The great resignation
Dermatologists and practice management experts share strategies for minimizing staff turnover.
By Allison Evans, Assistant Managing Editor, April 1, 2023
In 2021, 20% of health care workers left their jobs — more than doubling the pre-pandemic rate. According to a survey conducted by the American Medical Association, one in five doctors and two in five nurses intend to leave their current practice within two years. It’s clear that the pandemic, which has disrupted nearly every facet of life, has also left its wake in the health care sector. A Morning Consult survey of 1,000 American health care workers revealed that 18% of them left their jobs over the course of the pandemic, citing it as one of the driving factors behind their resignation. But beyond the pandemic, surveys show that a disconnect between employees and practice administration and the imbalance between workloads and compensation are also top reasons cited for leaving a position in health care.
The stakes are high
Constant upheaval is draining for every practice employee. Overburdened staff members are often forced to pick up the slack from departed employees while also being expected to train new employees. “Each time an employee leaves, a lot of knowledge is lost,” said Massachusetts dermatologist Steven Shama, MD, MPH, FAAD, who recently directed a session on managing office politics at the 2023 AAD Annual Meeting.
“Even if they train their replacement, there’s inevitably something lost in translation,” he said. “That might be the relationship they built with a patient, or something more subtle, like how your physicians like things done or the history behind that unresolved invoice. It all impacts consistency of performance.”
“Regardless of whether you’re a private practitioner or employed by a group or hospital, there is always a vested interest in minimizing staff turnover because it will always affect your life and the work culture,” Dr. Shama said.
“When you lose good people, it creates a void in your organization, and it’s costly — financially and otherwise. Not only is it difficult to find replacements nowadays, but you lose something of the culture as well,” said Peter Lucash, EdD, MBA, MPH, a former practice management consultant and current professor of business at Northeastern University.
According to the Society for Human Resources Management (SHRM), on average, it costs a company six to nine months of an employee’s salary to replace them. So, for an employee making $60,000 per year, that can be anywhere from $30,000-$45,000 in recruiting and training costs.
Burnout has been cited in numerous studies as a reason for health care workers leaving. While the idea of burnout has become ubiquitous, the condition has a definition in medical literature. The Maslach Burnout Inventory, first published in 1981, measures burnout on three dimensions: emotional exhaustion, depersonalization from work, and sense of personal accomplishment. Physician burnout is an epidemic in the U.S. health care system, with nearly 63% of physicians reporting signs of burnout at least once per week, according to a December 2022 study published in the Mayo Clinic Proceedings.
Lucash agrees that burnout is a widespread issue for most physicians and believes it may be the number one issue impacting staff turnover. “Fear and anxiety of illness for oneself and loved ones, dealing with kids and disruptions in school, increased workloads, financial pressures, greater administrative and regulatory burdens, and dealing with belligerent patients, to name a few,” he said, “can all easily contribute to burnout.”
Physician burnout can have a significant impact on organizational productivity and morale, although the odds of burnout are substantially lower among those who feel valued by their organizations, according to a study published in The Lancet’s open access journal eClinical Medicine.
My employees are burned out. Now what?
Once an employee is displaying clear signs of burnout, it’s important to address it as soon as possible. Unfortunately, there isn’t a cure-all for burnout, although there are steps you can take to make burnout less likely. The Academy’s Practice Management Center offers these simple tips to improve staff well-being and overall workplace culture.
Give recognition. Acknowledge a job well done. A little recognition can go a long way in boosting an employee’s confidence and reminding them that their hard work is worth the effort. It can be a simple thank you note or a gift card to their favorite restaurant.
Define expectations. Be clear about expectations and requirements. Your employees may be putting more stress on themselves than necessary. Make sure they know not only what they’re expected to do, but also what they don’t need to do.
Get feedback. There might be stressors in the workplace that you as the leader could easily fix, but you’re just not aware of them yet. For example, if using the EHR is stressing them out, you may be able to put them in contact with your EHR vendor so they can get their questions answered.
Address feedback. If your employees know that they can safely talk to you about problems at work, and that you’re gladly willing to help them, they may come forward about future issues — before they become major problems.
Encourage time off. Did you know that more than half of American workers don’t use all of their vacation days? One of the reasons is that they feel guilty for taking them. Let your employees know that their vacation days are there for a reason and encourage your staff to take their much-needed time off.
Align skills. Utilize your employees’ skills and interests to better align them with their jobs. Maybe you have a MACRA/MIPS master on your team or a compliance guru who’s excited by all things HIPAA. Find out what they are excited about, so they are more likely to succeed.
Feed them. The way to an employee’s heart may be through the stomach. Occasionally treating your staff to lunch or keeping the break room stocked with your employees’ favorite snacks can put a smile on everyone’s face.
Optimize workflow. Sometimes it is the simple stuff that can weigh down the day. Maybe the front office setup is not conducive to how the front office works. Perhaps a change in the size of the monitors or where the copy machine is located could make a big difference in how quickly and efficiently the staff can get their work done.
Show care. Take the time to learn about your employees as more than just employees. Who are they outside of work? If they know you care about them on a more personal level, they may feel comfortable coming to you for help.
Learn more about combatting burnout at www.aad.org/burnout.
In the end, health care is very personal, said Lucash, and often, attempts at cost-cutting backfire. “Money does not solve all problems,” he said. “Research has shown that a lack of compensation is what’s called a “dissatisfier.” Being underpaid is a problem for employees, although throwing more money at them will not necessarily make them satisfied.”
A 2022 MGMA Stat poll found that better pay and benefits at another organization was the top cause of medical practice staff turnover in 2021, followed by burnout. At the very least, the total compensation package, including benefits and salary, should be competitive, Lucash advised. Especially with current staffing shortages, more employers are under pressure to make their compensation packages more attractive in a highly competitive labor market.
“One thing that handcuffs us is that we can’t always alter someone’s salary because of the structure of an employed position,” said Michael Shane Chapman, MD, MBA, FAAD, chair of the Department of Dermatology at Dartmouth-Hitchcock. “One of the simplest ways to set a positive tone for the office begins when a physician steps foot into the office. Say ‘good morning,’ ‘please,’ and ‘thank you,’” Dr. Chapman said.
“Non-clinical staff are so important to what we do that sometimes a verbal reward is equal to, or even better than, a financial reward,” Dr. Chapman added. “You’ve got to put the energy and effort into being present and giving that verbal feedback to your team. If you don’t, some of these other strategies may not even matter.”
“Acknowledgment of a job well done, and expressions of gratitude go a long way,” agreed Lucash. “Simple gestures such as thank you notes with small gift cards or treating staff to lunch once a week express appreciation. Offering perks as simple as an additional paid day off, a local gym membership, or flexible schedules can help boost morale and retention with relatively minimal cost.”
“In medicine, there is purpose built into what we do (help our patients), but implied professional purpose is not a substitute for defining organizational purpose,” wrote dermatology resident Rebecca Yanovsky Dufner, MD, MBA, in an article published on Doximity. She spent several years managing a technical sales team before starting medical school. “Spend time defining your group’s mission and involving staff in your collective broader purpose.”
“Culture derives from the vision of the practice and what clinicians and staff do to achieve that vision,” Dr. Shama said. “It’s imperative that a practice has a clear vision, purpose, and mission that is transparent to employees. Get staff onboard and invested, so that the ‘job’ is more than just the daily grind of tasks. Staff should feel that they are an integral part of the mission.”
The fundamentals of recruiting, retaining high-quality staff
Read about how to overcome staffing challenges at www.aad.org/staffing.
Hiring the right team
“Hiring the right employees for one’s practice is a critical element in laying the foundation for its success. A good hire can not only increase the productivity of a given position, but also make everyone else better,” said Dr. Shama.
When recruiting and hiring staff, cast a wide net, advised Lucash. Aside from a well-thought-out and thorough job description, it can help to ask your current staff if they know anyone who might be a good fit. “The characteristics that should make or break a candidate should be personality,” noted Lucash. “Can they relate to people? Do they like being with people? Are they comfortable being around people who are ill? Are they service-oriented?”
“When I hire office staff, especially front office staff, I look for kindness first,” said Dr. Shama. “The rest, we can train anyone to do. You can teach a technical skill, but you can’t easily, if at all, teach the interpersonal skills needed to provide an outstanding customer service experience.”
Lastly, don’t exclude potential candidates simply because they have never worked in an office setting, Dr. Shama said. “Some of my best employees were found in day care centers.”
Becoming a leader
Staff turnover impacts physician satisfaction, patient care, and the practice’s bottom line. “Physicians don’t receive leadership or management training in medical school, and yet we all find ourselves in leadership positions, whether you’re in private practice, an academic setting, and everything in between,” Dr. Chapman said. Although he has an MBA, he admits that physicians shouldn’t have to pursue an entirely separate degree to be successful in their careers.
Dr. Chapman meets with his leadership team for a few hours each week. “We have a book club where we read the same management books. When someone joins the leadership team, we have them read The Five Dysfunctions of a Team and then we talk about it.”
“Medical training is years of open your mouth with the fire hydrant going,” said Dr. Chapman. “We never take time to develop our non-clinical skills. I often hear ‘we don’t have time.’ You have got to make time to ‘sharpen the saw.’ At some point, you can’t just keep swinging,” he said. “For every 30 minutes or hour you put into leadership development, you’re going to save hours in the future.”
“I think it’s time medical school training includes leadership mini courses or electives so that folks like me don’t end up having to do so much more work later in life,” he continued.
The Academy’s Leadership Institute provides training, mentoring, and networking opportunities to help dermatologists develop leadership skills. Learn more about Academy leadership programs.
Engaged employees are more likely to be involved in decision-making, feel as if they are valued, and believe they have a stake in the organization. “Everyone needs to feel like they are part of a team, that their contributions to the office are valued,” said Dr. Shama. “Make time to spend with your staff and have an open dialogue with them — seeing them as individuals who can contribute creative ideas to make your office run more efficiently and with an even greater caring spirit.”
One strategy that Lucash has seen that has the potential to set a positive tone for the day is a very brief daily meeting or check-in where everyone gathers — including clinical and non-clinical staff. These meetings can function simply to review highlights for the day, address particular concerns that could arise, or provide a safe space for employees to ask questions or provide feedback.
According to Lucash, the staff meeting is the perfect place for physicians and staff members to compare notes on patients or workflow issues, air concerns, and bring ideas to the table. “Ask employees what they want and what issues they are having,” he said. “When you ask if anyone has anything to bring up, sit and listen, count to 10 slowly to give staff time to speak up. While getting staff to speak up may take time, staff will eventually become comfortable with the culture in which leadership listens as well as speaks.”
Lunch-and-learn events are another engagement tool that may help staff feel enthused, engaged, and like they are truly part of the important work of the practice. “Close the office for an hour, bring in lunch for staff, and discuss a particular aspect of the practice that may help the team better understand how everyone functions together,” said Lucash.
“The key is engaging staff in a way that works with the office culture,” Lucash said. “That might mean sitting down with the front desk person at the end of the day and asking how their day went or simply remembering to consistently thank staff.” Research from Gallup shows that workplaces with engaged employees have 41% lower absenteeism, 40% fewer quality defects, and 21% higher profitability. Not only will adopting some of these strategies decrease overall turnover, but they will likely contribute to more engaged, productive employees, which will ultimately help the practice’s bottom line and lead to better patient care.
“Bring your staff along on your journey and keep them involved,” Lucash said. “They are the face of your practice, and they are an integral part of caring for patients.”
Building meaningful connections with staff
Read an interview with Craig Burkhart, MD, MPH, MSBS, FAAD, about how to build meaningful connections with staff.
Taking care of the team
Compared to 27 other industries, health care ranked last for employee satisfaction, according to a 2023 Qualtrics report of 3,000 health care employees. Dr. Chapman and his leadership team have worked to create a system of personal and professional development for staff. “We talk about the importance of 401k contributions and matching as well as future career goals. Because many of these jobs, like LNA or MA positions, may not be fulfilling enough for somebody for a lifetime.”
“We’ve started getting some staff involved in research activities that are often beyond day-to-day patient-facing responsibilities,” Dr. Chapman added. “Our staff help with poster presentations, abstracts, and planning clinical trials. A lot of our staff really appreciate being involved in other aspects of patient care, which keeps them engaged and enthusiastic.”
“Sometimes our best employees move on, and that’s okay,” Dr. Chapman continued. “It’s clear that some people are just superstars, and they need to be developed and encouraged and promoted — either within or from outside your organization. You get a much more honest effort from people with the time they’re with you if they know you’re on their side.”
“I think the pandemic has caused everyone to look at making sure that their current staff is happy, engaged, and bought-in because there is no one else to hire if they leave, or very few anyway,” he said.
Turnover, of course, is inevitable. “Some of this is just life,” said Lucash. “With that said, it all comes back to the culture of a practice — how people treat each other, and most importantly, how the physicians and clinicians treat the support staff. If employees don’t feel valued, they will leave. It’s that simple.”
How to calculate turnover rate
Typically, an annual loss rate of 15% or less is reasonable, while anything approaching 20% or more is too high, advised Lucash. The following calculation is commonly used to calculate turnover rate:
# of separations / avg. # of employees x 100
Determine the number of employees: Include all employees on the payroll, including those employed part-time, direct-to-hire temporary workers on the company payroll, and employees on temporary layoff, leave of absence, or furlough. Exclude any independent contractors or temporary workers on an agency’s payroll.
Calculate the average number of employees: Avg. # of employees = [(number of employees at the beginning + number of employees at the end)/2].
For example, your practice had five employees at the beginning of the year and nine at the end of the year. During this period, two employees left. The average number of employees = (5 + 9)/2 = 7.
Calculate turnover rate percentage: Annual turnover = [(number of employees who left/average number of employees) x 100]. The annual turnover % = 2/7 x 100 = 29%.
Lucash recommends practice administrators look for patterns in turnover that may emerge, such as finding out that most departing employees are from the same area or position. Practice administrators should also examine what types of employees are leaving. “Are new hires leaving or senior employees? If new hires are leaving, it may be that there is a gap between what the employee expects and what he or she is actually doing. If senior employees are leaving, it may be that you should consider implementing a career management program to retain them.”