Two Sides Of The Same Coin

As an outside recruiter I never understood that lack of urgency my clients presented as we teetered on the brink of losing a candidate after many months of work.  I never understood what went on behind the scenes and quite frankly I never bothered to try and understand.  All I knew was that the clients in ability to "pull the trigger" stood between me making a commission.  After all that was the goal, right?  My job was to deliver the interested candidate and close the deal, thereby, making my number, getting the cash, and moving on to the next account.  But it rarely happened that way. 

As an outside recruiter I was held to production numbers.  Make the number = Keep your job.  Simply put that is the equation all outside recruiters face every cycle.  Sometimes that cycle is 30 days, sometimes 60, sometimes 90.  Any way you slice it the outside recruiter is held to a number and that number is a measure of his or her effectiveness, talent, and skill set.  I can guarantee you that anytime an outside recruiter is getting pushy about getting a candidate signed (usually toward the end of the month) it's because they are being pushed to make their number.  Outside firms derive their revenue stream from multiple sources, e.g. mail, hourly billing, and the almighty placement fee.  It is the latter that helps an outside firm cover expenses, pay staff, and expand (sometimes the business and sometimes the partners bank accounts).  Either way you slice it the bottom line is revenue.  The firms see themselves as experts.  The motto is:  Follow their direction and plan and they will lead you to the promised land.  In-house recruiters are usually hurdles to be jumped over or blockades that need to be navigated around.  Often is the case that the firm does not understand that the in-house recruiter is an ally that will help them understand the unique obstacle course that is every hospital, group or individual client.   The firm erroneously assumes the in-house recruiter is a figure head position filled by someone who knows nothing about actually recruiting because they were transferred or promoted from HR or they were retiring as a nurse and must know something about bringing physicians to their institution.  While it is sometimes the case that in-house recruiters are plucked from other departments; it more often the case that in-house recruiters have valuable knowledge about their institutions and the politics therein making it easier for outside recruiters to do their job.  ASPR demonstrates every year that in-house recruiters are driven professionals looking for advancement in both their skill set and their professional standing.  Outside firms finally appear to be catching on.

On the flip side of this discussion the in-house recruiter is driven by results.  Fill empty positions = Keep your job.  Simply put that is the equation all in-house recruiters face every day.  While the outside recruiter is tasked with finding an interested physician the in-house recruiter is faced with a myriad of tasks that will result in the interested physician becoming a compatible physician.  The in-house recruiter sees the use of a contingent or retained firm as a sometimes necessary component of completing the task at hand.  But it is only one piece of the large puzzle that is in-house recruiting.  Let's run through what happens once a candidate is presented (my process will vary from others but you will get the idea).  First the candidate's CV is reviewed and discrepancies and holes are examined and questioned (often I re-format the CV to make it easier for my physicians to read and analyze).  The physician profile is then examined. The outside recruiter will present a 4-8 page document detailing background/history, family, current position/training, personality, interest in the community/position, and reason for looking at a new position.  This collaboration is vital to the process of qualifying a candidate but it where the outside recruiter leaves off and let's the in-house recruiter take over (most of the time).  This is an uncomfortable place for the outside recruiter as they have "given up control" of their candidate and left the next steps up to the in-house recruiter.  What the outside recruiter does not know is that there are protocols and procedures that the in-house recruiter is bound by within their institution/system that cannot be overlooked or circumvented. 

Once the in-house recruiter has what he or she believes to be a qualified candidate he/she makes contact with the candidate and re-screens them.  This is not a matter of distrusting the outside recruiter but rather a function of due diligence.  In addition, licensing, board certification and a Google search have all been completed on the candidate to determine if there are any red flags.  Once the qualified candidate passes that litmus test one of two things can happen.  Either the in-house makes a decision to bring the candidate out for a site visit, or the in-house recruiter presents the candidate to a committee which determines if the candidate will be invited for a site visit.  At this point the outside recruiter has called 2 or 3 times to find out if their candidate is in fact being invited out for a site visit.  Let's for arguments sake say we have a live one and the candidate is being invited out.  I think all of you know how to say "this candidate did not fit our parameters" in your own way.  Now the gargantuan task of building a site visit begins.  While the outside recruiter is pushing for the earliest interview date possible (again remember they are on a cycle) what they don't know is that the best interview, the one with the highest rate of success, takes time to plan.  You have to have the right people in the right places to make candidates really feel welcomed and wanted.  We all know if we had 50 candidates per search that the dog and pony show would not matter.  However, the reality is that we don't get that many candidates and "you never get a second chance to make a first impression."  It really does takes time to pull off a well orchestrated site visit.  In addition, what they also don't realize is that this position is not the only one with candidates and your a planning 2 more site visits in the coming weeks.  Nevertheless, hitting fast forward, you plan the best possible site visit you can having taken into account vacations, surgery schedules, clinic schedules, anniversaries, birthdays, and any other elements that could have scuttled your plans.  The site visit goes off with or without a hitch and the candidate goes home.  Now the outside recruiter wants to know if you are going to make an offer to his or her candidate.  What he or she does not understand is that you need to get feedback from all the participants to see if their is a consensus/majority of support or non-support for the candidate.  In many cases this a formal process requiring participants to email or fax their opinions to the in-house recruiter so a tabulation can be made to determine an outcome.  Consider that there is a majority of support and now we have to make an offer.  In many cases the outside recruiter wants a formal offer letter signed so that they can say their job is done.  Here comes the invoice and the subsequent desire for payment.  However, the truth of the matter is that an offer letter signals that terms are acceptable but nothing is real until the contract is signed.  So know we go to our respective legal advisors and draft a contract.  Negotiations are underway and the process takes a few weeks if not longer.  The outside recruiter at this point is wondering why the invoice is not paid and the in-house recruiter is wondering why the contract is taking so long to be put together.  Eventually the contract is signed and the invoice paid.  However, the candidate gets cold feet and does not show up for his/her first day...Until next time.

California - Wasting an opportunity

Here in California we hold ourselves out to be the last bastion of autonomous practice.  As one of only 7 states left in the union that do not allow hospitals to employee physicians directly we cling to a law written in 1930 that protects our physicians from interfering non-physician entities like CEO's, CFO's, COO, etc.  We do so in the face of the looming shortage of physicians (many say it already here) and at the detriment of all the Californians who don't live in suburban and metropolitan areas where access is not a problem.  Rural areas and the medically under served are left to find their own solutions, wallowing in Medicaid reimbursement or better yet indigent care that pays zero..


The state of California website states the following:

Business and Professions Code section 2400, within the Medical Practice Act, provides in pertinent part:
"Corporations and other artificial entities shall have no professional rights, privileges, or powers."

The policy expressed in Business and Professions Code section 2400 against the corporate practice of medicine is intended to prevent unlicensed persons from interfering with or influencing the physician's professional judgment. The decisions described below are examples of some of the types of behaviors and subtle controls that the corporate practice doctrine is intended to prevent. From the Medical Board's perspective, the following health care decisions should be made by a physician licensed in the State of California and would constitute the unlicensed practice of medicine if performed by an unlicensed person:

• Determining what diagnostic tests are appropriate for a particular condition.
• Determining the need for referrals to, or consultation with, another physician/specialist.
• Responsibility for the ultimate overall care of the patient, including treatment options available to the patient.
• Determining how many patients a physician must see in a given period of time or how many hours a physician must work.

In addition, the following "business" or "management" decisions and activities, resulting in control over the physician's practice of medicine, should be made by a licensed California physician and not by an unlicensed person or entity:

• Ownership is an indicator of control of a patient's medical records, including determining the contents thereof, and should be retained by a California-licensed physician.
• Selection, hiring/firing (as it relates to clinical competency or proficiency) of physicians, allied health staff and medical assistants.
• Setting the parameters under which the physician will enter into contractual relationships with third-party payers.
• Decisions regarding coding and billing procedures for patient care services.
• Approving of the selection of medical equipment and medical supplies for the medical practice.

The types of decisions and activities described above cannot be delegated to an unlicensed person, including (for example) management service organizations. While a physician may consult with unlicensed persons in making the "business" or "management" decisions described above, the physician must retain the ultimate responsibility for, or approval of, those decisions.
The following types of medical practice ownership and operating structures also are prohibited:

• Non-physicians operating in a business for which physician ownership and operation are required: any business advertising, offering, and/or providing patient evaluation, diagnosis, care and/or treatment. These are services which can only be offered or provided by physicians.
• Physician(s) operating a medical practice as a limited liability company, a limited liability partnership, or a general corporation.
• Management Service Organizations arranging for, advertising, or providing medical services rather than only providing administrative staff and services for a physician's medical practice (non-physician exercising controls over a physician's medical practice, even where physicians own and operate the business).
• A physician acting as "medical director" when the physician does not own the practice. For example, a business offering spa treatments that include medical procedures such as Botox injections, laser hair removal, and medical microdermabrasion, that contracts with or hires a physician as its "medical director."

"The Medical Practice Act" is not a static document and begs for updating and re-thinking.  It ties one hand behind the back of recruiters like me who simply want to serve their communities and serve their patients.  One interesting note:  Exemptions for direct hire exist in California for county facilities, the prison system, teaching institutions, and federal facilities like the VA.   Since we have these exemptions how about adding one more layer; rural/district hosptials!

Until next time...

ASPR 2009 - Minneapolis

Well another ASPR conference has come and gone and I have to say I truly felt I was among peers.  ASPR is a great organization for those of us looking to belong to a noble profession that attracts the very best recruiting has to offer while at the same time advancing our knowledge.  We have a tremendous fellowship program, which I felt compelled to volunteer for so that it maintains the highest degree of challenge.  I also volunteered to be on the committee for our journal (JASPR.)  I will contribute 2 articles in the coming quarters. 

What struck me the most was how passionate people were about recruiting.  Everyone was busy and we enjoyed sharing stories regarding our successes and failures.  The program was great with many opportunities to better understand Stark law and Immigration.  Our speakers were at the top of their field and shared their knowledge.  Better still they they answered every questions.  A special thanks to Robert Aronson, Esq. for taking the time to help me wade through an H1b quagmire.

If you are an in-house recruiter you have to join ASPR.  The camaraderie alone is worth the membership fee.