Full-time Job? Phooey!

With three kids at home and a 45-minute commute to the office, is it any wonder that primary-care physician Michaelle Holmes is willing to accept less pay for a more flexible schedule? Holmes says she needs extra family time to keep her sanity, so she sticks to a 25-hour-a-week schedule at Bel Air-Edison Family Health Center, a busy community clinic in Baltimore.

"After the second child, that's when the hours started going down," she explains.

Holmes, whose salary is based on the percentage of full-time she works, sees patients for full days on Mondays and Thursdays, with shorter Tuesdays and Wednesdays, and Fridays off.

Doctors in the group - both full- and part-time - form a pool for taking call, and Holmes estimates that she's on weekend call, which includes hospital rounds, four times a year, with telephone call once or twice a month; hospitalists attend to the group's inpatients during the week.

Holmes is hardly alone in her demand for more personal time - or her willingness to trade income to get it. Although the reasons physicians cite for practicing part-time vary widely, as do the arrangements they devise to make it possible, the trend toward part-time is clear and growing. Indeed, at Bel Air-Edison alone four of the seven physicians see patients fewer than 40 hours a week, including the group's director. A need for flexibility, and an appreciation for work-life balance, cuts across generational, gender, and geographic boundaries.

A Reason for All Seasons

There are almost as many reasons to go part-time as there are part-time physicians.

In addition to a need for more family time, a desire to take on other responsibilities within an organization - research, teaching, management - may contribute to the part-time decision.

Per diem and locum tenens positions may appeal to doctors nearing retirement looking to decrease their clinical responsibilities. In the past, such doctors went directly from full-time practice to full retirement. The newer model - in healthcare and elsewhere - is one of semiretirement that allows for easing out of clinical practice. This increased flexibility can help soften the blow of leaving patient care when one's identity is strongly rooted in a medical career.

Midcareer physicians who have built sufficient cash reserves may be attracted to part-time practice, too. Sometimes, they go part-time for a while as a sort of semisabbatical - using the time to reconnect with their families, travel while they're still fairly young, and cope with burnout - then go back to full-time practice. Physicians of all ages may simply want more time to devote to social causes, entrepreneurial enterprises, or furthering their education.

And younger physicians are perhaps most likely to see the value of balance of work and personal time.

Some, like Joseph and Theresa Newton, of Quincy Medical Group in Illinois, have never practiced full-time. These married DOs love their patients and their practice - Osteopathic Specialty Care for Musculoskeletal Medicine - but they have a strong commitment to family life and their four young children. "We wanted to be able to have dinner together on a regular basis. And we home-school - we had made a commitment to that even before we had children. ... In order to do that, it really does mean that one of us needs to be there ... so we made the decision to share a practice," explains Theresa Newton.

Between them, the Newtons are one full-time doctor. He practices Tuesdays, Thursdays, and Fridays, while she picks up the other two weekdays. The specialty nature of their practice allows them to have weekends free and means that none of the group's other doctors, who all practice in other disciplines, would be expected to take call for them.

Full-time equivalent (FTE) arrangements like this one tidily address many of the hurdles that go with a simple reduction of clinical hours. The Newtons' clinic simply treats them as a single full-timer in terms of salary and benefits (one spouse is covered under the other's health insurance), and they bought into the practice as one doctor.

Malpractice insurance is covered by the clinic group, which is a common arrangement. It's become less of an issue now for part-timers than a few years ago as more insurers offer customized, prorated solutions. (As with other types of benefits, some groups stipulate that the doctor work a certain minimum number of hours to qualify.)

Theresa Newton says there will likely come a time - when their kids are older and more self-sufficient - when they'll both go into full-time practice. For now, however, she takes issue with the term part-time, "because you're a doctor all the time." Newton points out that she fields patient calls at home and often discusses cases with her husband. "[E]ven though you're physically not there, a lot of the time you're still participating in the practice," she adds. "Your knowledge base, too, is expanding during that time. ... [I]f I'm home with the kids and we have quiet time, I'm reading a journal article or something."

Practices have their reasons, too, for valuing part-timers. Large groups with urgent care and 24-hour centers like them because they can parcel out shifts easily, for instance.

Take HealthCare Partners Medical Group as an example. The Torrance, Calif.-based group, with more than 35 clinics, employs 500 physicians - 400 FTEs - across a range of specialties. Bill Chin, MD, executive medical director, says per diem physicians in the group may choose to pick up, say, five of the 10 shifts for which a given site needs coverage during a month. Some of these exclusively "on-call" doctors cover vacations or after-hours care.

Share and Share Alike

Although there are compelling reasons for going part-time within every demographic group, the fact is that young female doctors are significant drivers of this trend. A growing feminization of the medical profession - roughly half of current medical school enrollees are women - and a larger cultural shift in the way family and personal time is viewed have led to a changing complexion for medical practices, with job sharing and other arrangements consequently coming to the fore.

Men, too, want to have time to be plugged into their families' lives, and Chin hopes everyone will consider job sharing. Although HealthCare Partners employs permanent part-timers who work set hours in addition to per diem part-time doctors, Chin says, "What I would like to do is to create a single FTE with two physicians. If Dr. A is not in the office Tuesday and Thursday, then somebody's got to cover their refills [and] questions from patients on Tuesday and Thursday. And that's the hassle that the permanent, full-time doc dislikes. They hate to pick up a chart regarding a patient they don't know and try to answer questions.

"But if I could create an FTE," Chin continues, "where Dr. B is working Tuesday and Thursday, and Dr. A Monday, Wednesday, and Friday - and the patients all know that if Dr. A is not there, Dr. B will take over - then I can create a better continuity of care and I can potentially improve the morale in my office by not dumping on the permanent physicians working full-time."

The Newtons are no strangers to tailoring challenging situations to fit their needs, having shared their professional responsibilities in one way or another for all of the eight years since they finished school. After bringing their request to the American Osteopathic Association, they were the first osteopaths to complete their internships and residencies on a shared basis, even dividing teaching duties at Kirksville College of Osteopathic Medicine in Missouri.

"We split the clinic - I did a little more clinic and [Theresa] did a little more classroom, but we both did some of each," says Joseph Newton. As in their home-schooling efforts, the couple was able to make the most of each one's strengths. Sharing doubled the time for residency from three to six years, but the trade-off was worthwhile for the couple, who say the extra time they're able to spend with their kids is invaluable.

MDs can seek permission to complete their postgraduate training part-time, too; requirements vary by specialty and residency location. Like employers, residency sites may find unexpected value in part-time arrangements. Joseph Newton points out that the site - and its patients - will experience the benefit of a longer relationship with the doctor, making for better continuity all around.

Some believe that fostering access to part-time educational and clinical opportunities will be crucial to addressing the looming shortages and gender imbalance in certain specialties and between general practitioners and specialists. The changing face of medical practice will make these arrangements ever more crucial - and feasible, with the aid of technologies like PDAs, laptops, and EMRs.

Bend, Don't Break

A little flexibility can go a long way in job sharing and in regular part-time work. Chin says clinic administrators have told him, "'Well, I can't have a meeting at 8 [a.m.] because two of my doctors have to take kids to school.' ... I say, 'Look, you're having this meeting twice a year. You mean they can't find somebody to take the kids twice a year?'" He adds that handling these difficulties often depends on the skill of the intermediate manager.

Achieving an FTE staffing model has so far been a struggle for Chin, "because the part-time docs say, 'I want to work Monday, Wednesday, and Friday, in the mornings, no evenings, and I want to be done by 1 [p.m.] And they expect us to fix it. And I'm trying to throw it back at them: 'You want permanent part-time work? I can do it, but you have to work with your colleague in meeting the organizational needs.' And that has been a tremendous hurdle that I've not yet been able to overcome."

A situation like the Newtons' and the one Chin envisions clearly requires meticulous planning and communication. As doctors engaged in any form of partnership well know, compatibility is key. Chin returns to the patient-centered approach, stressing that, "[O]ur job is to care for our patients, to provide good care for our patients, and to maintain good morale at the [clinic] site. And I think when you speak with the part-time doctors, they understand this. But sometimes when they're talking about their own personal needs, they forget about that."

Clarity of vision and expectations, along with established procedures, are a must on all sides. When talking with both colleagues and employers, part-timers need to be upfront about the motivations behind their decision. Attitude is of paramount importance - appearing to have zero flexibility, even though a doctor may view his free time as sacred, will be viewed negatively by full-timers and administrators.

The Part-time Bottom Line

A 2003 article in the Journal of General Internal Medicine indicates that physicians who work part-time may actually have better patient outcomes than their full-time peers. The part-timers had small but significantly higher rates for cancer screening and diabetes management. The authors suggest that part-timers may, in an effort to dispel their peers' negative perceptions or questions about their commitment to medicine, be especially attentive during their time in the office.

But didn't patients resent their doctors not being available full-time? Nope. Most patients respect the motivations behind doctors' reduced schedules and are willing to trade a little inconvenience for seeing their chosen provider. Holmes says the only real resistance she's experienced came from patients who were upset when she discontinued her Monday evening hours, which had been popular among those with full-time jobs. Nevertheless, "[T]he majority of them found different ways to make the switch ... so I think if you really like the doctor you'll adjust."

Theresa Newton advises keeping your eyes on the part-time prize: "[K]nowing your reasons for what you're doing is very important. Because [they will] sustain you through those challenging times, and also help you when there's a question possibly about perception from other physicians about why you're [working part-time]. ... [I]f you have your priorities in order, then this is something that is very enjoyable and very rewarding."

Chin says it's vital to maintain a patient-centered perspective, noting that the approach for managing a part-time physician's patient panel and workload should be tied directly to the reasons that physician wants to work less than full-time. "Whenever a physician hands off care on a patient to another physician, there's always a communication gap," he says. "As detailed as you are, as conscientious as you are, it is not always easy to communicate with precision what ... needs to be done."

Laurie Hyland Robertson can be reached at lrobertson@mediq.com.
This article originally appeared in the November/December 2005 issue of Physicians Practice.