What an Unfilled Physician Post Costs: Turnover as Departmental Economics

Friday, 3:30 p.m., the physicians' room of a surgical department. On the table sits a sheet cake, next to it a card full of signatures. The specialist being sent off today spent seven years in the hospital; she is moving to an outpatient care center — regular hours, no night shifts. People wish her luck and mean it.

On the way home, the department chief runs the numbers anyway. It is the third farewell in eighteen months. The job posting goes live on Monday, and HR is already speaking, as a precaution, of "bridging with locum staff." What this gap will cost appears in no cost center — and for precisely that reason disappears from every discussion about working conditions.

How widespread the problem is

On prevalence there are German figures. In the 2019 Krankenhaus Barometer of the Deutsches Krankenhausinstitut (DKI), a German hospital research institute, 76 percent of hospitals reported difficulty filling open physician posts — on average around four unfilled full-time physician positions per affected hospital, extrapolated to about 3,300 nationwide [1]. In 2022, 72 percent reported staffing difficulties; the number of open posts per affected hospital had nearly doubled to around seven full-time positions [2]. More recent DKI values do not exist — the 2024 and 2025 Barometer editions contain no chapter on physician posts. That the problem has resolved itself is unlikely: in the 2024 survey of young physicians by the Hartmannbund, a German physicians' association, 55.2 percent reported unfilled medical posts at their own employer [3].

On the costs of a vacancy, by contrast, the German data is thin. According to our research, no robust study of replacement costs per physician post exists. What exist are approximations — and they should be labeled as such.

The approximations, honestly labeled

The international standard reference comes from Shanafelt, Goh and Sinsky (JAMA Internal Medicine, 2017): the departure of a physician costs, by that account, two to three annual salaries — recruiting, onboarding, the productivity ramp-up, forgone revenue [4]. The figure comes from the US system; compensation levels and revenue logic differ there. A review on hospitalists (Pappas et al., 2022) found absolute estimates in the literature ranging from 88,000 to one million US dollars per physician — and arrived at markedly lower values for its own, conservatively calculated cohort [5]. The range is itself the finding: turnover costs depend on specialty, role and institution. Anyone offering a precise universal number has not measured it.

For Germany there is a model calculation by the job portal praktischArzt — not a study, but a traceable formula [6]: an unfilled attending post with an annual salary of 130,000 euros, weighted with an importance factor of three, costs around 156,000 euros over 100 days of vacancy, roughly 1,560 euros per day — including the team's extra work, cover costs and quality effects. The German Federal Employment Agency, by that account, puts vacancy durations for physicians at up to a year, for chief physician positions at up to two.

Best documented are the costs of compensation. Locum physicians cost hospitals on average about 87 to 120 euros gross per hour — residents around 75 to 90, specialists around 100 to 120 euros, more depending on specialty and urgency [7]. For comparison: an employed specialist under the TV-Ärzte collective agreement earns around 6,400 euros gross per month. A hospital that bridges a specialist post with locum staff for months pays a multiple of the negotiated salary — and receives in return less continuity in training, referrer contact and team routine.

The calculation for your own department

Because the literature only supplies ranges, your own calculation is the most credible one. Five items that can be compiled with HR in an afternoon:

1. Departures over the past 36 months, by role. Three years smooth out chance; the role determines the order of magnitude.
2. Vacancy duration per post — from resignation to the successor's actual first day.
3. Directly quantifiable costs: locum hours times hourly rate, advertising and placement fees, cancelled clinics or reduced surgical programs.
4. Onboarding: months until full working capacity, set conservatively — the time of those doing the onboarding counts too.
5. What cannot be seriously quantified is named rather than guessed: extra load on the team, quality of training, continuity toward referrers. Stated as a risk, this persuades a management board more than an invented euro figure.

Whoever calculates this way almost always reaches the same conclusion: the cheapest vacancy is the one that never arises.

Documentation burden — one driver among several

Why do physicians leave? The MB-Monitor 2024 — the Marburger Bund physician survey, covering 9,649 employed physicians; a membership survey, self-reports, an interest group — sketches a bundle: 49 percent frequently feel overburdened, an average of three hours of the working day goes to administration and documentation, and 28 percent are seriously considering leaving curative medicine; in 2022 it was 25 percent [8]. Staff shortages and work intensification stand there on equal footing with bureaucracy. Anyone declaring the documentation burden the sole culprit is overstating the evidence.

What can be documented: in a US cross-sectional survey of 1,792 physicians, the feeling of not having enough time for documentation was associated with 2.8-fold odds of burnout [9] — an association, not causation, and odds are not frequencies. A German longitudinal study linking documentation hours to actual resignations does not yet exist.

For departmental economics, the causation question is secondary anyway. What matters is which drivers a department chief can actually influence. The pay scale she cannot change, the regional labor market barely. The working environment she can: how often things are documented twice, how many systems an admission requires, how letters come into being, how much of the day happens at the bedside. What young physicians concretely measure this by, we have compiled in a separate article: What young physicians expect from documentation (in German). And before a department invests in tools, an honest stocktake of its own time distribution pays off: Measuring physician time honestly (in German).

The departments that hold their own in the competition for specialists are rarely those with the largest budget. They are the ones where the working day feels most like medicine — and that can show this in conversations with candidates. If you would like to read calculations like these and the evidence behind them regularly: Visite, our weekly briefing on documentation and AI in German healthcare (German; English edition Grand Rounds is in preparation).

Sources

1. Ärzte Zeitung. Drei Viertel der Kliniken fehlen Ärzte (Bericht über das DKI Krankenhaus Barometer 2019). https://www.aerztezeitung.de/Wirtschaft/Drei-Viertel-der-Kliniken-fehlen-Aerzte-407406.html
2. Medi-Karriere. Krankenhaus Barometer 2022 (Bericht über das DKI Krankenhaus Barometer 2022). https://www.medi-karriere.de/magazin/krankenhausbarometer-2022/
3. Hartmannbund. Ergebnisse der Umfrage 2024 unter der jungen Ärzteschaft (n=487). August 2024. https://www.hartmannbund.de/wp-content/uploads/2024/08/2024-08-19_Ergebnisse_Umfrage-2024_junge_Aerzteschaft.pdf
4. Shanafelt T, Goh J, Sinsky C. The Business Case for Investing in Physician Well-being. JAMA Internal Medicine. 2017;177(12):1826–1832. https://pubmed.ncbi.nlm.nih.gov/28973070/
5. Pappas MA, et al. Estimating the costs of physician turnover in hospital medicine. Journal of Hospital Medicine. 2022. https://pmc.ncbi.nlm.nih.gov/articles/PMC9547978/
6. praktischArzt. Kosten für eine unbesetzte Stelle (Cost-of-Vacancy-Modellrechnung). https://www.praktischarzt.de/magazin/kosten-fuer-unbesetzte-stelle/
7. Facharztagentur. Honorararzt: Gehalt, Verdienst, Steuern. https://www.facharztagentur.de/magazin/honorararzt-gehalt-verdienst-steuern/
8. Marburger Bund. MB-Monitor 2024: Hohe Belastung, unzureichende Rahmenbedingungen. https://www.marburger-bund.de/bundesverband/themen/marburger-bund-umfragen/mb-monitor-2024-hohe-belastung-unzureichende
9. Gardner RL, et al. Physician stress and burnout: the impact of health information technology. Journal of the American Medical Informatics Association. 2019;26(2):106–114. https://academic.oup.com/jamia/article/26/2/106/5230918