Part-Time Physician Practice on the Rise
Published: Oct 29, 2011
Career Resources articles posted on NEJM CareerCenter are produced by freelance health care writers as an advertising service of the publishing division of the Massachusetts Medical Society and should not be construed as coming from the New England Journal of Medicine, nor do they represent the views of the New England Journal of Medicine or the Massachusetts Medical Society.
Career Resources Editor’s Note: Part-time or nontraditional schedules for physicians are gaining greater acceptance, particularly in primary care. Two-physician families, younger physicians, and those with the retirement horizon in sight find flexible schedules a key factor in achieving work-family balance. However, to foster collegiality, part-time physicians in an outpatient practice setting usually take full call. They also are not immune from the clinical and administrative burdens associated with full-time work. Part-time practice usually entails more hours than physicians might have anticipated.
— John A. Fromson, M.D.
Once viewed as either untenable or undesirable, part-time and flex-time arrangements are becoming more common.
By Bonnie Darves, a Seattle-based freelance health care writer
Most physicians don’t go to medical school and endure the rigors of residency with the intention of only working part time when they get into practice. These days, however, an increasing number of physicians are doing just that. Part-time physicians now make up 21% of the workforce, compared with 13% in 2005, the recent Cejka Search/American Medical Group Management Retention Survey found. And among those part-time physicians, the fastest growing segments are men approaching retirement age and women in early to mid-career. This data suggests that the old stereotype of the hard-driving, perennially exhausted physician who always puts patient concerns before personal ones, spending little time with family, is waning.
“You cannot control the economy or the demographic trends that are quickly changing the face of medicine. But [practices] can develop flexible practice arrangements that appeal to the two fastest-growing segments,” said Lori Schutte, president of the St. Louis, Missouri, recruiting firm Cejka Search, citing recent American Medical Association data. In 2009, 61% of physicians, the vast majority of them men, were age 44 or older; and 51% were male, compared with 58% in 1997.
A 2008 survey by The Physicians Foundation in Boston that included nearly 12,000 physicians underlines the changing landscape. Thirty percent (30%) of respondents who indicated they would modify their practice within three years planned to either cut back on patient panels or switch to part time.
For the majority of part-time practicing physicians, the decision to cut back is driven by family considerations, primarily a desire to ensure they have time to spend with their children — and their spouses.
Laura Boehlke-Bray, MD, a Wisconsin family physician, found only one group, Duluth Clinic, in the Minnesota-based SMDC Health System, willing to consider her request for part-time practice 15 years ago. “I was married to a physician, and I realized that the two of us couldn’t practice full time and have a family,” she recalls. “But after I interviewed with three different groups, only one was receptive.”
Today, Duluth Clinic-Spooner in rural northern Wisconsin has evolved into a practice that not only accommodates but welcomes part-time physicians. “We went through a time when some of the physicians were critical [of part-time practice], but that’s changed,” said Dr. Boehlke-Bray, now section chair of the group. “Now, even some of the older, hardcore doctors are saying, ‘I want that now — some quality time at home.’ ”
Several Duluth Clinic-Spooner physicians at both ends of the career spectrum now practice part time, and the group has developed a reputation for its family-friendly culture. “It’s one of the reasons we’ve been able to recruit many doctors right out of residency — we make it an option for them to have some flexibility,” she said.
Many groups — especially in primary care — are making such adjustments despite physician shortages. “We don’t have many clients who have only ‘half’ a need, but many are having to accommodate part-time or flexible-practice [requests] now,” observed Tommy Bohannon, vice president of hospital-based recruiting for Merritt Hawkins in Irving, Texas. He cites recent personal experience. “The last four primary care physicians looking for opportunities wanted less than full-time practice,” he said, “and three were in established careers.”
Christine McGee, vice president of physician practices for Licking Memorial Health Professionals in Newark, Ohio, is receiving so many requests for “alternative” schedules — part- or flex-time — that she hesitates to call the trend minor. “In our recruiting, we advertise for full-time physicians, but about half of the candidates want to do something different,” she said. “Five years ago we wouldn’t even consider that, but we can’t turn a blind eye to the market.”
To boot, several of the group’s 85 current physicians want to make a change. “Many already have cut back,” she said, and the group is struggling to accommodate new requests. Two OB/GYNs work only four days, one family physician (FP) works six-hour days, sharing a practice with another FP who also works six hours. Two specialists, including one general surgeon, take the winter off to travel. “Now, when they come to me to ask for a different schedule, I ask them to talk to their colleagues first, and then come back,” she said.
Part-Time Models Run the Gamut
Medical groups that have accommodated physicians eyeing part-time or nontraditional schedules have devised a variety of arrangements. Depending on the specialty, some practices simply allow the part-timers to work out their own schedules, provided their colleagues are amenable and aren’t unduly burdened. Others require formalized arrangements with fixed schedules set well in advance — months ahead, in the case of some high-volume hospitalist groups.
When Priyanka Borah, MD, a hospitalist with Physicians Clinic who practices at Methodist Hospital in Omaha, Nebraska, requested a shift to part time three years ago, she expected that her colleagues’ response would be the biggest hurdle. But it was scheduling that made the adjustment difficult for the 15-hospitalist group, four of whom now work part time. “So far there’s been no negative response to us being part time, but the schedule is a big challenge sometimes,” said Dr. Borah, who, after two years at 50%time now works 70%. “We schedule three months at a time, and if someone ends up with too many unsavory shifts, we have to even things out. That’s complicated, because the four of us combined make up 2.5 FTEs.”
After tweaking the module for optimal care continuity, the group decided that part-time hospitalists would work an intensive schedule the weeks they were on duty. “We come on for a longer stretch — five to seven days — and that always includes one night,” Dr. Borah explained. Somewhat ironically, the fact that some hospitalists work part time has proved beneficial. “When one of the full-timers has an emergency, the group pulls in one of the part-timers,” she said. “We’ve found that the arrangement works in everyone’s favor because one of us is always free.”
At the other end of the spectrum, Hospitalists of Northern Michigan, in Traverse City, has developed an elaborate flexible scheduling system to accommodate not only the part- and flex-time physicians but also those who request more than full-time work. “We have one doctor who likes to work most of the time, and others who work only part time or travel a lot. Our software system, Lightning Bolt accommodates both,” said Richard Woodbury, MD, who is clinical director of the 50-provider group and is among the part-time practicing hospitalists because of his administrative duties “Of course, if seven hospitalists ask for the same weekend off, only the first four who requested it will get it.”
Over the years, the group’s flexible practice arrangements have proved a major recruitment and retention tool. “What makes our doctors happy, we’ve learned, is feeling respected and being paid fairly. But right up there, competing head to head with the first two, is having a flexible schedule,” he observed.
David L. Knocke, FACHE, president of the 178-physician organization BJC Medical Group in St. Louis, Missouri, observes that hospitals are adjusting to physicians’ requests for alternative arrangements because they must. “One reason for changing attitudes about part-time employment is hospital leadership’s recognition that recruits graduating from medical school now are demographically distinct from those even a decade ago,” he said. “The so-named ‘sandwich generation’ also carries a lot of family responsibility, and physicians nearing retirement may want a flexible schedule. Across the board, more physicians are looking for work-life balance.”
Multispecialty groups like his are more amenable to nontraditional schedules, Mr. Knocke maintained, in part because so many physicians are moving to part-time or job-share arrangements. “We actually have more of a pool to draw on that we can pair physicians together to keep a practice operating full time,” he said.
Income and Benefit Issues Easy to Manage, but Others Less Straightforward
Scheduling can be an impediment to smooth operations when part-time physicians practice alongside their full-time counterparts. But the financial aspects of the model appear relatively straightforward. Most part-time physicians are compensated on a prorated basis, depending on the number of hours they practice. Most groups also apportion health and retirement benefits in the same fashion, but interestingly, few cut back CME allowances for part-timers, likely because of the rapid pace of change in medicine.
One of the more politically charged issues with part-time practice is call duty. Never a particularly pleasant topic among doctors, it easily becomes a sticking point during group negotiations when physicians, especially in primary care, request call duty commensurate with part-time status. In most of the groups interviewed for this article, part-time physicians take full call, regardless of their clinic hour numbers.
“Just because you’re part time doesn’t mean you’re not a good physician. All I want are good doctors — who can get the quality scores I need, treat patients with respect, and pull their load when they’re there,” Dr. Boehlke-Bray said. “But taking full call really reduces whatever animosity there might be.”
Part-time practice may work in primary care, but it’s tougher to pull off in the specialties, especially surgical ones. That likely has to do with both practice and financial realities, suggested Thomas Gadacz, MD, a longtime chair of surgery at the Medical College of Georgia who recently retired. “With the malpractice premium and reimbursement situation, it’s very difficult for a surgeon to be in part-time practice. You don’t get a part-time break on premiums,” he said. “And in surgery in general there’s more intensity. When you operate on a patient there’s just this responsibility, and it’s hard to hand that over.”
Tampa, Florida, surgical oncologist John Kiluk, MD, concurs with Dr. Gadacz. “I suppose part-time practice could be done, depending on the group’s culture and your partners’ expectations, but it’s definitely more difficult in the surgical specialties,” said Dr. Kiluk, who practices at Moffitt Cancer Center and whose wife, a pediatrician, practices part time. “The more difficult the subspecialty and more complex the operations or cases, the less possibility that part-time practice could work, I think. And even for my wife, when she adds up the hours, well, it’s significant and doesn’t seem very part time.”
Practice Sharing on the Rise
To achieve their personal objectives of scaling back, some physician couples have taken a now increasingly common approach: sharing a practice. Job-sharing is seen more in primary care than in the specialties, but even in the latter, the trend is emerging.
OB/GYNs Michele Byron, MD, and David Bihrle, MD, knew that their request was unusual when they went looking for a shared-practice opportunity more than a decade ago. The pair found few practices willing to consider the idea, Dr. Byron recalls, and “no one was offering the arrangement.” But the couple, who met during training, was intent on making it work because they knew that the demands of obstetrics would make for a family-unfriendly lifestyle.
“In retrospect, we probably wouldn’t have chosen the same specialty,” Dr. Bihrle said, jokingly, “but there wasn’t much we could do about that.”
The couple found their welcome mat in Rice Lake, Wisconsin, with the Marshfield Clinic. Initially, Dr. Bihrle worked three-quarters time and Dr. Byron half time. Two children later, the couple continues to adjust their schedules, and they’ve mostly worked in a roughly 50-50 split. They share call 50-50 as well, and are “one unit for call purposes,” Dr. Bihrle noted.
The pair’s initial request to have simultaneous vacation time has worked out as well, precisely because of their 50-50 split. “We cover our practice’s patients when we are here, so our partners only cover our patients when we are on vacation, just as they do for the full-time partners,” Dr. Bihrle said. “That’s one advantage of a job-share situation.” The job-share arrangement also addresses a complaint that Drs. Bihrle and Byron have heard about other part-time situations: that full-time partners have to cover part-time colleagues’ emergencies and urgencies in their absence in a disproportionate manner.
In addition, the couple shares support staff and office space, so there’s no additional financial burden on their partners or the employing entity. “Overall, Marshfield has been very supportive,” Dr. Byron said. The clinic system, which serves a largely rural population, has developed a reputation for being flexible in meeting physicians’ scheduling needs, Dr. Bihrle observed, and today employs many part-time PCPs.
Among those Marshfield primary care part-timers are another husband-and-wife team, Drs. Matthew and Anne Drewry, in Minocqua Center, Wisconsin. Their situation is also somewhat unusual, in that he is an internist and she a family practice physician. That made for a bit of up-front negotiations when the couple first approached their partners about the job-share idea, Dr. Matthew Drewry recalls. His wife tried, without success, to cut back her practice hours as their family grew, and the administration was reluctant to recruit someone for a job share with her.
“When we asked, everyone was kind of shocked because no one there had done it before, and they didn’t know what to expect. Part of the concern was the differences in our training,” he said. “The other issue was call coverage.”
The latter was readily addressed by a simple political maneuver: Dr. Matthew Drewry agreed to take the equivalent of full-time hospital call so that his fellow internists didn’t incur an additional burden. The couple shares one pager and one medical assistant, which simplifies matters for colleagues and staff trying to find out which one is working.
“Our partners were willing to give it a try because there’s such a shortage of PCPs up here and they didn’t want to lose anyone,” Dr. Anne Drewry explained. The differences in training have proved to be a non-issue generally, she noted, because her practice does not include pediatric patients. Interestingly, the couple has split their patient base largely along gender lines over time.
“I mostly see the boys, and she mostly sees the girls,” Dr. Matthew Drewry quipped, adding that initially, patients sometimes ended up on the wrong doctor’s schedule. Today, the couple effectively splits the week. He works three full days and she works two but also handles some administrative tasks for the group. The couple shares hospital rounds and nursing-home duties equally, and each night they brief each other on the status of those patients. “But honestly, it doesn’t matter who’s on call, because ‘the house’ is on call those nights,” he admitted.
Challenges Include “Schedule Creep”
Part-time physicians acknowledge that their status, while offering numerous personal benefits, has its own challenges — the chief one trying to make part-time practice truly part-time.
Most of the physicians interviewed for this article concurred that part-timers work commensurately more hours than their full-time counterparts. None reported working fewer than 35 hours weekly, and some work 45 or more, largely for logistical reasons. The paperwork, quality measure performance reporting, e-mail communications with colleagues and referring physicians, and call duty add up to more than half of a full-time position’s load.
“I think that part-time physicians have a tendency to put in more hours, and to have their clinic time bleed over into non-scheduled time,” Dr. Byron observed. “If I am working mornings, often I’ll stay through the afternoon to do paperwork — or do it on the fly at home.” Her husband concurs, admitting that he’s not sure how many total hours he puts in each week because so much of the work is “unscheduled.” He suspects the total doesn’t exceed 40 hours a week. The average OB/GYN works about 60 hours a week.
“How do you count the time if you have a patient in labor, but you’re at a basketball game?” Dr. Bihrle said.
Anne Drewry, MD, also figures she works at least 35 hours a week. But she tends to do her paperwork and administrative duties and even makes many of her patient phone calls from home, which makes the schedule “less demanding.”
For Matthew Drewry, MD, the three days a week become long ones. “I generally work about 12 hours instead of 10, but honestly, it’s a lot easier to sprint for three days than for five. And there’s always at least a half-hour of paperwork each day, whether I’m there or not,” he said. “I think that the amount of paperwork and e-mails are about the same whether you’re part time or full time.”
Amy Herbst, MD, a general pediatrician for Marshfield Clinic who works part time, concurs with the Drewrys on the “schedule creep.” In part because of her additional administrative duties, Dr. Herbst has tallied her time periodically. “Although, my partners have been very supportive of my schedule, and I have shortened my appointment times to accommodate more patients. Most of the time, I work at least 35 hours a week.”
Considering Part Time? Take Veterans’ Advice
Physicians who’ve managed to carve out a part-time or flex-time schedule admit that even though it’s more feasible these days when compared to a decade ago, forethought and contingency planning are vital. Physicians interviewed for this article offered their advice to those eyeing alternative arrangements.
Make your plans — and wishes — clear. “Particularly for female physicians, I think it’s better to discuss working part time from the start, rather than saying they will work full time, then switch. Get that political discussion done first, and then you won’t have this huge practice to try to cram down into fewer days.”
— Anne Drewry, MD, family practice physician
Utilize a flexible scheduling system, but be prepared to accommodate contingencies. “You have to be a little cautious about balancing flexibility with the realities of a practice, because the more flexible you build your schedule, the more erratic the schedule can become. First and foremost, you have to be able to take care of the patients. Start with minimum staffing, and never go below that.”
— Richard Woodbury, MD, hospitalist
Be consistent — and educate patients about your schedule. “I’ve always worked the same days, and that makes it easier on everyone concerned. We’ve watched this over the years, and have found that patients now really do know when you’re in the office, and schedule [non-urgent] appointments accordingly.”
— Amy Herbst, MD, pediatrician
Offer to take equal (full-time equivalent) call duty. “I think that if you’re part time but share call equally with your colleagues, any of the political or other issues work their way out.”
— Laura Boehlke-Bray, MD, family physician and administrator
Consider an outsider for a job-share. “If you’re working full time and try to cut down to part time, you’re better off having someone from the outside come in who doesn’t already have a patient population they’re bringing to the job-share.”
— Anne Drewry, MD, family practice physician