In the ED, half time doesn’t have to mean half committed
When Karen Sibert, an anesthesiologist with four children, wrote an op/ed piece in the New York Times about the deleterious economical and societal impact of physicians who choose to work part time, my email inbox exploded. Comments were all over the place, from “You’ve gotta be kidding,” to “Wonder if it would have been printed if a man wrote it,” to “Raises some interesting points.” But within a few hours, a second slew of even more emotionally-loaded barbs started arriving. This batch challenged the appropriateness of voicing dissenting opinions on a topic for which many women want unanimous solidarity. Pandora’s box flew open.
In the editorial, Sibert essentially argues that there is a huge need for qualified physicians, and since the government heavily underwrites physician training costs, it is a bad return on their investment if physicians choose to work part time. At first glance, although incendiary, her reasoning appears solid. But cracks begin to form quickly. Sibert basically directs her piece towards women with small children, as statistically they are the ones most likely to go part time. A 2006 AAMC survey reported that approximately 24% of female physicians younger than 50 work part time. Her argument, however, suggests that anything physicians do besides using a stethoscope or scalpel is a net loss.
Let us return for a moment to Sibert’s concept of owed debt. For most new physicians this is not a conceptual issue, but one looming large –current medical school debt averages just shy of $160,000. So, when is our debt to society repaid? Is it after a certain number of patients seen? How about working in under-served areas, or providing free care. Wait, emergency physicians already provide all sorts of free care. It’s called EMTALA. One might even argue that with the discrepancy between the cost of care and what Medicare pays, we’re even.
To paraphrase Bob Dylan, the times, they are a changin’. The days of Marcus Welby with his unquestioned authority and exclusive country club membership are long gone. Today’s physicians are still dedicated to delivering high quality care, but they want more control over the balance between life and career and are interested in defining themselves beyond their medical degree. A 2008 Boston Physician Foundation survey of 12,000 doctors showed that only about half of doctors imagined that in three years they would be continuing with their current practice pattern. The other half envisioned alternatives such as reduced clinical hours, part time, locum tenens or alternative employment. These choices are less about gender and more about a subtle cultural shift of priorities.
First and foremost we need to identify factors that prevent physicians (regardless of gender) who desire to work full time from doing so. Usually this comes down to flexible scheduling, which has traditionally been very difficult in most small private groups. Ironically, another large change in the medical landscape may actually help to provide a solution to this problem. In the past 10 years there has been a steady shift of physicians away from private groups into hospital-based employment (according to Medical Group Management Association, private practice groups have decreased from 66% to 40% in just the past five years). One advantage of these large groups is their unique position to pool administrative and supportive resources.
Of course, the other white elephant in this discussion is day care. About half of medical grads are women, and the other half will likely marry someone who may plan to work. Reliable and affordable day care is a huge issue for two income families and becomes even more complicated if one or both partners have nontraditional hours. This difficulty can become a root cause of the physician wanting to limit monthly hours to increase flexibility. If groups want to keep their physicians working (and billing), the time is ripe for them to partner up with local businesses to develop innovative programs (regular care, on call coverage, snow days and sick care) to fill this gap. A successful example of this is Princeton University’s Backup Care. This subsidized program covers everything from emergency coverage for sick kids to having someone wait that infamous four-hour window for the plumber to show up. Now that’s a recruiting perk!
What about part time? If we want to maximize our physician work force we need to creatively develop part time positions for the more traditional cut-throat specialties. The first step is to remove the stigma associated with working part time. It is no secret that in many specialties, individuals who cut back their hours are ostracized and viewed as slackers. These part time physicians may be excluded from mentoring, non-clinical and profit-sharing opportunities, which all leads to resentment. The result is a catch 22 and a vicious reinforcement of the specialty’s part time stereotype. To maximize their talent, it’s time for specialists to create and support “chunkable” part time alternatives such as surgical hospitalists or job sharing. Culture change and buy-in starts with authentic administrative support and with the development of objective policies that clearly outline logistics and expectations, including call, compensation and faculty development. The pay off is that a part time employee is more likely to return to full time if they feel valued and committed to the group.
Finally (and paradoxically), there are actually financial incentives for groups to encourage part time and flexible scheduling. First, it decreases the need for outsourcing. Most CFOs would be happy to raid the $2 billion+ coffer of the locum tenens industry. In addition, the workload of two .5 employees is usually more productive than that of a single full timer. Put this together with savings on prorated benefits and the ability to use flexible scheduling as a recruiting tool and you’ve pretty much hit the trifecta.
Medicine is changing. If we hope to retain the talent of our current work force and to recruit the next generation of the most qualified young adults we need to redefine our traditional work models so that they are creative and flexible.
Read the original op/ed by Dr. Karen Sibert at tinyurl.com/6gpqowt