Lower Compensation
According to Daniel Sitterly, VA’s assistant secretary for human resources, VA lacks the flexibility of the private sector medical facilities that it’s competing against for top talent. As health demand increases and shortages of professionals grow, private sector employers are quick to adjust to changes in local labor markets and modify starting salaries and compensation packages accordingly. VA is forced to attract top talent willing to take lower compensation in order to work with an organization with “a noble mission,” Sitterly said.
For example, the San Francisco VAMC is located in one of the highest cost-of-living markets in the United States. Highly specialized surgeons in that market average nearly $800,000 in yearly salary and bonuses. VA is capped at about 50% of that rate. These statutory limits on total compensation mean that VA must contract out critical healthcare services, such as surgery and interventional radiology.
VA’s hiring difficulties are shared with government agencies as a whole, explained Robert Goldenkoff, GAO’s director of strategic issues. “Structural issues impede these agencies’ ability to recruit, retain and develop workers. These issues include outmoded position classifications and pay systems, ineffective recruiting and hiring processes, and challenges in dealing with poor performers.”
High turnover at the top levels also hinders hiring, Goldenkoff noted. “Leadership continuity is very important, because, if you have a plan in place, leaders set the tone. And if there’s consistent turnover, much of that never happens, or it’s just much more difficult to happen when essentially the people at the top are temporary employees.”
Asked how Congress can help with this high-level turnover, Sitterly said he would love more authority to offer medical center directors a higher salary. “While I have direct hire authority for medical center directors, I can only pay them at $156,000 a year if they’re not Title 38. By fixing that, it will improve our ability to hire senior level directors.”
The Association of American Medical Colleges predicts a shortfall of 120,000 physicians nationwide by 2030. Asked what VA is doing to prepare for this, Sitterly said that VA would like to have the ability to create their own dedicated pipeline of clinicians.
“[We’d like Congress to] give the VA authority to provide salary support to send medical students to the Uniformed Services University,” Sitterly declared. “As the DoD moves their health agency model around, I think you’ll find—and we’ve spoken to the university’s dean about this—that they have excess capacity. We’d love to grow our own doctors.”
The DoD also is pushing to recruit more qualified physicians and foster diversity. This spring, more than 100 competitively selected physicians gathered in Falls Church, VA, to attend the Military Health System Female Physician Leadership Course, sponsored by the DoD Defense Council for Female Physician Recruitment and Retention.
It’s not always about the money. Other things that can be an enticement are longer shifts with a shorter work week with appropriate annual leave compensation. This doesn’t cost the VA anything and it existed for Emergency Medicine physicians until this last quarter. We suddenly switched to an hourly leave status, lost our usual annual “shift based” leave and a third of everything that we had already accrued vanished overnight. In what industry can you take away leave that has already been promised to you! Lower pay and the fact that you can’t trust your employer means poor retention.
Hospitalists working compressed tours experienced the same as Dr. Walter. Salaries have not kept pace with the private sector. The “theoretical” salary range for Hospitalists increased about 3 yrs ago but implementation never occurred for any Hospitalist that I know. Now as already discussed by Dr. Walter, there is a loss of time already earned with no advance notice so that doctors could use the time. These recent actions will further facilitate the exit of physicians and hamper recruitment. Morale is at an all time low but yet the demands on physicians continue to increase, with physicians told that they don’t do enough for the “institution”.
Having 30 years in medicine and the last ten at the VA, I can say that recruitment begins with retention. Almost all health care workers have had some time at a VA as part of their training, and executives should worry that these folks are not interested in VA employment. Trainee physicians can see where their trainer physicians are happy. By and large, It’s not at the VA. I would also tell executive that my own retirement will be ten years earlier than I had originally planned. Much of my day is consumed with clerical and administrative tasks which make it harder for me to take care of the patients–the whole reason I went through the ordeal of medical practice. I am now on my third and last VA. Local leadership at the two previous sites made sure that they had good numbers by abusing and pressuring clinical staff, and turnover was horrid–as bad as 50% in 18 months in primary care. Larger VA does nothing about turnover; apparently it is not seen as a problem.
If the VA wants to attract and retain physicians, leadership needs to stop tasking clinical staff with administrative and clerical tasks which give us less time to be with the patients (FYI, I just got some email about CONCUR, which is a case in point). Virtual scribes are available from Jafra, and probably elsewhere, as are real human medical scribes. Clerks can be hired for clerical tasks. Leadership should also read articles on physician “burnout” by Peter Yellowlees, MBBS, MD.
The VA needs to be very concerned about this. 60% of VA physicians are 55 or older, and 60% of psychiatrists nationwide are also 55 or older. We are working on exit strategies.
As an additional concern, I would point out that 60% of VA physicians are 55 or older, and 60% of psychiatrists nationally are also 55 or older. We are looking at exit strategies, and the VA has to start looking like a better use of our time than retirement.