INTRODUCTION

Hospital medicine in the USA has grown considerably since the term “hospitalist” was coined in 1996.1 It is the largest internal medicine subspecialty, with more than 50,000 hospitalists.2 Hospitalists early in their career represent a large proportion of the growing hospitalist community (47.5%).3,4,5 They are part of the larger millennial workforce, defined as those born from 1982 to 1996.6 The generational cohort of millennials prioritizes work-life balance and clear communication,7 and is highly focused on repaying significant financial debts.8 Job turnover in this group is high. Research on millennial employment attitudes suggests that about one-quarter plan to leave their current job within 1 year and two-thirds intend to do so in the next 5 years.9

A Society of Hospital Medicine (SHM) survey found that the annual hospitalist turnover increased from 6.9% in 2016 to 10.9% in 2020.5 On average, each hospital medicine group (HMG) with ten or more hospitalists loses one provider every year.10 One-third of those who take a hospitalist position migrate from another HMG.5 Millennial hospitalists may be contributing significantly to hospitalist turnover. Hospitalists in the first 2 years of their practice use job switching as a strategy to find a better fit.11 While millennial-specific turnover prevalence is less clear, the overall physician turnover is known to be the highest during their first years of practice, as high as 25% in the first 3 years, compared to about 4.6% turnover rate among physicians practicing for more than 10 years. Turnover and recruitment are expensive. Hiring a new hospitalist costs somewhere between $400,000 and $600,000.10 This estimate includes various “soft costs” such as advertisement, recruiter fees, increased staffing expenses (associated with moonlighting and locum tenens), signing bonuses, interviewing costs, onboarding costs, and revenue lost due to reduced productivity of the HMG. The COVID-19 pandemic has placed an additional strain on the hospital medicine profession and argues for an increased need to recruit and retain these physicians.

A few characteristic differences between millennial physicians and more established physicians are known, but data is sparse in the hospitalist specialty. Physicians early in their career report to have lower satisfaction with career choice, higher frequency of work-home conflicts, higher rates of depersonalization, and a higher likelihood of leaving current practice within the next 2 years than older professionals.12 Female physicians early in their careers work full-time less often than males, and these differences are higher among women with children than men with children.13 Hospitalists who are early in their career define academic success as “being respected and recognized,”14 yet they report lower salary and clinical autonomy than the more-established hospitalists.15 In non-hospitalist specialties, retention strategies for millennials have included less time on call, flexible schedules, ample vacation time, robust communication channels, rewards, a clear career ladder, valuing their skills, and strong mentorship.16,17,18

It is unknown whether millennial hospitalists have similar preferences compared to mid- to late-career hospitalists or what may be important to them in choosing a job or remaining with their current HMG. Therefore, we performed this study to understand what influences the recruitment and retention attitudes of millennial hospitalists born in 1982 or later.

METHODS

Study Design, Subjects, and Setting

This was an online survey-based study conducted across 7 HMGs spanning seven states in the USA. All hospitalist physicians born in 1982 or later were included.

Survey Development and Data Collection

After a review of the literature, our HMG’s data on hospitalist morale,19 and informal interviews with division faculty from September 2019 to March 2020, the hospitalist recruitment committee at Johns Hopkins Bayview Medical Center (JHBMC) met in a series of rapid cycle sessions to generate and revise a list of elements that hospitalists consider when choosing or remaining at an HMG. In consideration of these inputs, 18 elements were ultimately identified and subsequently grouped into four major categories: culture of practice, work-life balance, financial considerations, and career advancement. The steps mentioned above served to confer content validity evidence to the survey instrument. For each of the 18 elements, respondents were asked: (i) “How important was this element in your decision-making process for choosing to join your current hospitalist group?”, and (ii) “Now that you are working in your current group, how important is this element in your decision to remain with the group?”. For these two central questions, response options were: 4 = Utmost importance, 3 = Fairly important, 2 = Fairly unimportant, 1 = Totally irrelevant. The survey also included questions assessing respondents’ gender, race, parental status, specialty (adult, pediatrics, or med-peds), medical school graduation year, and fellowship training.

Pilot testing was conducted at a departmental Research-in-Progress session and then again with ten physicians born shortly before 1982 to assess the clarity and lack of ambiguity. The survey was iteratively revised based on feedback. During the pilot testing, physicians explained how they interpreted the questions and what they were thinking as they were answering; this step serves to confer response process validity evidence to the survey.

All hospitalists working across the 7 HMGs were emailed a request to complete the survey anonymously via a weblink to Qualtrics. The first contact was made on August 13, 2020, and up to three reminders were sent to encourage full participation through September 22, 2020. The study was approved by our institutional review board (IRB00229841).

Statistical Analysis

We calculated descriptive statistics for all survey items and Cronbach alphas for elements within categories. We dichotomized the responses for 18 elements as important (combined utmost importance and fairly important) and not important (combined fairly unimportant and totally irrelevant). Comparisons of proportions rating each element as important for choosing vs. remaining at an HMG were calculated using z-tests of two proportions.

We calculated the means for all 18 elements reported as important across the sample. We then calculated means by averaging elements within each category. We used unpaired t-tests to compare differences in means for categories for choosing vs. remaining at an HMG.

As a sensitivity analysis, we also performed the analyses outlined above after dichotomizing the responses for 18 elements as important (utmost important) and not important (combined fairly important, fairly unimportant, and totally irrelevant) (Supplement A). This analysis showed changes in p values, but the patterns were similar to our primary analysis, and we focus on results where they were consistent across both analyses.

We tested for associations between gender, race, parental status, and the ratings for elements. Survey responses with missing data were excluded from the analysis. Analysis was performed using STATA version 13 (StataCorp. 2017, College Station, TX).

RESULTS

One hundred forty-four of 235 hospitalists responded to the survey (61.2% response rate). Four respondents were born before 1982 and were removed from the analysis. Respondents’ mean age was 34.4 years, and 49.6% were females (Table 1). Sixty-nine percent of the respondents were in their first hospitalist job following residency, and 80% were not planning on pursuing a fellowship. Forty percent respondents reported student loan debt between $100,000 and $400,000. Cronbach alphas ranged from 0.6 to 0.8 for internal consistency of elements within each category.

Table 1 Respondent Demographics (N = 140*)
Full size table

Table 2 shows the comparison of participant responses for the 18 elements in regard to the importance for both choosing and remaining with their HMG. The individual element that was most frequently rated as important in choosing an HMG was a “cohesive workplace” (99%). “Having the leaders’/practice values aligned with my own” (99%) was the element most important for remaining at an HMG.

Table 2 Elements Rated as Important by Millennial Hospitalists for Selecting and Continuing to Work with Their Current Hospitalist Group
Full size table

Culture of practice was the category with elements most frequently rated as important for both choosing (mean 96%, SD 12%) and remaining (mean 96%, SD 13%) at an HMG. Work-life balance was the category that ranked second in importance for choosing (mean 82%, SD 22%) an HMG, while financial considerations ranked second for remaining (mean 90%, SD 27%) with an HMG. The category least frequently rated as important for both choosing (mean 69%, SD 35%) and remaining (mean 76%, SD 32%) at an HMG was career advancement.

Among “other” elements, “geographical location” was highly favored by the millennial hospitalists both for choosing (91%) and remaining (90%) at an HMG, with no statistically significant difference in choosing or remaining at an HMG (P = 0.81). There were no statistically significant differences between respondents’ gender, race, or parental status and ratings of elements for choosing or remaining with HMGs.

DISCUSSION

The results of this study illustrate that the elements that are the most important for millennial hospitalists in choosing an HMG are not necessarily the same as those being considered when thinking about remaining with the group. This enhanced understanding of these issues may be helpful for those seeking to recruit and retain talented hospitalists.

A 2006 survey of 17,000 physicians from 92 organizations showed that more than half of respondents cited poor fit with the “culture of practice” as the principal reason for leaving their job.20 Another 2012 survey of 2381 faculty from 28 US medical schools reported that negative perceptions of institutional culture were associated with a tendency towards dissatisfaction at work.21 A study of US surgeons showed that hospital culture was significantly associated with frustrations,22 which led to considerations about quitting.23 Attrition among hospitalists early in their career is, in part, due to their job switching tendency in pursuit of a better-fitting job where the organizational values align with their own.11 A survey of early- to mid-career pediatric hospitalists linked job satisfaction and financial factors with higher retention.24 Our research study focuses on the recruitment and retention of millennial hospitalists, most of whom were internal medicine trained. The results are congruent with these previously published findings investigating other physician cohorts.

Culture of practice has been shown to contribute to satisfaction and retention of physicians;25 this element was unanimously rated to be highly important by the respondents in this study. Organizational culture refers to the shared values and beliefs regarding norms of appropriate behavior in an organization.26 HMG culture is associated with “work control, cohesiveness, an emphasis on quality over productivity and on clear communication, and values alignment of the whole team with leadership”.27 Organizational culture is informed by various factors such as group solidarity, innovativeness, management style, trust, autonomy, cost/quality control, organizational mission, vision, values, etc.28 HMG leaders can create a millennial-friendly culture at work29 by implementing strategies such as regularly scheduled division meetings where millennials can voice their opinions and concerns,30 enhancing transparency in operations,31 and creating fair organizational policies.32 A culture of effective two-way communication and formalized prolonged onboarding has also been shown to reduce turnover rates for physicians early in their practice.33 Groups that have established a great culture should not hide this information as it may be a differentiator—demonstration of the flourishing culture should be on display through video testimonials,34 on-site visits hosting luncheons with group’s millennial hospitalists for potential recruits,35 and with group activity photos hanging on the walls. Conducting structured exit interviews to improve the experiences of future hires and gathering feedback from candidates who turn down a job offer may also help strengthen future recruitment.35

Work-life factors were also found to be an important contributor to respondents’ decision in choosing an HMG. Specifically, the clinical schedule factor was ranked important by 93% of respondents in our study. Work-life imbalance is associated with personal burnout.36 Clinical schedules conflicting with home activities are associated with a tendency to reduce clinical work hours or quit.37 Our study similarly highlights the importance of work-life balance for millennial hospitalists in remaining at their current job. The SoHM 2020 report shows that only about a quarter HMGs offer a variable schedule with more than half adult HMGs currently following the traditional 7 on 7 off schedule.5 Careful discussions with HMG stakeholders to address scheduling conflicts can be helpful in improving job satisfaction and retaining millennials. Offering flexibility in scheduling, some work-from-home opportunities, and safeguarding parental leave time may also be especially significant in the wake of the enduring COVID-19 pandemic.38

In our study, the category of financial consideration had the largest gap between choosing and remaining with an HMG, and this difference was statistically significant. Financial considerations are important to millennials largely due to student-loan debt, which is currently at a record high.39 Hospitalists with lower compensation and higher debt concerns have a higher attrition rate.24 The gap in choosing versus remaining for financial considerations may have implications for how HMGs choose to steward resources. Loan repayment/forgiveness incentives for those who choose to stay with their HMGs are an excellent strategy to recruit and retain.40 Tuition reimbursement (for professional development courses, or advanced degrees such as master’s in business administration, master’s in public health, or master’s in education) may also be attractive to this cohort.41 HMGs may consider starting with reasonable salaries, then focusing on incremental experience-based salary increases. While many HMGs address hospitalists’ financial concerns by providing productivity incentives, attainable quality metric-based bonuses, moonlighting opportunities, partnership track opportunities, tenure track options, individualizing such benefits based on HMG’s millennials’ needs is essential. Explaining historical statistics pertaining to HMG’s incentive structure (work relative value units or wRVU and quality-metrics bonuses) gives the potential recruits a chance to understand the compensation model with complete transparency. Equally important is for HMGs to continuously reevaluate their compensation package to stay at par with the competitive market rates. Such market data is readily available through reports published by SHM5 and the Medical Group Management Association (MGMA).42

We also noted that geographical location is a popular element considered by millennials, both during recruitment and retention. A 2016 survey of 102 internal medicine residents found that a significant proportion (53% respondents) selected hospital as their preferred practice location, and the most commonly cited reason (71% respondents) for the desire to practice in a specific location was “being close to family.”43 Respondents in that survey also indicated increased compensation and shorter work schedule as the top two incentives to consider a less desirable location. HMG leaders may explore such geographical ties during the hiring process to determine if the new recruits plan to relocate in the near future. Such conversations can inform expectations and avoid any surprises later.

Several limitations of this study should be considered. First, some subjects did not complete the survey. However, our response rate is relatively high compared to other published surveys of hospitalist physicians.5 Second, much of the inquiry explored attitudinal variables. Although some may not place complete confidence in such responses, this is one of the only viable ways to characterize informants’ feelings and perspectives. Further, respondents knew that the data was being collected and analyzed anonymously, so there is no reason to believe that those taking the time to answer questions would do so disingenuously. Third, we surveyed physicians at seven HMGs, and their viewpoints cannot be expected to necessarily represent those of the broader population of millennial hospitalists. Fourth, we chose to also define our respondents according to the millennial generation age limit, which introduced a specific and somewhat arbitrary age cutoff. This classification allows for comparisons to other studies of millennials, but we recognize that generational theories have inherent limitations.44 The stereotypes of generational cohorts are arbitrary, not always evidence-based or generalizable, sometimes even likened to narrow-minded perspectives. Generational theory is often criticized for ignoring intracohort differences like race, geography, gender, political alignment, parental status, and marital status.45 Finally, this study was conducted during the early phase of the COVID-19 pandemic, when physician burnout, COVID-related anxiety, and job quitting tendencies were high.46,47 This may have confounded the results of our study, particularly if HMGs were impacted more or less by the pandemic. Additionally, COVID may be more likely to have an impact on the remaining than choosing an HMG given the timing of the study.

CONCLUSIONS

Recruiting and retaining talented millennial hospitalists is a costly and competitive process for HMGs. In addition to the tremendous financial burden, turnover also translates into the loss of professional relationships, which can negatively impact group morale. Attention to a millennial-friendly organizational culture and addressing individual needs may mitigate such losses. Additionally, financial stewardship by instituting experience-based rewards may be a helpful strategy. Millennials comprise a growing proportion of the hospitalist workforce, and the results of this study may be especially helpful in recruitment and retention.