Physician alignment beats “engagement” perks when trust and autonomy are on the line

Scott Polenz has spent years in health care operations and physician recruitment, onboarding and retention, including leading systemwide efforts to standardize onboarding and improve physician engagement. Now a principal consultant in advisory services at CHG Healthcare, he works with organizations on physician relations, recruitment and retention strategy.

In this interview with Physicians Practice, Polenz argues that “engagement” programs alone often miss the deeper issue: alignment. He describes alignment as a trust-based relationship between clinicians and leadership, rooted in whether leaders live the organization’s mission, communicate decisions clearly, and support physician autonomy in clinical care, scheduling and long-term practice strategy.

The following transcript has been edited for clarity and length.

Physicians Practice: Scott, tell us a bit about yourself.

SP: I’ve had quite a career in health care. A majority of my career has been in central Wisconsin, kind of northern, western central Wisconsin, so more of a rural background. I’ve done a variety of different things: a financial background, but mostly in operations. I oversaw, at one point, probably about 25 or 30 clinics, about 225 physicians, and about 1,500 staff.

Then I moved into an organization that started to buy and build hospitals. We built a brand-new hospital while still overseeing clinic relations and things. Then, my last five years or so, I was part of our executive team. I oversaw physician and APP recruitment, onboarding, retention and engagement, and oversaw our whole engagement journey.

That’s really where I got exposed to it, and I have a great respect for physicians and their well-being, their engagement and alignment. I’m at CHG Healthcare now, helping other health care organizations improve their physician relations, recruitment and onboarding.

Physicians Practice: You draw a distinction between engagement and alignment. What does that look like day to day in a practice?

SP: Let me step back a little bit. In a larger rural health care system I worked for, we did an engagement survey, and the scores weren’t that good. Over time, my dyad partner, my physician partner, and I realized we actually had physicians who were engaged and wanted to be there. They just weren’t aligned with the mission, the vision, the values and our executive leadership.

We felt that if we’re going to improve engagement, which ultimately retains our physicians, then we need to focus on alignment, which, to a certain extent, boils down to trust: trust that we’re living our mission, trust in executive leadership, and so on.

At the end of the day, physicians truly care about quality of care and the patient experience. It’s important for them to be able to practice medicine the way they want to practice medicine, take care of patients, and do it with a great experience and high quality.

But as things evolve and you start seeing engagement wane, you start seeing alignment issues. Physicians can become quieter. Early on, they go to meetings, they’re on time, they raise their hand, they have ideas. And then, just like all of us, if we’re not aligned with the organization, we don’t suggest as much, we put our heads down and try to get through the day.

Or you can become more sarcastic: “Oh yeah, I can’t wait to see what administration did today.” You’re so frustrated that you verbalize it every chance you can, to your medical assistant, your nurse, your manager, even leadership, because physicians are extraordinarily blunt. They’re not afraid to tell you what they think went wrong that day.

Physicians Practice: When you say “alignment,” what are physicians being aligned with?

SP: Alignment is: How do I live the mission, the vision and the values of the organization, and how do I contribute to the success of the organization?

But it’s also, if not more important, about the executive leadership and leadership across the organization: Do I trust them? Do I know them? If I shake their hand, do they look me in the eyes? Do I believe they’re living the mission, the vision and the values? That’s alignment.

I’ve had a lot of physicians come up to me and say, “Scott, I don’t trust administration. I don’t trust executive leadership.” And I’d say, respectfully, I want to dive into that. I’m not just going to accept, “I don’t trust them.” What does that mean to you? What does that look like?

I studied it, and there’s work by Frances Frei where she talks about a “trust triangle.” She says there are three elements of trust: authenticity (Do I know you as a human being? Can I be real around you?), empathy (being there for people during good days and bad days), and logic (logical decision-making and communication).

If I report to you and you’re very authentic and we know each other, and you’re empathetic, you’ve been there for me through my career ups and downs, but you wake up on a Monday morning, make a rash decision, and don’t communicate it, don’t tell me the why, then I’m not fully trusting of you. There’s a wobble in that trust triangle.

So when we talk about alignment, it’s living the mission, vision and values, and trust in executive leadership, and whether we’re all moving together to move the mission of the organization.

Physicians Practice: A lot of practices try lunches, shout-outs, surveys, wellness perks and gift cards. Why do these efforts fail sometimes, even when participation is high?

SP: Early in my career, it was all about: What’s the sign-on bonus? What’s my salary? What are my benefits? Over time, those things are important, but the world’s evolved.

You can do a lunch, but it doesn’t always land the way you think. Or you buy a cake. I was reading a book on leadership, and someone talked about recognition: “Don’t buy a cake. Bake a cake.” Meaning: Put effort into it. When you break it down: “Oh, you bought me a cake. Great, thank you.” Or you sent me a card your secretary signed, it’s not real to me.

So go bake a cake. Or bring me the card and say, “Hey, I wanted to give you this card and say thank you for everything you’ve done.” Those things matter, and you should do them, but they don’t really get at sincerity, and what physicians are looking for in relationships with executive leadership, ops managers and everybody.

Physicians Practice: So it’s about authenticity, more than a checkbox?

SP: Yes, being authentic. I’ve been in executive leadership positions where you’d get holiday cards. Someone in marketing put time into the message inside, but nobody signed it. And I’d think: Why don’t you put that into something meaningful?

In recruitment, something I was big on with our team was: Every time you’re recruiting a physician you really want, find out something unique and important to them.

For example, Leinenkugel’s beer is a big beer where I’m from. We had a board member connected to that brand. One physician we were recruiting came in and said, “I like Leinenkugel’s.” And we didn’t just give them a generic gift, we got something signed that said, “We would love for you to join our organization. Call me anytime.”

We had one female surgeon come in and she had three kids in the hotel room. We knew the ages of the kids and what games they liked, and we gave them those gifts. The kids said, “Let’s go to the place that gave us all those toys.”

Obviously it’s more than just that, but from a recruitment standpoint, being genuine, being unique, and doing something meaningful matters. Because if they feel that in recruitment and you continue it in onboarding, they’ll feel somebody cares about me as a human being. Yes, I’m this doctor, and yes, I’m bringing in revenue, and yes, I’m working hard, but I’m like everybody else. I want somebody to care about me as a human being.

Physicians Practice: From a practice manager’s perspective, where’s the highest-leverage place to start to build alignment: onboarding, scheduling, workflows, compensation, expectations, communication?

SP: Onboarding is extraordinarily important. That first experience matters, and onboarding is mission critical.

We work with a lot of organizations, and one of my first projects at my last organization was: We want a consistent onboarding experience across our whole system of care. We don’t want docs going into one part of the organization and getting a different experience than another.

So it’s onboarding, setting expectations early and saying, “Here’s what we want out of you. Here are your expectations. Here’s how we’re going to support you.” You start to build psychological safety so physicians can communicate with you.

And the “why” matters. Often, health care organizations make decisions and they don’t talk about the why. They don’t share stories. People resonate with stories. They don’t resonate with data points on a PowerPoint slide. So explain the why, and keep communicating throughout onboarding and moving forward.

Physicians Practice: Mission statements and day-to-day reality often diverge. What are common mission-versus-reality gaps that drive turnover?

SP: One that always comes up is: “The patient first. The patient first.” But then a leader says, “You need to see 27 patients a day.” As the physician, how can you tell me to put the patient first if you want me to see 27 patients today?

Another one would be “physician-led.” What we recommend is more of a dyad model, partnering an administrative person like myself with a physician. Physicians want physician-to-physician communication. So if an organization says it’s physician-led, that means the physician should be at the table at step one of any change or decision.

Other cliches: “team-based care,” but you’re not going to give staff to do it. “Flexibility,” but scheduling is rigid. “We’ll give you flexibility,” but you can’t go see your kid play soccer at 3:30 without a bunch of people signing off.

And another one: “We listen.” You do a survey, but there’s no feedback, no follow-up, no change made, and you’ll never get a physician to fill out another survey again if nothing happens with it.

Physicians Practice: During interviews, what questions should managers ask to gauge fit with values and leadership style, without turning it into a culture quiz?

SP: There should be structured interviews. Sometimes once you get the physician there, you want to dive into clinical questions. But we don’t always ask the questions you or I would be asked in other roles.

A couple I like: “Tell me about a time you felt supported by leadership. What did that look like?” If I’m listening to that, I learn what “support” means to that physician.

“What do you need from the practice to do your best work?” A good EHR? Strong staff?

“How do you want decisions communicated?” Some physicians want to be at the table. Some want to be in a meeting. Some never want to go to a meeting. They’d rather get a text, or have someone pop into their office and tell them what’s going on.

Another: “What frustrates you most in poorly run practices?” You learn a lot from those answers, and then you manage the practice based on what you learned in the interview.

Physicians Practice: If a practice is losing good doctors now, what’s a 30-, 60-, 90-day action plan, plus metrics to track?

SP: People talk a lot about stay interviews, implementing those. We used to say the recruiter should spend two or three years getting to know the doc and their family. Do stay interviews: a 30-day, 60-day, 90-day, and then ongoing.

Early on, focus on the operational issues and friction points. Maybe they used a different EHR at another organization, what’s frustrating them right away? Fix those off the bat.

Also touch points with leadership. Depending on who top leadership is, make sure they’re involved and engaged in onboarding and bringing people along.

On metrics, one area we focused on is compensation. Physicians are often hired on a guarantee period, maybe two years. Then after that it’s based on production. We would track: Is this physician going to start making less money in year three? Because we’re probably going to lose them if that’s the case. Then: How do we help build their practice?

You can also look at PTO usage, whether they’re trading call, panel access. There are a lot of different metrics to look at.

Physicians Practice: What’s one thing a practice manager can do right now to strengthen alignment with the practice mission?

SP: Presence, sincerity, trust. I know it sounds touchy-feely, not metric-based, but I’ve been doing this a long time. Physicians are frustrated, burned out, COVID, all of those things, and they want to work with people who help manage their practice in a trustworthy way.

If I can leave you with one other area that’s extraordinarily important: autonomy. We break it down into three areas.

One is clinical autonomy: “Can I make the best decisions for my patients?”

Two is schedule autonomy: “I want to work hard, I want to see my patients, but I also want work-life balance.” It comes down to trust, trust me that I’m going to get my hours in and see my patients.

Third is strategic autonomy: How can we partner to grow my practice, which helps me financially, helps my family, lets me see more patients, and helps the organization?

Trust matters, but autonomy matters, too. I have a lot of friends, and that’s all they talk about: “Some administrator told me I had to do X, Y, or Z,” and they have no idea, because they’ve never been a doctor. They don’t know what they’re talking about, and it drives them nuts.

Physicians Practice: Anything else you want to add?

SP: Maybe just a couple stats. When you think about retention, and you’re getting at the end of the game, engagement and alignment, there are studies out there. I’ll say an engaged physician is 26% more productive than a disengaged physician, which is about what we track at close to $460,000 in annual revenue. If a doc is feeling good, engaged, aligned, they’re going to bring in another half a million dollars to your health care organization. This is mission-critical work.

And depending on which stat you look at, if you lose a physician, depending on specialty, based on lost revenue, recruiting costs, and patients you may lose, it can be up to $1.2 million.

I encourage organizations: Don’t just say physicians are important, and “yeah, our strategy is to make them happy and aligned and engaged.” It has to be part of your strategic plan, with a formal retention program in place. The recruitment agency that oversees recruitment across the country says only 26% of health care organizations have a formal retention plan.

That’s another area I’d encourage every organization, small, large, medium, to have a retention plan. And when you’re recruiting and onboarding those docs, tell them: “We have a formal retention plan. We’re going to take care of you from day one until the day you retire.”