Not every gap is a full-time permanent hire

A while back I was working on a medical director search, and about three conversations in, something didn't add up. Every person I spoke to described the job a little differently. One wanted someone to steady the department and stay for the long haul. Another wanted someone to come in, fix a specific set of problems, and move things fast. It's interesting because both of them were right. They were just describing two different jobs, and somebody had stapled them together into one posting.

We ended up changing the structure before we changed the person. That search taught me something I keep coming back to: a lot of what we call a recruitment problem is actually a structure problem. We reach for the same tool every time a gap opens, and then we're surprised when it doesn't fit.

In healthcare right now there are really four tools on the table. Most organizations use one or two of them for everything.

Staffing: coverage, not commitment

Locums, agency, short-term contracts. This is the tool for keeping the lights on — a maternity leave, a sudden resignation, a summer in a rural emerge that would otherwise close on weekends. Nobody should apologize for using it. Patients need care today, right?

Where it goes sideways is when "temporary" quietly becomes the plan. I've seen roles covered by rotating locums for years. The shifts get filled, but nobody owns the program, nobody builds relationships with the nurses or the family docs in town, and the cost adds up to far more than a permanent hire would have. Staffing buys you time. It doesn't buy you continuity or culture.

Permanent recruitment: when you need someone to belong

This is my world, and I'll be honest about where it fits. Permanent recruitment is the right answer when the need is ongoing and the role has to become part of the place — a family physician building a practice, an internist who'll anchor a service, a chief of staff who needs the trust of the medical staff.

It's also the slowest of the four and the most expensive to get wrong. That's why the front end matters so much: defining what problem the hire is actually solving before you go looking. And it's why I think the hire isn't finished on the start date. Most physicians and leaders get dropped into a new system and told to figure it out. A little support in those first months is the difference between someone who stays three years and someone who's gone in eighteen months.

Project-based: a clear start and a clear finish

A couple of weeks ago I wrote about Providence creating temporary, topic-based leadership roles for physicians. That's the project model. Accreditation prep, launching a new clinical program, an EMR transition, a regulatory change, a physician engagement review. Defined scope, defined deliverable, defined end date.

What I like about it is how honest it is. You're not pretending a twelve-month problem needs a thirty-year hire. And for the physician, it's a low-risk way to find out whether they like leading — and for you to find out whether they're good at it — before anyone commits to the bigger seat.

Fractional: senior capability, part of the week

This is the one I think smaller hospitals are underusing. If you're a 60-bed hospital, you may genuinely need CMO-level thinking — quality, credentialing, medical staff relations, strategy and stuff like that — but not five days a week, and maybe not at a salary you can justify or a location that attracts someone full-time.

A fractional leader gives you that experience a day or two a week, on an ongoing basis. It's different from a project because it doesn't end when a deliverable ships. It's different from permanent because you're buying a slice of someone's time, not all of it. The watch-out is the same one I see with part-time leadership everywhere: if you don't protect the time and support the person, "fractional" turns into "absent."

So how do you pick?

Before you post the next role, I'd sit down with your team and answer four questions:

1. How long is the need, really? Weeks, months, or years? Be honest, not hopeful.
2. Is it coverage or capability? Do you need shifts filled, or do you need someone to change something?
3. Does this person need to belong here? Some roles only work if the person becomes part of the culture. Some don't.
4. Can you support what you're asking for? Any of these models fails if the person is set up to carry it alone.

Often the answer is a mix. Locums to hold coverage while you recruit permanently. A fractional physician leader for a year while you develop someone internally to take the role. A project that turns out to be the audition for the permanent seat. The organizations that get this right aren't the ones with the biggest recruitment budget. They're the ones that match the structure to the actual problem.

One question

Look at the roles you have open right now. How many of them are posted as full-time and permanent because that's what the last one was?

Take care of the people that take care of us.

Kevin