The Association for Advancing Physician and Provider Recruitment (AAPPR) is redefining recruitment to retention and is the only professional organization where physician and provider recruitment leaders and others who influence recruitment, onboarding and retention can connect, learn and advance their careers.
Like the communities they serve, rural health systems are unique and, unsurprisingly, have unique challenges. In September, AAPPR hosted a series of member roundtable discussions on the topic of rural recruitment. A common theme to all the discussions was how much has changed in the last six months.
The landscape of health care nationwide has been changed, possibly forever, by the COVID 19 pandemic, and rural areas are no different. From telemedicine to candidate pipelines, recruitment professionals have seen a shift and felt the impacts of a changing world.
If you asked recruitment professionals in rural areas a year ago about the most significant challenges they faced, the first would likely have been location, the second sourcing, and the third perhaps competition from larger, urban health systems. A year ago, most would have agreed that these challenges were, in many cases, difficult to overcome. Now, however, it seems that the pandemic has shifted the landscape in ways that previously seemed unimaginable.
Over the last six months, what was once the biggest challenge for recruitment professionals, a rural location, has become one of their most significant assets. AAPPR members who recruit in rural areas almost universally reported that they have seen an increase in providers seeking opportunities outside of major metropolitan areas. Individual reasons for relocation vary from wanting to reside in less densely populated areas to hoping to be closer to family. Still, the commonality is a search that looks more closely at rural areas. The result is recruitment professionals in rural areas seeing more robust, deeper pipelines.
Traditionally, sourcing has also been challenging for recruiters. Many rural recruiters relied heavily on career fairs, residency and fellowship program visits, and clinical conferences to meet candidates, network and, build relationships with them. Brad Lindblad, Director of Provider Development, Professional Development at Mary Lanning Healthcare, in Nebraska, has been working in a rural setting since 1997. He believes that “in rural recruitment, it always comes back to creative sourcing and building relationship. In some cases, that means starting to recruit someone 4-5 years before they are actively looking for a job and building a long-term relationship.” For the first time this year, Lindblad signed a provider virtually. He feels that “a good recruiter sees a challenge and turns it into an opportunity. Providers who may not have been interested in a rural area a year or two ago are now interested and will have a conversation with us.”
Other rural recruitment professionals agree as the pandemic continues to change how teams approach searches, many are finding new and creative ways to source, recruit, and hire candidates. In some cases, recruitment professionals have noted that virtual interviews and site visits have allowed them to show off practices and communities to candidates who might not have previously thought about a more rural area without having a significant impact on timelines or budgets. Furthermore, as both health systems and candidates become increasingly comfortable in a virtual world, many AAPPR members noted that their timelines to interview and hire candidates have tightened. With so many employees continuing to work from home, recruitment professionals report that their teams have invested the time to streamline their processes and adapt them to remote work. Additionally, as virtual interviews and site visits become the norm, many providers who otherwise would have to take several days to travel to a rural location can get a feel for the hospital, clinic, colleagues, and community in a few hours without ever leaving home.
Rural health care has also seen considerable benefit from the increased use of telemedicine. Rachel Ruddock is the Workforce Development Manager at the Michigan Center for Rural Health and serves as a board member for the National Rural Recruitment and Retention Network (3RNet). She has also noted the number of providers interested in telemedicine opportunities, which for rural communities, could bring needed services into underserved areas. Ruddock believes that “telemedicine will transform how medical care is delivered to rural communities. Pre-Covid many rural clinics and hospitals already utilized telepsychiatry, teleneurology, and other telehealth services due to providers shortages and lack of access to these specialties. This usage has exploded in the last several months as a result of Covid-19. Overall, the feedback from patients and providers who are using telemedicine during this pandemic has been positive. Patients are grateful to no longer need to travel far distances to access care, and providers appreciate being able to see patients in a manner that keeps them healthy and safe. Telemedicine is here to stay even after Covid-19 ends.”
There are, however, two sides to every story. There are certainly health systems struggling with the impacts of COVID 19, and rural communities are no exception. They, too, have had their share of hospitals and clinics furlough employees or freeze hiring initiatives. Ruddock notes that “six months ago, almost any rural healthcare employer would have told me they needed more primary care providers. Now, as a result of COVID 19, I’m seeing rural primary care providers being let go due to a lack of volume and financial constraints. This isn’t happening everywhere, but I’ve seen this occur more in the past six months than the last five years.” Many continue to wonder if the financial implications of COVID-19 will lead to an increase in mergers between health system and how the plans of large corporations like Walmart and CVS to enter the health care field will impact the already tight competition for providers, especially in rural areas.
Like their counterparts in metropolitan areas, rural recruiters are watching trends and working hard to leverage what they can to continue to bring top talent to their communities. In rural areas, recruitment professionals understand that they have a window to work with providers seeking new opportunities in smaller communities.
They continue to work hard to build long-term relationships with candidates while being mindful that health systems’ long-term viability may depend significantly on how the pandemic continues to unfold in the coming months.
Absent a crystal ball; the future is uncertain whether you live in a city of millions or a town of just a few hundred. But one thing is sure; rural recruitment professionals are continuing to adapt to an ever-challenging and changing landscape. With COVID-19 still a very real presence across the United States, collectively, they are finding creative solutions to both old and new challenges and are embracing the success of every new provider they bring to their communities.
After attending the AAPPR conference in Orlando last month, and a few of our NP Now representatives were very impressed with Allison Dimsdale’s discussion on the topic, “Transforming Recruitment and Onboarding for Ambulatory APPs ” We were fortunate to be able to have an interview with her in order to further learn from her expertise.
Allison Dimsdale, DNP, NP-C, AACC, FAANP is the Associate Vice President for Advanced Practice for the Private Diagnostic Clinic at Duke University Health System. Her clinical practice is as a Board-Certified Nurse Practitioner in the Department of Medicine-Division of Cardiology, where she specializes in the treatment of heart failure, acute coronary syndromes and primary prevention of coronary heart disease. Her third appointment is as Clinical Associate in the Duke University School of Nursing where she lectures to graduate students in the areas of professional practice and cardiology and serves as content expert on student doctoral committees. She is an Investigator on clinical trials through the Duke Clinical Research Institute and is an active participant in nursing research initiatives through the Duke Translational Nursing Institute focusing on implementation science. She has an interest in creative nursing education and mentorship, as well as the leadership interface between systems of care, provider utilization, access to care and excellent patient outcomes. In her role as Associate Vice President of Advanced Practice at Duke, she is responsible for leading the effort to facilitate Nurse Practitioners and Physician Assistants to work to their full scope of practice by implementing ambulatory practice redesign with the aim to increase patient access to high quality, safe and cost-effective care.
Allison sustains active memberships in the American Association of Nurse Practitioners, American Heart Association, American College of Cardiology, American Nurses Association, and the North Carolina Nurses Association. She is a peer reviewer for Elsevier Publishing, and has been published in several nursing and medical publications including Circulation. She serves on a variety of community task forces and boards and was a Fellow in the 2016 AANP Leadership Program. She holds the Associate of the American College of Cardiology recognition and is a Fellow of the American Association of Nurse Practitioners.
She earned her Doctor of Nursing Practice (DNP) and Master of Science (MSN) degrees from Duke University, and her undergraduate degree from the University of Texas.
I have 21 years of experience as both a critical care Registered Nurse, and then a Nurse Practitioner in Cardiovascular Medicine at a large academic medical center. My doctoral work led me to a leadership role where I found myself designing and establishing best practices to design interprofessional teams to provide specialty care. This in turn, defined the need to create a structure to recruit, hire and retain Nurse Practitioners (NP) and Physician Assistants (PA) in ambulatory specialty practice. I am fortunate to be given abundant support and resources at Duke and was able to share my dream with Donna Ecclestone, FASPR, who quickly joined me to change our institutional culture, and to reframe how we bring Advanced Practice Providers (APPs) into our organization, and subsequently utilize their skills to provide increased patient access to high quality, high value patient care. This was a new concept for us and then led to the need to reframe and redefine our care delivery systems.
As APPs are now being asked to work as independent providers of care, their onboarding has become far more complex and important. As we all know, if a detail is missed around billing, or patient scheduling, or certification/credentialing – it becomes a work stoppage issue and thus a patient care issue. Reframing the way we do things and deploy APPs was the only way to create an Advanced Practice organization that provided professionalism and attention to detail in terms of hiring the right provider for the right position at the right time to take care of the right patient. That’s a mouthful, but it truly does define our goals. When an excellent interprofessional team is formed intentionally, everyone wins and the entire group can look forward to a long and fruitful collaboration in order to deliver the highest quality patient-based care.
The process of creating our Advanced Practice Office (which includes professional APP recruiters, HR and onboarding or integration) is one that we have defined and created along the journey. We saw the need as outlined above to create structure and advocacy for APPs, and to create intentional teams where APPs would be working to the top of their scope. We started with a strategic hire program, where in a small way we brought APPs into a funded subvention program for their first year of practice. These providers were carefully supported through the onboarding process, and gradually other practices around our enterprise started asking for our help in designing new practices as well as the recruiting and onboarding process. In order to meet those needs, our office expanded, and Donna developed tools for onboarding (referenced online checklists). We were able to combine with our Provider Recruitment team, which was important because in our state the nuances of NP and PA practice are unique yet important.
Today, our Advanced Practice Office offers practice consulting, recruiting, hiring, onboarding, practice metrics/data, transition to practice Fellowships, and regulatory oversight for almost 500 ambulatory specialty APPs. We continue to learn and grow and believe that APPs and their MD colleagues and practice administrators are better prepared for practice due to the professionalism, energy and enthusiasm of our office.
It is very important for recruiters to understand the professional landscape for Advanced Practice Providers. Although an NP was first a Registered Nurse, as an NP they are practicing medicine from the nursing perspective. This makes their practice wellness based and generally very holistic. A PA has never been a nurse, and they are trained to do the same work from a biomedical perspective. Once in practice for a few years and depending on the nuances of state laws (which are ever changing), their practices may look very similar. APPs are in high demand all around the country, and they will be attracted to an organization that from day one treats them as a professional. The communication, interviews, and hiring process is best done in a way that mirrors that of their physician colleagues. This will attract highly qualified candidates who can be assured that they will be treated professionally in your organization.
The difference between administrative onboarding and clinical onboarding is important. The introduction to the clinical practice is imperative to develop trust between the physician and the APP, and that trust must be bi-directional. A clinical liaison or access coordinator within the practice can be very helpful in designing a practice model and a patient flow that makes sense for the patient population. For instance, will the APP work alongside the physician and manage their non-direct patient care duties, or will they see patients independently in a proscribed visit flow (either manage their own patient panel, or see patients in combination)? Will they augment the MD work by providing a procedure clinic, acute clinic or rounding services? When these things are left to chance or are not well defined, misunderstandings happen easily, and practices are not well optimized. This may lead to increased turnover and attrition, which is expensive and demoralizing for the practice.
Advanced Practice Providers should always work to the top of their scope, training and licensure. Sometimes the answer to the need to grow a clinic is an excellent nurse rather than an APP who is trained and licensed to assess, diagnose, treat and prescribe. Avoiding competition between MD and APP for RVUs or patients, such as in the case of a productivity incentive, is imperative. The group should function as a team without such distraction or competition – in this way they can provide the highest quality, highest value patient care.
Recruiters should be sure they are posting a specific and relevant position description. APPs are increasingly trained as specialty providers, and don’t want to waste time applying for a position that is ill defined or lacks enough detail to determine a good fit. APPs should be treated and deployed as providers rather than as nurses for both job satisfaction and access to care. A good relationship with their recruiter and onboarder, and then with their clinical team can set the stage for a long and fruitful tenure in an academic medical center.
Interviewed by Dorothy Blalock, Director of Brand Management at NP Now
Telemedicine is already transforming healthcare in the United States. Barely heard of a decade ago, it’s now all the rage—with healthcare administrations across the country talking about how they can get in the game. While in a field as personal (and emotional) as healthcare, the goal is not to replace face-to-face physician communication, telemedicine does augment and help deliver care to patients who would otherwise have great difficulty getting medical help. Here are 3 ways it’s already transforming healthcare:
Our primary care system in the United States is already broken, and even patients in major metropolitan areas with an abundance of healthcare facilities, still struggle to find appointments. In reality, physical visits to the clinician are not always required, and a quicker and more efficient telemedicine consult is more appropriate. Certain technologies are also starting to show promise, which allow for “virtual examinations” to take place. Watch this space.
Certain outpatient specialties such as dermatology, which do not typically come into the hospital for consults, are perfect for the world of telemedicine. Especially if they involve a “spot diagnosis” without an array of tests. Other hospital specialties, which struggle to staff adequately and involve frequent emergent consultations—neurology being one such example—are already increasingly utilizing telemedicine.
For a long time rural America has struggled to attract and retain physicians. Telemedicine probably offers the best hope to those communities for receiving quality medical care. Ideally, the physicians should be located in the nearest major town or city.
There’s already a massive physician shortage in the US, and latest estimates project it could be even worse than the 100,000 projected within 10 years. Telemedicine probably represents the most promising method to help ease this looming crisis. The new tech-savvy generation particularly will be more open to seeing their doctor this way. Watch out for it being delivered somewhere near you soon.
About the Author: Suneel Dhand MD is an internal medicine physician, author and speaker. He is the cofounder of DocsDox (www.DocsDox.com), a service that helps physicians find local moonlighting and per diem opportunities, bypassing the expensive middleman.
We at Health eCareers had the distinct pleasure of hosting Carey Goryl, CEO of the Association for Advancing Physician and Provider Recruitment (AAPPR) at our offices. She was kind enough to organize a series of questions and answers among AAPPR board members on current trends, pain points and the role of AAPPR in physician recruitment. In this interview, we hear from AAPPR board members Tammy Hager, MBA, FABC, Lynne Peterson, MBA, FASPR, Robin Schiffer, FASPR, and Bruce Guyant, FASPR. Learn what these experts have to say.
Tammy Hager: Some of the biggest pain points in my role is not being able to get in-house physician and recruitment data instead of using search firm surveys and data.
Robin Schiffer: I have multiple roles. The biggest pain points are: Scheduling and credentialing locums. Hard to find specialties such as GI and Urology. Creating meaningful onboarding and retention strategies.
Bruce Guyant: Aside from just the sheer uber competitive market dynamics of a physician shortage, perhaps the biggest pain point is clinical leaders who do not have a strong enough sense of urgency in the hiring process.
Lynne Peterson: Besides the shortage of physicians, there’s not a lot of alignment between recruitment teams and operation teams. The operations team for example may not have realistic timelines and not fully know when to involve the recruitment team, and thus, finding the right candidate may not be successful if they don’t know the time it takes. For example, some specialties can take over a year to fill those open searches.
Tammy Hager: Organizations, including mine, are using tools to hire for cultural fit more than ever. This includes making sure the entire family is a part of the recruitment process to retain the whole family. In addition, in our organization, telehealth is a big component for many of the physicians hired. We are using that to work with other organizations across the country to provide care. Rural communities are even tougher to recruit for, so we are having to have a personalized and strategic plan for every one of our rural practices.
Robin Schiffer: All specialties need unique approaches when you are in a more rural location. We have to wow the physician and family. Start friendships from the interview day.
Bruce Guyant: Despite a limited pool of candidates to draw from, most senior administrative and clinical leaders still expect their health system or medical group to maintain time to fill averages that are as quick or quicker than the competition or the rest of the industry.
Lynne Peterson: There seem to be more physicians of all specialties going toward hospital or ambulatory practice. Also, physicians are moving more readily from one organization to another, where in the past they stayed their whole careers in one place. They’re more likely to move if their employment isn’t going well.
DO ANY SPECIALTIES NEED UNIQUE APPROACHES?
All: We find that primary care, psychiatry, neurosurgery, rheumatology, and neurology all need unique approaches because of the shortage of physicians in these specialties.
Tammy Hager: Our recruiters have a main focus on retention. We are taking a unique approach in how we reach out to physicians that have ties back to our areas (in the 4 states we serve). In addition, at Mercy Health, we reach out to residency programs that have a faith-based culture to recruit physicians to our faith-based system. Also, we have increased referrals from recent physicians we hired, and the recruiters do that by developing such a great relationship with them while going thru the recruitment and onboarding processes.
Robin Schiffer: AAPPR members that are in recruitment are working on finding a physician for the long haul. Sometimes recruitment firms are more worried about filling the position and getting paid. It depends on the firm. Some are excellent.
Bruce Guyant: The best way to influence job retention is to find the right candidate from the beginning. However, the truth is that recruiters have very little influence over the decision on the part of a provider to stay. Many organizations are seeing the value of having people on the team who are not recruiters who instead have focus on the on-boarding and retention piece full-time.
Tammy Hager: If recruiters truly look for physicians who fit culturally, have ties or spousal ties back to the locations/areas, and make sure the whole family is involved in the recruitment process, they can target those specific physicians.
Robin Schiffer: You don’t just look for skill. You look for a good fit culturally.
Bruce Guyant: The key is to understand your organization’s culture, team, and the needs of the position itself. The better you understand what is needed, the better you can appropriately assess “fit” upfront for your organization with the candidate’s needs and desires.
Lynne Peterson: Start the recruitment process early enough, and ensure that the proper screening is in place to get top talent. Know well in advance about credentialing and where the physician is in that process. At my organization, we do our checks and balances throughout the recruitment process to ensure the proper screening mechanisms are in place prior to offer and well before credentialing.
Tammy Hager: Many physicians do not know the different between in-house and 3rd party recruiters. We have to educate them, and we are doing that at Mercy with content on our physician career site, sharing content in specific magazines and journals that are sent to physicians, in residency program lunch and learns, and in email campaigns.
Robin Schiffer: I don’t think physicians realize the differences until they experience them personally.
Bruce Guyant: While Physicians are getting savvier and better at understanding the differences, most still do not know the differences. Even more really do not seem to care and just respond to each the same way and view them as a means to an end.
Lynne Peterson: I think it depends. On one hand, the 3rd party can advocate for them, but they’re not sure of the information they might get since the recruiters don’t get it straight from the organization they want to work for. The in-house recruiter has more in-depth reliable information, but they can be viewed as advocating for their organizations. It really comes down to what kind of kind recruiter they feel like they work with the best and how they go about their job search.
ARE MOST FULLY AWARE OF THE DIFFERENCES?
Robin Schiffler: It is really the recruiter at those firms. Sometimes you get lucky and find a gem!
Bruce Guyant: The most successful partnerships are those where communication has occurred up front with both parties fully understanding the needs and expectations of one another. Those who can do that and are respectful of the value of one another in the process will do well. I have personally had some excellent relationships with third party agencies who have sent me a high volume of quality and quantity of candidates.