Ethan Babcock, MD, MBA, the executive medical director of hospital medicine at Providence Swedish in Seattle, can still recall in detail his first days on the job there 14 years ago as a new hospitalist.

“I did one shift with another doctor who had been here awhile, and then I was set loose to do the next shift by myself,” he told Medscape Medical News.

His reaction? “I was nervous and scared,’’ he admitted.

Alan Hathcock, MD, MPH, now the CEO and medical director of Northern Colorado Hospitalists Group and NCH Health Partners in Fort Collins, Colorado, remembers a similar first-day experience when he arrived at one of his first jobs as a hospitalist more than a decade ago. It was: “Get your badge, log in, go see patients.”

Times have changed, Hathcock and Babcock agreed, and for the better.

What used to be known as orientation — perhaps a 1-day or briefer introduction — has evolved over the last several years to more commonly be known as onboarding. Good onboarding — research shows, and experts said — has value beyond retention and saving money. It can make new hires feel part of the team and community — very much valued, researchers have found, especially among millennials.

The more comprehensive approach also makes sense because most new hires come directly from residency or fellowship programs, without any previous experience as hospitalists, according to a recent survey.

Orientation vs Onboarding

While orientation and onboarding both connote introducing new hires to information they need to function and succeed in their new position, onboarding is a more continuous process, said Manpreet Singh, MD, chief of the Division of Hospital Medicine at Milton S. Hershey Medical Center, Penn State Health in Hershey, Pennsylvania.

Onboarding programs tend to follow new clinicians more closely, to see how they are doing, and might involve checking back and following up with more experienced team members, Singh told Medscape Medical News.

In the last 4 or 5 years, programs have become more comprehensive, said Hathcock, who is also a member of the Society of Hospital Medicine’s Practice Management Steering Committee and studies the trends. “Orientation seems sort of transactional,” he said, a check-the-boxes approach.

Onboarding is typically much longer than orientation. “Ours is a full 13 months,” Hathcock said, of the onboarding for Northern Colorado Hospitalists.

Society Guidelines

The Society of Hospital Medicine offers general guidelines for hospitals to follow, Hathcock said, and hospitals often incorporate these suggestions with their own needs and policies.

“People need to feel welcomed,” Hathcock said. Mentorships are also advised. “We recommend a slower ramp up of patient volumes [for new hires].”

Connections matter, he said, and new hires ideally need to feel tied into the group.

Don’t overlook simple logistics, Hathcock said. “They need to know where the bathroom is, the physicians’ lounge.”

It’s important to take into account the outside interests of new hospitalists, Hathcock said. If several new hires are interested in a particular activity, such as running, consider pairing them up, he suggested.

Typical Program Features

In this survey, 30 representatives of institutions shared topics covered in their onboarding programs. Among the common ones: clinical workflow, billing and documentation, logistics, electronic health records, hospital policies, admission and discharge processes, sign-out, and cross-coverage.

The onboarding at the Milton S. Hershey Medical Center includes many of these components. Its onboarding, Singh said, is also focused on practical information, such as what to know and do if there is a fire in the hospital, who to call for security concerns, training in billing and submitting charges, training in the electronic health record.

Singh introduces new hires to the medical director, the director of clinical operations, and others. “We try to provide them with a lot of information about what to expect, who to reach out to.”

Mentors are important, Singh agreed. For several years, the program has included mentorship, but now “we are asking mentors to meet a little more often,” Singh said. It’s usually biweekly or monthly, but the frequency is left up to the participants.

Singh also checks in personally with new hospitalists.

“We give them an option to shadow staff,” he said, working a nonclinical shift when they can, simply to observe and ask questions.

In the first clinical week, he said, new hospitalists are given a lower census. That’s increased gradually. At the end of the first quarter, there’s a check-in with Singh, who pulls out charts and checks documentation, offering suggestions for improvements.

At Providence Swedish, other staff members are encouraged to check in with the new hires and welcome them, Babcock said. The focus is on connections. One new hospitalist began a Young Physicians’ Journal Club, Babcock said. They meet once a quarter or more often, he said, and review journal articles of interest.

Importance of Culture, Camaraderie

To encourage camaraderie, Singh said, they encourage more experienced staffers to sit near new hires to help them out.

The culture of a hospital environment matters, Hathcock said, especially to millennials. In a 2022 report, 144 hospitalists born in or after 1982 responded to a survey, rating the level of importance of 18 elements in their decision to choose or remain at a hospital medicine group.

The culture of the practice was most frequently rated as important for choosing and remaining in a group.

It’s important to consider interests of the hospitalists beyond work, Hathcock said. “We consider onboarding not only within hospital walls but outside,” he said. It’s crucial to acknowledge that hospitalists have partners and family members who need to feel comfortable in the new environment, he said.

At his program, for instance, “[w]e ask: ‘Do we need more social events?’”

Onboarding: Payoffs

Experts often cite reduced turnover as an expected benefit of comprehensive onboarding. Estimates of turnover costs for hospitalists vary. A study at one institution over 3 years found the direct cost per hospitalist leaving was over $6000, but that calculation ended in 2020.

However, not everyone finds that onboarding reduces retention, and not everyone has concerns about retention. “We’ve never had a problem with retention,” Babcock said, crediting the institution’s reputation and Seattle being “a great place to live.”

“It really didn’t affect our retention,” Singh said of his program, but he cited other benefits. “Overall satisfaction improved,” he said, as did proficiency at tasks. Hospitalists reported feeling more comfortable with electronic health records, for instance.

That’s the real bottom line for Singh. “The majority of it is [about] making them more accustomed to the organization and more comfortable.”

The experts cited in the article had no relevant disclosures.