. At this stage, the hire should be at or near the break-even point, especially if the practice owns its ancillaries. Mature-state production benchmarks (i.e., work RVUs) are available to members of the Medical Group Management Association and Association of American Medical Colleges and are valuable as additional benchmark data points. Deficits for the first three years of a new hire are significant. For academics, a three-year total deficit up to $400,000 is not
Viability of the practice (e.g., overall financial health, patient demand to support the new practice, and local market dominance) Likeability of the partners and perceived social ‘‘fit’’ Quality of the hospital and operating room Transparency around the compensation plan and the practice finances Work hours and call obligations Timetable for career advancement opportunities
Lastly, the decision to accept or not accept an offer is often strongly influenced and/or driven by where the spouse wants to live. Five Critical Inclusions in a Solid Offer Letter The offer letter encapsulates the main components being offered to the hire and should also include the expectations for the hire in return. These are ‘‘five critical inclusions’’ that should be outlined within the offer letter: 1. The Pay
This should spell out base pay, benefits, and bonus potential. 2. The Guarantee Period
This speaks to the duration of the compensation that is being guaranteed—typically, two to three years. 3. Expectations of the New Hire
Case volume or work RVUs per year (based on existing faculty production) Number of clinics or clinic visits per year Practice and hospital locations, including outreach location Participation in call schedule Teaching, publications, and other academic production Participation in societies and associations
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4. Mentorship Assignment(s) (Very Important to ‘‘New Generation’’ Hires)
Detail the kind of help and support the hire can expect from more senior partners. 5. Resources Provided to the New Hire
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Operating-room block time Clinical resource (e.g., nurses and certified medical assistants) Continuing medical education (CME) allowance Secretarial assistance Office, computer, smartphone, and supplies Relocation expense reimbursement Startup package and sign-on bonus (if applicable)
There are ways to make an offer more attractive without increasing the costs. As an example, if the assumption is that the new hire will receive $270,000 base pay and $30,000 bonus pay in the first year, the following alternative plans could be considered:
Other nonfinancial perks include:
Other Optional Items
Non-compete agreement Partnership provisions (private practice) Academic and/or appointment title(s) (clinical appointments).
Starting Compensation for Hires Directly Out of Fellowship
Compensation packages (base and bonus) for hires who are coming directly out of fellowship are guided primarily by two or three factors: 1. What the local and/or regional competition is paying 2. Established benchmarks 3. Most importantly, what the hiring department can afford, balanced with internal equity Traditional benchmarks (e.g., benchmarks of the Medical Group Management Association and Association of American Medical Colleges) have no orthopaedic data points that can be referenced for starting compensation. However, the Academic Orthopaedic Consortium encompasses these data within its annual survey among seventy distinct academic orthopaedic programs nationally to isolate physician compensation, clinical productivity, and the flow of funding from external sources that serves to enable academic orthopaedic departmental operations. This information is released through the Physician Collaboration Network platform (https://forMD.com) to all of the member executive directors for further distribution to their department faculty and leadership. In 2011, the benchmark data compiled by the Academic Orthopaedic Consortium revealed that the mean base starting compensation for new academic hires directly out of fellowship was $282,667, with a range of $220,000 to $375,000. For hires directly out of fellowship, compensation packages during the guarantee period typically include base and bonus compensation elements (e.g., $270,000 base plus $30,000 bonus). The bonus element is typically 10% to 15% of the base salary. The trigger for the bonus may be subjective, such as being a ‘‘good citizen and working hard,’’ or it may be tied to such metrics as work RVUs (most common), case numbers, charges, or collections.
Allowing the $30,000 bonus to be paid up front rather than at the end of the first year Allowing a salary of $300,000 and no bonus Allowing the new hire to transition from a guaranteed salary model to one based on productivity (e.g., based on work RVUs) if it pays more prior to the end of the guarantee period
Conferring a title or leadership post Offering a preferred operating-room time or practice location
Maintaining Perspective It is not wise to be the ‘‘highest bidder,’’ but the salary offer will generally need to be at least in the ‘‘middle of the pack’’ among competitors. All things considered, new hires want the starting salary to be ‘‘in the ballpark’’ of other offers (outliers excluded). Hires who have just finished a fellowship often have considerable debt and look favorably upon packages that offer high cash flow early rather than later. Although the starting salary is important, prospective hires are often interested in future earning potential beyond the period of guarantee. Projecting a range of future production levels and associated (projected) compensation levels not only provides the candidate with the potential for future earnings but also forces the practice to project the potential market for these services and transparency about what they would project to pay for that production. Starting Compensation for Hires Coming from Another Practice Established physicians are generally unwilling to take a substantial pay cut (i.e., >10%) during a guarantee period without the expectation of recouping it in the future. It may be important to look at the candidate’s most recent production figures to see if this would support the future desired compensation. The practice weighs what it can afford against the urgency of need and how this would impact internal equity. It is not wise to offer a new hire more in base compensation than that earned in total compensation by existing mature-state faculty in the same subspecialty. Financial losses are steeper for new hires that come in at a high salary that must be reduced over time, since their starting compensation is always higher. Use of Benchmarks—the Medical Group Management Association and the Association of American Medical Colleges For paying members, the Medical Group Management Association and the Association of American Medical Colleges are useful in providing numerous compensation and productivity
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benchmarks (associated with mature-state practices [i.e., established practices that have stopped growing]). The data published are also categorized according to geographic area and setting (academic or private practice). Having said this, the data also have some limitations, with representative examples shown below: There may not be data for certain orthopaedic subspecialties. The total number of survey data for a particular subspecialty may be extremely small. The national benchmark average may not be applicable as it is too broad. There are no starting salary benchmarks for orthopaedic surgeons.
Regardless of the criticisms, these benchmarks can be valuable and are often referenced by physicians and administrators, especially in relation to physician compensation and clinical productivity. Accordingly, it is imperative to be able to explain any major variance in comparison with these benchmarks. Approach to ‘‘Closing the Deal’’ The approach to closing the deal should be more of a conversation than a negotiation. It is appropriate to take inventory of mutually shared goals and to determine if there are enough of these to warrant a future together. Getting the prospective hire to talk about his or her goals, vision of the future, special needs, and concerns is valuable in determining ‘‘strength of fit.’’ It is important, especially at this stage, for the parties to
talk openly about the opportunity, goals, and possible conflicting goals associated with the position to avoid a poor fit that results in subsequent disconnect or worse (a decision to leave the practice). In the spirit of partnership, it can be helpful to share a draft of the offer letter with the prospective hire and ask him or her to take two weeks to consider it and return it with any suggestions for change. This ties both sides to the process of identifying areas of possible contention, and it allows negotiation and maintains communication during the progress. The timeline helps to ensure that the process moves forward. Academic Orthopaedic Consortium The Academic Orthopaedic Consortium was established in 2005 by a handful of executive directors at the top academic programs in the country. This consortium was formed largely out of necessity since there was no overarching society or association that existed solely for academic orthopaedic programs. The purpose of the Academic Orthopaedic Consortium is to provide a network that, through the collective wisdom of community, could educate, empower, and enable administrators in academic orthopaedics. Today there are executive directors from more than seventy U.S. academic orthopaedic programs who participate as members. Membership in the Academic Orthopaedic Consortium is free and is open to executive directors of all academicaffiliated orthopaedic programs. A prospective member must have a profile to participate, as all of the executive directors connect and share by utilizing the for[MD] platform. Information
Fig. 1
Table showing representative data from the Academic Orthopaedic Consortium survey of 2011. FY 09 = fiscal year 2009, FY 11 = fiscal year 2011, WRVUs = work relative value units, and RETMNT = retirement.
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regarding membership in the Academic Orthopaedic Consortium or with regard to the for[MD] platform can be obtained from [email protected]. The collective body of the Academic Orthopaedic Consortium is committed to providing national-level analysis, benchmarking, and organized discussion that will improve the national academic orthopaedic community as it tries to understand its environment and, accordingly, as it processes how it should evolve. The 2011 Academic Orthopaedic Consortium survey on ‘‘Physician Compensation, Clinical Productivity, and External Support’’ across U.S. academic orthopaedic departments was released in December 2011 and contains a snapshot of helpful information relative to compensation for academic orthopaedic surgeons (Fig. 1).
spondents described themselves as being born between 1946 and 1962, and 39% described themselves as being born between 1963 and 1981. Seventy-one percent of those born between 1946 and 1962 and 65% of those born between 1963 and 1981 believed that the current generation of graduating residents does not have the same level of commitment to the profession as did the respondent. Work ethic is perceived to be changing over time. It is clear that the experienced chairperson’s perspective, recognition of generational issues, and a reasonable initial compensation package will be key in hiring your next partner. n
Conclusions Hiring a next partner requires a good deal of diligence and preplanning. Financial, generational, and social issues are important. Hiring into an academic organization requires some additional consideration above and beyond that of a private practice setting. In particular, academic rank, teaching responsibilities, faculty development, and opportunities for research become important. Attendants at this actual AOA symposium were polled regarding several questions relevant to hiring. The majority (58%) of respondents felt that the most common reason for a member of a practice to be asked to resign from a group was poor fit within the practice environment or culture. The most common (48%) perceived reason for a member to voluntarily leave a practice was poor fit with the practice environment or culture. It is clear that a good fit between the hire and the practice is key to successful retention within a group. With regard to compensation, most respondents (89%) believed that the proper level of compensation for a new hire should be guided by market rate but that the level ultimately must be a balance between what the department can afford and the impact that the rate will have on departmental internal equity. Generational issues seem to matter. At the symposium, 48% of re-
R. Dale Blasier, MD, FRCS(C), MBA Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 3 Children’s Way, Little Rock, AR 72202. E-mail address: [email protected] Michael R. Gagnon, MBA Department of Orthopaedic Surgery, Duke University, 4709 Creekstone Drive, #227, Durham, NC 27703. E-mail address: [email protected] Joseph P. Iannotti, MD, PhD Department of Orthopaedic Surgery, A41, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail address for J.P. Iannotti: [email protected] Sandra Jarvis-Selinger, PhD eHealth Strategy Office, University of British Columbia, 855 West 10th Avenue, Vancouver, BC V5Z 1L7 Canada. E-mail address: [email protected]
References 1. Blasier RD. Hiring your next partner. Presented as a symposium at the 125th Annual Meeting of the American Orthopaedic Association; 2012 June 28; National Harbor, Maryland. Symposium no. 1. 2. Twenge JM. A review of the empirical evidence on generational differences in work attitudes. J Bus Psychol. 2010 Feb 18;25(2):201-10. 3. Walsh DS. Mind the gap : generational differences in medicine. Northeast Florida Med. 2011;62(4):12-5.
4. Coupland D. Generation X: tales for an accelerated culture. New York: Martin’s Press; 1991. http://familiesandwork.org/ downloads/GenerationandGender.pdf. Accessed 2014 Apr 17. 5. Twenge JM. Generation me: why today’s young American’s are more confident, assertive, entitled—and more miserable than ever. New York: Simon and Schuster; 2006.
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