Re: Why Do Physicians Depart Their Practice? A Qualitative Study of Attrition in a Multispecialty Ambulatory Practice Network

To the Editor: We read with great interest the article from O’Connell and colleagues on drivers of departure for physicians from a multispecialty ambulatory practice.¹ Physician turnover can be attributed to both push and pull factors.² Push factors are typically negative that drive a person to leave their current position, and pull factors are typically attractive that pull toward a new opportunity. Authors used a qualitative methodology to assess determinants of physician attrition from their current practice. This was achieved by interviews that were analyzed to identify major domains for departure, including: the health care business model, practice characteristics/culture, and personal considerations.¹ Although a broad set of themes were revealed, the themes with negative connotations were isolation/burnout, corporatization of medicine, and the COVID-19 pandemic and inbox burden. An important contribution of this study is that it is not based on physicians’ self-reported intent to leave - which can be a proxy for job satisfaction – but rather on physicians who had already left. Studying this population highlights the unique drivers of actual turnover as opposed to modeling job dissatisfaction. We believe identification of these factors and their impact on attrition are an important step in implementing interventions that promote retention.

Although O’Connell and colleagues addressed factors for turnover, few specifics on interventions were addressed. One consideration for turnover is the literature on belonging. Belonging is not a new topic in Psychology research but is being more readily addressed in the medical field. Current publications have begun to publish on attrition in health care settings. A survey study by Schaechter and colleagues investigated the association between workplace belonging and the likelihood of women health care professionals leaving their institutions.² The results revealed a significant link between greater workplace belonging and a reduced likelihood of leaving an institution within the next 2 years. Another publication by Silver and colleagues looked at the field of Rehabilitation Medicine – where there are significant workforce shortages - and addresses these challenges discussing push and pull factors contributing to attrition.³ To enhance retention, emphasis should be placed on stay factors, achieved through the establishment of a culture that nurtures a sense of belonging as well as addressing the push and pull factors.

We agree with the authors that their work uniquely highlights the actual factors of physicians who left a large, multispecialty ambulatory practice network, and feel there must still be a focus on intent to leave and prioritization of efforts to mitigate job dissatisfaction. Proactively studying and addressing these aspects contributes to employee well-being and fosters belonging in the workplace environment. Allan et al. identifies 5 strategies that can be implemented by leaders in medicine to enhance gender equity.⁴ The strategies include conducting stay interviews, analyzing department/division metrics, implement best practices for parental leave and return policies, inviting midcareer women faculty to publish with senior faculty, and avoiding bias in evaluations. Given that the majority of the physicians that left the ambulatory practice were women, these strategies are imperative to implement across an organization.

As O’Connell et al. suggest, efforts to improve retention in clinical medicine are critically important and must be evidence-based. The qualitative approach of these authors is helpful to identify factors quantifiable and modifiable for intervention for physicians who have actually departed their institution. Proactive initiatives, rooted in belonging, are essential for implementing targeted interventions that promote retention and contribute to the overall well-being of health care professionals.