After numerous meetings, phone calls, dead ends and as much as $100,000 invested in recruiting, the new doctor finally arrives to set up shop.

The work is just beginning, however, for hospital leaders who want to protect that long-term investment in the facility and surrounding community, rural health experts say. Along with recruiting costs, the hospital likely already has paid a salary premium to entice the doctor. The average rural family practice physician earns nearly $205,000 compared with $171,328 for an urban counterpart, according to recent data provided by recruiting firm Merritt Hawkins.

If, in a few years, that doctor decides to leave the hospital, the financial and patient care ripple effects can be painful, says David Schmitz, M.D., program director of Rural Training Tracks for the Family Medicine Residency of Idaho. "There's certainly the time necessary for physicians to become familiar with their environment before they can be more efficient, for patients to establish some relationships with their physicians, as well as the issues around contracting and use of technology," he says. "All of those issues add up to the cost of rural turnover."

Schmitz echoes others who stress that hiring the right doctor in the first place is a critical part of the retention equation, and he's helped to develop a program assisting communities in that regard [see Assessing Your 'Recruitability,' Page 11]. But hospital leaders and trustees can set themselves up for turnover by allowing their attention to wander in the weeks and months after a draining recruiting process, says Mike Williams, chief executive officer of Community Hospital Corp., a nonprofit organization in Plano, Texas, that focuses on improving health care access in community settings.

"A lot of these small communities, unless you were born there, it's really hard to become a part of it," he says. "We can't just recruit them and forget them. We've got to recruit them, embrace them and engage them."

To be effective, physician retention must be a multifaceted community effort, from troubleshooting housing headaches to introducing the doctor's spouse to job opportunities or people with like-minded interests. Back at the hospital, leaders should stay flexible and attuned to shifts in the physician's needs and stressors, whether that's a bumpy transition to a new electronic record system or another physician's departure that's ramped up the on-call workload.

Never doubt that your doctors are being courted by someone, says Tommy Bohannon, divisional vice president of recruiting at Merritt Hawkins. If the Irving, Texas-based firm is searching for a family doctor to practice in a town of 8,000 people, it's not uncommon to contact all family practitioners in towns of less than 25,000, he says. "Heck, a lot of times we'll do it nationwide," he says. "Even docs in small towns are being recruited heavily to other small towns."

Anne Camber, M.D., the sole obstetrician-gynecologist in Libby, Mont., can vouch for that.

"There's not a week that goes by that I don't get a phone call, an email or something in the mail looking to hire me," she says. "They call my office. They call my cell phone. They call my house. The recruiters are merciless."

Want to keep your doctor from returning that call? Here are five strategies to recruit-proof your physicians.

1 Cement Personal Connections

Doctors are lured to a rural area in part by their desire to build strong connections with the surrounding community for their family and themselves, says Lisa Benzel, who, until recently, directed recruitment and workforce development at MHA: An Association of Montana Health Care Providers. Jump start that process, she stresses. Introduce the children to the local baseball league and the spouse to the biking club. "It doesn't matter if the physician is happy, because if the whole family isn't happy, he or she will feel that stress at home," she says.

In Cut Bank, Mont., hospital CEO Cherie Taylor encouraged her trustees at Northern Rockies Medical Center to help acclimate the two family practice doctors who joined the 20-bed hospital last year. The recruiting process lasted roughly two years and Taylor had practiced some tough love along the way, making sure the physicians — then wrapping up their residencies — understood the sort of practice they were contemplating. "I definitely told them, 'This is not for everyone. It's small and rural, you are totally isolated. You have to be able to manage by yourself, for the most part.' "

Now board members, such as Bess Hjartarson, are trying to help physicians and their families adjust to their new home. Hjartarson vividly recalls arriving in town five years ago herself, the wife of the new veterinarian with two young children. Cabin fever is not uncommon, she says, quipping that "there are nine months of winter." Some days, when the temperature drops toward zero and below, the kids can't even play outside, she says.

Hjartarson has introduced the wives of the physicians, both of whom are staying at home with young children, to local gatherings such as a program held at the civic center a few mornings each week during the worst of the winter months. "You want some place to go," she says, "where the kids can play and the moms can talk."

2 Strengthen Collegial Backup

To feel supported in sometimes isolated circumstances, rural doctors need to know they can rely on more than token backup, says Benzel, who recently started a new job as director of the Montana WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) Targeted Rural Underserved Track, or TRUST, program. Benzel suggests introducing the new doctor to another physician mentor, someone he or she can call or meet with on a regular basis. "Maybe it's from the town 30 miles down the road — just so they develop that relationship with other providers who have been around longer," she says. This relationship also can be a starting point to connect with specialists on consults for unusual cases.

Allowing medical students or residents to rotate through the hospital creates a teaching opportunity that can energize a new physician and help him or her to maintain links to the larger medical world. "A lot of these young physicians really want to keep learning," Benzel says. "And the best way to keep learning is to teach."

Don't bury the new doctor in endless work, because they won't have a chance to enjoy life outside of practicing medicine, Benzel adds. "That's why people live in rural areas — they want that quality of life." If need be, hire a locum tenens physician to enable a much-needed break or work a deal for call coverage with the town down the road, she suggests.

Williams agrees. "We are burning them out," he says of rural doctors. One strategy is to look at where the rural hospital typically refers patients, and approach that larger hospital or practice to talk about formalizing a more two-way relationship, he says.

After all, he notes, those urban providers benefit from the smaller community's referrals. Could some of those doctors commit to periodically handling call, or stepping in to allow the rural doctor a vacation or to break away for continuing medical education? "Or even have a network of collegiality to whom they can turn when it's been a hell of a day," Williams says.

3 Know the Market

Hospital leaders and boards can disagree about the value of a physician, particularly a subspecialist, and there's the risk that the compensation package will become outdated, says Merritt Hawkins' Bohannon. Revisit market trends periodically. If feasible, make sure a physician is already on the board or high up in the hospital's leadership. He or she might have a better understanding of some of the salaries being discussed, he says.

"I've had a client tell me that, 'We have people on our board who make $50,000 a year as farmers.' They don't understand why someone would make $200,000 a year for being a doctor," Bohannon says.

It's important that trustees view their doctor as a community asset and not "get stingy unnecessarily," says Brock Slabach, senior vice president for member services at the National Rural Health Association.

"If you have someone who is worth $15 million dollars to you and the system, the pay is going to be secondary," he says. "But oftentimes, the management and the trustees get tangled into the pay issue, and are missing the bigger picture."

4 Demonstrate Flexibility

Camber and her husband, orthopedic surgeon Joshua Urvater, M.D., were recruited in 2006 to St. John's Lutheran Hospital in Libby, Mont. (The critical access hospital will move into a new replacement facility with a new name, Cabinet Peaks Medical Center, early this year.) As the only ob-gyn and orthopedic surgeon practicing within nearly 100 miles, the couple figures prominently in local medical care, although the hospital's family practice doctors also deliver babies.

One of the lures, along with a fair compensation package, was some practice flexibility, Camber says. The couple agreed to meet their patients' medical needs, along with emergencies and on-call coverage. In return, they didn't want anyone micromanaging their hours while they raise their four children. It shouldn't "require a federal case" to attend the kindergarten Christmas play between 11 and 11:30 a.m., Camber says.

The ob-gyn was talking from home on her day off; her husband, technically on his day off, was at the hospital treating a broken ankle. "One of the challenges for boards is to understand the value of physician good will," says Camber, who also is a trustee at St. John's. "There's nothing better than having a surgeon who wants to come in," she says. If the patient with a hip fracture is shipped out of town, for example, a hospital not only loses out on inpatient revenue, but any related revenue from nursing home or rehab care, she says.

John Henderson, CEO at 39-bed Childress (Texas) Regional Medical Center, mulled over the value of good will a few years back when a decision had to be made regarding the distribution of federal meaningful use payments related to the implementation of an EHR at the public hospital's affiliated outpatient clinic. The Childress hospital invested in the software, Henderson says. The question was who, the hospital or the doctors, should receive the related payments for meeting meaningful use standards?

Henderson consulted then-board president John Inman and they quickly agreed to compensate the physicians, given that it was their work that had made it possible. "He was the one who said, 'You might have a good argument for that,' " Henderson recalls. "But I think [in the]long term, it's going to be better for us to be generous."

5 Think Longer Term

Hospital leaders leave themselves vulnerable to doctor poaching when they postpone developing a physician succession plan, Bohannon says. One potential scenario: Two surgeons cover the hospital and the older one reaches age 65 and decides to retire. "Now I'm on call every night because the hospital took too long to start recruiting." How vulnerable, Bohannon asks, will that surgeon be the next time a recruiter calls?

Jim Hayes, CEO of 56-bed Trinity Muscatine (Iowa) Hospital, says that he strives to remain aware of any early warning signs that a doctor might be edging toward the door. Among them: grumpiness, irritability or a shift in the physician's commitment to the hospital. "Maybe pulling back from participating in some of the committee work, kind of a lack of interest in building a practice, working extra hours, taking their fair share of the call," he says.

Asking the physician if anything is going on likely will elicit an "everything is fine" response, Hayes says. Instead he uses a different tactic, asking the doctor: " 'If you could pick one thing that we could change about the way things are working in the organization, what would it be?' Try to get them to talk, rather than [having] you talk."

Still, it's important to take the long view to guard against any yawning patient care gaps, Henderson says. The Childress Regional CEO recently signed recruiting agreements with two family practice residents, with an eye toward adding them to the hospital's roster within the next few years.

As of late 2013, none of the doctors had announced retirement plans, including Henderson's own father, a family practitioner in his early 60s who delivers babies and covers the emergency room. "He's shown no indication of slowing down," his son says.

But demographics can't be ignored, Henderson says. His nine doctors span the age spectrum, including two in their 30s, two in their 40s, two in their 50s, two in their 60s, and one 70-something physician. Ideally, those two incoming physicians will plant roots in the community and one day will have walked the hospital corridors for decades, he says. "That's when you've hit a home run."

Charlotte Huff is a health and business writer in Fort Worth, Texas.

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