Many observers of our specialty tend to think of hospitalists as itinerant shift workers, many of whom have little emotional commitment to the organization that employs them and will quickly decide to leave for another job where the grass is greener. Even my colleague John Nelson often describes hospitalists as preferring to “date” rather than “marry” their practice. And more than one hospital executive has told me, “They’re just going to leave in a couple years anyway, so why should we invest a lot in their development and morale?”
But there’s at least one organization where hospitalist group leaders see things differently, and are working hard to understand the determinants of hospitalist wellbeing and the relationship between wellbeing and retention. I recently spoke with Dr. Shalini Chandra at Johns Hopkins Bayview Medical Center (JHBMC), lead author of an article recently posted online by the Journal of Hospital Medicine about a new hospitalist morale index tool the JHBMC team has developed. The tool measures morale based on five multi-question factors and five single-question items, as shown below. Scores were calculated based on a 5-point Likert scale.
Dr. Chandra’s article explores the relationship between morale and provider retention, pointing out that the loss of a single physician can cost an organization hundreds of thousands of dollars in direct costs and lost revenues. Their finding: every one-point increase in personal morale score was associated with an 85% decrease in the odds of intending to leave the practice due to unhappiness.
Dr. Chandra explained that they chose to focus their research on hospitalist morale, which she described as an overall sense of wellbeing and esprit de corps, instead of the narrower concept of job satisfaction which is related to things like workload, pay, and the nature of the work. People with high morale tend to be more engaged; this isn’t necessarily true of high job satisfaction.
We talked about the downward spiral that seems to infect some groups in which the negative attitudes and behaviors of some members of the group tend to infect and reinforce the morale decline in other members of the group. An interesting insight from Dr. Chandra’s study: people’s perception of their own morale is generally higher than their perception of the group’s morale – kind of like Lake Wobegon, where the children are all above average.
In addition to understanding the relationship between happiness and retention, the JHBMC team wanted concrete information that would enable them to actually make changes to improve retention. What they found is that what makes one person happy doesn’t necessarily make someone else happy. “We need to understand that every person is an individual who has different things they feel are important,” she said. But the research did find some commonalities among individuals within a given hospitalist group: her take is that people tend to flock toward people who are like them and have similar values. I wonder if the opposite is true in some cases: do people who hang around each other tend to adopt some similar values and group-think?
The valuable thing about the morale index tool developed at JHBMC is that it assesses both what the individual sees as most important for his or her own happiness, and the degree to which those attributes currently exist in their work environment. This should enable leaders to customize their interventions to improve morale and retention for specific individuals and groups. Hospitalist groups interested in taking the pulse of their providers’ engagement might also consider participating in SHM’s Hospitalist Engagement Benchmarking Service; this tool addresses measures of engagement and perception of burnout, but doesn’t directly address issues of morale and intention to leave.
What comes next? Dr. Chandra says the research team is currently using the instrument for all five Johns Hopkins hospitals, but would love to have other hospitalist groups participate in order to expand their database. The JHBMC folks would administer the survey, analyze data, and provide a report to interested groups (you can contact Dr. Chandra at [email protected]). And they are beginning to explore various demographic characteristics to understand whether some types of people tend to have higher morale than others. She says, for example, that their research to date indicates that the longer someone works in the same hospitalist group, the higher their morale tends to be – with a dramatic rise at about the 36 month mark. They are also developing a supplemental survey to explore how well group leaders know their group by seeing if they can predict how their group will respond to morale survey questions. And in the long run they’d like to explore the relationship between hospitalist morale and patient satisfaction. Quite an ambitious agenda.
I’m personally interested in how these issues of general wellbeing, esprit de corps, job satisfaction, and retention relate to the bigger issue of career sustainability. The JHBMC research only looked at intention to leave the current job, not intention to leave the specialty of hospital medicine. Dr. Chandra did note that people who describe themselves as career hospitalists tend to be more engaged, though this varies. For me, that’s the $64,000 question: can we define a set of attributes that are meaningfully associated with people wanting – and being able – to do this work for a career?