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Working part time: Can it fit into your practice?

From the July-August ACP-ASIM Observer, copyright © 2002 by the American College of Physicians-American Society of Internal Medicine.

By Bryan Walpert

Three years ago, at age 52, cardiologist Marianne T. Serkland, MD, was finding her 60-hour workweeks too demanding and decided it was time to slow down.

One of her colleagues, an older physician at CentraCare Clinic—River Campus in St. Cloud, Minn., had also grown tired of the grind. So the clinic agreed to let the two share a single position, and each now works every other month.

Dr. Serkland uses part of her months off to work overseas with an international health service. She also spends time riding her bike, enjoying the outdoors and quite literally smelling the roses that she grows in her large garden.

"I think at a certain point in a person's life, this is a good arrangement," Dr. Serkland said. "I don't know why more people don't do it."

She and her job-share partner aren't the only ones enjoying that kind of flexibility: Though their job-sharing arrangement is unique at CentraCare, 18 of the multispecialty clinic's 140 physicians—including five of the clinic's 17 general internists—work half or three-quarters of a full-time position.

Experts say that growing numbers of physicians are working part time, either in job-sharing arrangements like Dr. Serkland's or, more typically, by reducing their hours. Some are older doctors who want to gradually phase into retirement. Others are young physicians, early in their careers, who want to spend more time with their children and pursue interests outside medicine.

"Physicians are increasingly interested in taking more time off," said Amanda Smith, director of health care consulting at Gamble Givens & Moody in Charleston, S.C. "Practices are often quite amenable to that sort of arrangement."

Recruitment and retention

Practices that offer part-time schedules say that flexibility gives recruitment and retention a big boost. A valuable older physician who is refused a part-time schedule might decide to retire early, while a younger physician who wants a more flexible schedule will look for work elsewhere.

CentraCare is a good example. "We've recruited several physicians this past decade who would not have come here if we weren't able to offer them some flexibility to handle family responsibilities," said clinic president Terence R. Pladson, MD.

The same is true at Scott & White Clinic in Temple, Texas. Of the clinic's 500 physicians, more than 20 work part time, including eight part-time internists and one internist couple who share a position.

"Spouses look at where we're located [an hour north of Austin] and think of cowboys, Indians, sage brush and outhouses," joked nephrologist Charles J. Foulks, FACP, the clinic's medical director. While that's hardly a fair characterization, he added, "We're willing to be accommodating because we understand it's a tough recruiting environment."

That flexibility made a big difference to Raymond J. Harrison, ACP-ASIM Associate, and Karen L. Harrison, ACP-ASIM Member, two internists in their 30s who came to Scott & White out of residency in 1999. They began full-time but didn't like leaving their young daughter in daycare, seeing her only when everyone was tired. They also found it disheartening to watch household chores pile up because neither had time to do them.

But since neither wanted to quit medicine to stay home full time, they approached the clinic about sharing a position and, with its support, began job sharing in August 2000. Now she works mornings, he evenings; they alternate working the Friday evening clinic. She has the health benefits and he is on her plan as a dependent. They share a desk and a secretary, and they cover each other's patients.

If the clinic had refused to try the arrangement, they would have considered leaving. While it would have been tough to leave a practice they both like, "We would have considered it 'family first,' " Dr. Raymond Harrison said.

Both experts and physicians insist that part-time providers put in at least as much effort as their full-time colleagues during the hours they work, reducing or eliminating any friction from colleagues.

A study published in 2000 by The Health Institute, a practice research group at Boston's New England Medical Center, found that part-time primary care physicians performed as well as full-time physicians. After surveying more than 2,700 patients, the study reported no difference between the two physician groups, based on criteria such as access, communication, exam thoroughness, preventive counseling and familiarity with patients.

According to the study, patients were better able to see their own doctor when they wanted if the physician worked 65 hours or more. But that group of full-time physicians paid a price: They were less satisfied with their professional and personal lives.

Dr. Raymond Harrison could recall only two patients who balked at his and his wife's job-sharing arrangement. He believes he's now more efficient in the afternoon than when he worked full time because he arrives fresh and energized after lunch and has no problem working in extra patients.

He and his wife each see about a dozen patients during their half-day stints. In fact, he said, they made a higher annual productivity bonus sharing a position than either made working alone full time.

Part-timers often work more than their scheduled hours, seeing extra patients, answering calls and reviewing charts with nursing staff, said CentraCare's president Dr. Pladson. "They generally do their fair share and a bit more."

Pay and benefits

Consultants warn that there are costs associated with part-time work. How steep those costs are depends on practice size, the group's compensation plan and the physician's length of service and partnership status. The question of who bears those costs—the physician or the practice—needs to be negotiated.

Typically, physicians dropping to part time must be willing to take more than a proportional cut in take-home pay to make up for fixed expenses, like overhead costs and health and malpractice insurance. Dr. Serkland receives only about 45% of her former salary for 50% of her previous hours, which consultants say is not unusual.

CentraCare pays 80% of health premiums for full-time physicians; those working part time must pay proportionally more. But the clinic does absorb part of the cost of allowing physicians to work part time: According to Dr. Pladson, the clinic pays the full cost of malpractice insurance for its part-time physicians.

Smaller practices may not be able to afford that luxury. Veronica Coyne, MD, founder of the four-physician Peace Valley Internal Medicine in Fountainville, Pa., said she finds the malpractice insurance issue particularly vexing. The 65-year-old internist cut her schedule to 3.5 days a week earlier this year, and plans to drop hospital work and weekend and evening call this month. In September, she'll cut back to three days a week.

But because malpractice premiums aren't discounted for part-time work, Dr. Coyne worries about the financial impact on her practice. "With such high premiums, it's almost prohibitive to reduce my workweek," she said. She hopes that a new physician, who starts part time this summer and goes full time in the fall, will bring in enough to cover those premium costs. She is also looking for part-time administrative work elsewhere—income that would go to the practice and offset the cost of premiums.

But if insurance costs prove to be too steep after a year of three-day workweeks, Dr. Coyne said, she and the group's other partners may have a tough decision to make.

"They may say, 'We think you ought to retire now' and I wouldn't blame them," she said, adding that she hopes this scenario doesn't come to pass. "I'm not at all ready, because I can function well and provide a service. I'd hate to give up practicing."

Call schedule

Perhaps the most difficult and contentious detail to work out is call. Some physicians going part time want a proportional reduction in call—or to give it up altogether if they are close to retirement.

The problem becomes critical if the practice does not have a large enough patient base to justify hiring another physician, said Geoffrey T. Anders, JD, president of The Health Care Group, a consulting firm in Plymouth Meeting, Pa.

"Many groups say, 'If you're going to be in this practice, you have to bear the full burden of responsibilities, including call,' " he said. "That's somewhat short-sighted, because it could lead senior doctors to leave the practice unnecessarily. Besides, I'm not sure I'd want a 62-year-old cardiologist getting up in the middle of the night to take care of me."

Instead, Mr. Anders suggests, groups should consider asking physicians to pay for the privilege of giving up call—perhaps as much as 25% to 30% of their income in a practice with a heavy call schedule. Or groups might put a quarter of total provider income into a call pool that gets divided among only those physicians who take call.

Support staff

Ancillary staffing is another issue practices must consider. In busy practices, nurses and other medical staff supporting part-time physicians may find plenty to do, by substituting for staff on vacation or assisting other physicians. In some cases, nurses and medical assistants are happy to work part time for the same reasons as physicians.

But in other groups, when the physician goes part time, practices are forced to reduce nonphysician staff hours, said Mr. Anders. As a result, nurses may quit to find a full-time job and the practice is forced to find part-time support staff. Ideally, he said, a practice will have the patient base to hire another full-time physician and hold onto full-time staff.

Partnership

Practices also must decide whether a partner who wants to go part time should give up his or her stock and partnership status. Randy Bauman, president of Delta Health Care, a practice consulting group in Brentwood, Tenn., generally recommends a stock buy-back in that situation because part-time physicians—particularly those heading toward retirement—might not have the same financial commitment to the practice's future.

For instance, a part-timer may not be as willing to take on the financial risk of purchasing new equipment or a new building. "If you're making half of what others are making, that number may look a lot bigger and loom a lot larger," Mr. Bauman said.

But, he added, there are no hard and fast rules. He recalled one family practice physician who wanted to go part time and sent a letter to the other partners. In it, she committed herself to working full days when she was scheduled, paying for her own malpractice insurance and signing on for new debt. The group agreed to keep her on as partner.

"It really changed my view forever," said Mr. Bauman, who kept the letter as a reminder. "You have to decide on a case-by-case basis."

Other practices may not be so accommodating. Still, physicians today are finding many more opportunities to work part time than when Dr. Coyne started practice in 1972. Unable to find work as a part-time physician, she worked in an emergency room and took temporary jobs until she founded her practice in 1977. At first she worked from 9 a.m. to 3 p.m. to make time for her family, gradually increasing to full time as her children got older.

She sympathizes with young women who want to balance job and family, and has recruited several part-time physicians over the years, including one who works at the practice now.

"I often felt a little inferior when I was younger, seeing all the doctors around me who were always working," Dr. Coyne said. "I felt as if I wasn't quite measuring up to the standard. Yet in the long run, I think part time work was the very best thing for me. If I had to do it all over again, I wouldn't do it any differently."

Bryan Walpert is a freelance writer in Denver.

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