In the traditional model of physician orientation, the established physician introduces the eager, young physician to his or her nurse, points out the new physician's three exam rooms and lets him or her know about the established physician's upcoming two-week vacation in Europe. The hope is that when the established physician returns, the new physician will know how to find the emergency room, be familiar with the local specialists and understand the peculiarities of the office staff. All this accomplished without a lot of pesky questions for the senior doc, right?
Well, the problem with this – and similar orientation models that assume a new physician can immediately jump in and be successful – is that they don't quite work. Instead, it takes longer for new physicians to become oriented to the practice and, thus, longer to feel like an integral part of the practice.
At Austin Regional Clinic (ARC), the multispecialty group I work for, this is something we learned the hard way – and something that made us rethink how we integrate new physicians into our practice. Our clinic has 125 providers, 50 of whom are family physicians, but this program could easily be adopted by a practice of any size with any specialty focus.
This group's orientation program sets a visit-frequency target for new physicians: 25 visits per day within the first seven to eight weeks.
Physicians' coding and documentation are reviewed after one and four months of employment as part of the program.
New physicians receive guidance through a mentoring program and short vignettes about various practice management issues.
Time for a change
Although the “traditional” orientation program at ARC was less draconian than the model described in the introduction, it was still unstructured beyond two days of introductions and meetings with human resources, quality assurance, information technology and credentialing, among others. Subsequently, the clinic manager and the new physician's nurse played large roles in setting up the new physician's schedule, which didn't encourage the physician to take charge of his or her practice and productivity. Instead, it created a passive attitude from the new physician toward the practice.
When we started to see a growing decline in finances, morale, loyalty and buy-in – and a sharp increase in physician turnover – senior leaders determined that we needed to expedite the assimilation of new physicians. I was tapped to develop a new orientation and integration program.
Improving new-physician orientation
The goals we established for our new program were to accelerate the new physicians' gradual increase of visit volume, optimize their coding and documentation and instill in them a sense of group loyalty and recognition of the benefits of shareholder status. This involved making changes in the new-physician scheduling system, putting more emphasis on coding and documentation accuracy, developing a “chief orientation” to highlight citizenship and benefits issues, and providing more advice and assistance – in the form of mentoring and practice-management tips – to the new physicians. We began by reorganizing the administrative portion of the orientation to allow the physicians to see patients on their first two afternoons instead of devoting their entire first two days to orientation. Then we rolled out the components of the new program.
Scheduling. The biggest change we made to the scheduling system was to set visit-frequency goals. In our old program, the new physicians weren't building volume quickly enough, partly because we had not set any targets for them (i.e., see X number of patients by Y date). In our new program, the new physicians' schedules initially allow 30 minutes per visit, which gives them time to become familiar with the use of our billing system, referral network, medical records format, etc. Then, we work with them to gradually increase their visit frequency to 25 visits per day (21 15-minute visits and four 30-minute physicals) within the first seven to eight weeks.
We also try to help our new physicians build a loyal patient base by emphasizing same-day appointment availability. Although the number of same-day appointment slots a physician can have varies greatly by the physician, the clinic and even the time of year, we suggest that new physicians try to have between 30 percent and 70 percent of their total daily or weekly appointment slots available for same-day appointments when they begin.
Coding and documentation. New physicians tend to undervalue their efforts. Our group has always done an extensive coding review approximately three to four months after a new physician starts. Now, I also provide an informal assessment approximately one month after a new physician joins our group. I choose to do these assessments myself, but they could be well handled by a nonphysician coding expert.
Chief orientation. To highlight the importance of citizenship and benefits issues, we decided to handle these issues separately from the rest of the orientation with each group of new physicians. We call this part of the program “chief orientation,” because it is led by our group's department chiefs. Our goals are to decrease the number of misunderstandings, improve practice consistency and foster some positive peer pressure among the new physicians. The chief orientations also give our new physicians a chance to develop some camaraderie and realize that settling in to a new practice is a challenge for everyone.
The two-hour chief orientations are held at one of the chiefs' homes. We discuss such issues as provider support, hours, sick days, call, triage, professional courtesy and vacation benefits, among other things. We also take this opportunity to explain the benefits of shareholder status and invite discussion.
Mentoring. New physicians have always asked established physicians for advice. We decided to incorporate a more formal mentoring system into our orientation to ensure that new physicians have the opportunity to talk to physicians in other groups.
We identify and recruit specific mentors for new physicians prior to their arrival. Ideally, the mentors are positive role models from a different clinic site who are in their first two to three years of practice. They're asked to be available by phone and to meet occasionally with the new physicians in nonclinical settings, for example, by going out to dinner together.
In addition to the formal mentoring system, we encourage the department chief, clinic manager and administrative representatives to make scheduled contact with the new physicians through phone calls or drop-by visits at lunch to provide reinforcement and positive feedback.
Practice management tips. Another way we offer advice to our new physicians is with our new practice management tips, or “pearls.” These single-page pearls are intended to enhance consistency within the department and impart the wisdom of the ages on such practice management issues as handling patients with long lists, physician-patient communication, refills and angry patients. After writing the pearls, I circulated them to the entire department for peer review before implementing them in our new orientation program. Although developed specifically with our clinic in mind, most of the pearls could easily be adapted to fit any type of practice.
PRACTICE MANAGEMENT PEARLS
As part of the new orientation and integration program at Austin Regional Clinic (ARC), the physicians developed single-page, practice management pearls to advise new physicians and increase consistency in the clinic. They chose the topics of the pearls based on which subjects prompted the most questions, problems or complaints from new physicians in the past. Here is the complete list of pearls offered at ARC:
Discharging patients from the clinic
Patients with lists*
Poor outcomes and unexpected deaths
Referring patients to the after-hours clinic
Specialty phone advice
*Click below to download four of the pearls in one file.
We only have initial impressions of the impact of our new orientation and integration program since we've just recently implemented it. However, so far we've generally seen positive results with each change:
Visit volume is on pace or exceeding our goals in all cases.
Productivity per provider is dramatically better than a year and a half ago.
As we expected, coding reviews have shown a tendency to undercode, but there is enthusiasm for improvement; and documentation has been complete.
The chief orientations have been well received and have generated some good discussions.
Physicians are resuming shareholder equity buy-ins.
The mentoring has worked well, although inevitably there's been some variation in the extent of the mentors' help. Some mentors have been great, taking the new physicians out to lunch or dinner once or twice, some just call to make themselves available and, unfortunately, some volunteer but don't follow through.
Just about all the responses to the practice management pearls have been positive. In fact, the internal medicine (IM) chief now gives copies of the pearls to the new IM physicians too.
Morale is significantly improved.
An unofficial, informal survey of the new physicians first oriented with this program indicated satisfaction with the process, awareness of the program's goals and a sense of control over their schedules and practices.
Leading the change
Recovering from our group's financial and turnover problems has been a tremendous challenge. However, we're a better department and a better group than we were two years ago due to the quality of the new physicians who've joined us as well as the group effort from our established physicians to make our new orientation program work and to hold the department together through difficult times. Perhaps a few years down the line it will be clearer as to whether the aged led the young or the young led the aged.