"The pressure to always be available for your patients, to work longer hours, to do more, to see more patients, is almost overwhelming. No one tells you at 2 o'clock on Tuesday afternoon to go home and be with your family," says Susan Harmon, MD. But Harmon is doing essentially that, joining the ranks of physicians who are choosing more time for family and personal and professional enrichment, even though it means less money, fewer benefits and communication challenges with colleagues and patients. Here's how - and why - some part-time physicians make it work.

KEY POINTS

Nearly a quarter of family physicians have reported practicing part time at some point in their careers. The desire to spend more time with family or to scale back prior to retirement are the most common reasons physicians choose to work part time. Job-sharing is emerging as a different and, in some cases, improved form of part-time work.

Choosing part-time work

Nearly a quarter of family physicians have reported practicing part time at some point in their careers. Physicians in other specialties, such as pediatrics and psychiatry, have reported similar numbers, and ob/gyn and internal medicine aren't far behind at 18 percent and 16 percent, respectively.1

Today, physicians are more interested than ever in working part-time or flexible schedules, says Mark Smith, vice president of recruiting for Merritt, Hawkins & Associates, a national physician search firm based in Irving, Texas. The desire to spend more time with family or to scale back prior to retirement are the most common motivators, he says.

Lindsay Phillips, MD, chose part-time work right out of residency for family reasons. "I feel that the most important work of my life is being a mother," says Phillips, mother of three and part-time physician with Strong Health at East Ridge Family Medicine in Rochester, N.Y.

Eve A. Knapp, MD, who gradually cut back her hours after her children were born and her husband was deployed to Iraq, feels the same. "Once my husband returned, I realized that I enjoyed working three days a week and preferred to keep my schedule that way. He frequently works weekends, so the days I have off are often the only days in the week that we see each other and spend time together as a family," says Knapp, who practices at the Family Care Clinic in Jacksonville, N.C.

Though Smith says one of the trends driving the interest in part-time work is the influx of women into medicine, men are seeking part-time work as well. Kelly Locke, MD, and his wife, Karen Locke, MD, both work part time, job-sharing one full-time-equivalent (FTE) position in the Alpine Medical Group in Basalt, Colo. Job-sharing allows one of them to work while the other is at home with their three young sons. (See "Job-sharing: A different kind of part-time work.")

Since cutting back to part-time hours over three years ago, Roger C. Shenkel, MD, of Primary Care Partners, in Grand Junction, Colo., is not only enjoying more personal time but also gradually easing his way into retirement - even though he's not yet sure when or whether that will be. "I'm now working at a pace that I can continue until I am ready to retire," says Shenkel.

JOB-SHARING: A DIFFERENT KIND OF PART-TIME WORK

When it comes to working part time, there's more than one way to do it. Kelly Locke, MD, who shares one full-time-equivalent (FTE) position with his wife, Karen Locke, MD, says it's important for physicians, especially those considering a switch to part-time work, to know what makes job-share arrangements different. Unlike regular part-time work, which usually involves individual physicians working reduced schedules and relying on others in the practice to cover for them while they're gone, Locke describes a job-share as one FTE position covered by two separate physicians who each work half time. The physicians may or may not have a relationship outside of the job-share arrangement. Eve A. Knapp, MD, is working a regular part-time position now, but she has experienced a job-share arrangement in the past. "I would much prefer a job-shared position, as this cuts down significantly on the paperwork and actually allows me to be more productive, see more patients and have the patients' concerns (labs, phone messages, prescriptions) addressed in a more timely manner," she says. These benefits make it easier for job-sharing physicians to actually work within the reduced hours they set rather than working somewhere between part-time and full-time hours as many regular part-time physicians end up doing. Still, Locke says some job-share arrangements do have their problems. "A job-share arrangement can work well if the docs have the same personality and style. However, if one doc really enjoys alternative therapies but the other doc is more traditional, it could lead to one doctor feeling uncomfortable with the care the job-share partner is giving," says Locke, adding that work schedules and days off may not always mesh well either. Job-sharing with a spouse, as Locke does, may make work schedules and days off easier to deal with, but if the spouses have vastly different practice styles, some of the same problems could emerge. Not all practice-style differences are bad though, according to Locke: "Karen and I have very similar personalities and approaches to medical care. She sees more female patients and I enjoy hospital care more, but these differences tend to complement each other by giving our FTE position a broader scope than one physician might have." Locke also says that job-sharing with a spouse makes life at home flow better. "When one of us is at work, the other can run errands and pick up the kids," he says.

Finding support

Whether you're switching from full time to part time in your current practice or you're looking for a practice interested in hiring a part-time physician, finding acceptance and support may not always be easy. "I think at times doctors who work full time resent the schedule flexibility that part-time physicians have and the added time they have with their families. Any time we encounter people with a different model, it makes us wonder how valid our choices are," says Phillips. The Lockes experienced this kind of reaction from physicians during their job search: "When we first decided to do a job-share arrangement, we received lots of 'deer in the headlights' looks from the docs we interviewed with. Occasionally, someone would imply, 'But don't you want to be real docs?'"

A study published in the April 2000 Archives of Family Medicine showed that part-time physicians were performing as well as full-time physicians in all aspects of primary care except visit-based continuity of care. The study found that the physicians who provided the best visit-based continuity of care (and happened to be the least satisfied with the amount of time they had for their family and personal lives) were those who worked more than 65 hours per week.2

But negative reactions to part-time practice are common among physicians, Smith says. "There is an unfair stigma that part-time physicians are not interested in working hard," he says. "A part-time physician might only be working three days a week, but if he or she is seeing 30 patients a day, the physician is being very productive. That's 90 patients a week that might otherwise go unseen."

Patients' reactions to part-time physicians tend to be more positive than many colleagues'. These physicians have found that most patients have no problem adjusting to a part-time physician's schedule and, in fact, are often quite understanding. "I find that most patients appreciate a doctor who understands the priorities of family," says Phillips. Pointing out that most things can wait 48 hours, Locke says that patients seem to "get into a rhythm" for his and his wife's schedule. For those things that can't wait, their patients know they're covered. "The patients are happy to see a partner in the clinic for an acute one-time visit, such as sinusitis or an asthma attack, but come back to see you in the long run," says Locke. You're bound to run into the occasional patient who expects you to be available 24/7, Knapp says, but that's true regardless of your work schedule.

Some part-time physicians are their own harshest critics. Harmon, who switched from full-time to part-time work last year, says she still feels guilty about her part-time status at times, telling herself that she's not working hard enough or she's not a good enough doctor. To deal with these issues, Harmon recommends finding a support program, as she has at the Center for Professional and Personal Renewal in Palo Alto, Calif. "Through career and life coaching, I receive validation that this course of action is true and right; that other physicians have gone through the same problems and come out better," says Harmon.

MAKING THE SWITCH

Transitioning from full-time to part-time work - as opposed to seeking a part-time position at a new practice - has its own set of challenges. The biggest of these may be deciding how to handle your existing full-time patient load. Eve A. Knapp, MD, suggests temporarily closing your patient panel to new patients. "This way the panel size will gradually dwindle as people move, switch insurances or leave for other reasons, and it will become manageable for part-time work," she says. If you do need to ask some of your patients to leave, Roger C. Shenkel, MD, says you'll need to be firm. "Stick to your plans. Don't succumb to the 'You are so wonderful, won't you please keep me on as a patient' trap," he says. Since this transition can amount to a fairly significant lifestyle change professionally and personally, Susan Harmon, MD, recommends physicians begin by evaluating their finances with an accountant and then spend some time thinking about their time-management goals before they decide specifically what their part-time schedule will be. "I filled out a table on how many hours in a typical 168-hour week I was spending on personal and home maintenance, spouse or partner, children, other family, work, friends, volunteer work, exercise, hobbies, spiritual growth, 'tuning out the world' and sleeping. Then I filled it out again with my 'ideal' responses. This exercise gave me concrete goals to work toward," says Harmon. Making this transition can be hard on the physician emotionally too, according to Shenkel, who advises that physicians should just give themselves some time to get used to their part-time work arrangements. "It took two years for me to get over feeling like I had to be needed and no one else could take care of my patients but me," he says.

Inside a part-time work arrangement

Constructing a part-time arrangement that works for all concerned is essential for success, but what works for one practice may not work for another. (See "Making the switch" to find out about the unique challenges that face physicians who convert an existing practice to part time.) Here's how some part-time physicians handle the key aspects of their work arrangements:

Setting a schedule. Smith says that the most common part-time schedule is one that allows the physician to be available for his or her children at some point before the end of the regular workday. "A three-day week is quite common, but other options are available, including an 8 a.m.-to-noon, five-day-a-week schedule or a schedule made up of two full weekdays and a Saturday clinic," says Smith. Though half days are often an option, Shenkel, who works Tuesdays, Wednesdays and Thursdays, cautions that they can be hard to pull off. "Half days turn into full days," he says.

The particulars of each physician's schedule depend on the practice's coverage needs and whether other physicians in the practice work part time. In the Lockes' job-share arrangement, one of them works Mondays, Thursdays and Friday mornings and the other works Tuesdays, Wednesdays and Friday afternoons - a schedule that enables them to cover the whole week. In Phillips' practice, where a number of physicians work part time, schedules are coordinated to ensure not only adequate coverage but also timely care. "As a group we agreed that we should only have one office day off between our sessions so that patient callbacks and lab responses occur in a timely fashion," says Phillips, who works two long days and one short day for a total of 20 patient-care hours.

"I find that most patients appreciate a doctor who understands the priorities of family."

Handling patient care on the physician's days off. When part-time physicians are out of the office, patient care gets handled in a variety of ways. In a job-share arrangement such as the Lockes', the solution is simple: Whenever one of them is gone, the other one is there to see patients. When they are both gone (on a family vacation, for example), their absence is handled by their partners just as any full-time physician's vacation time would be.

Physicians in a more typical part-time arrangement rely more on help from other physicians or nonphysician providers in the practice when their patients need to be seen on their days off. However, this doesn't come up often, according to Knapp. "My patients know which days I'm there and tend to arrange their appointments for those days," she says. Still, Knapp cautions that you do need to be prepared for the times you will need help: "Ensure that there is adequate coverage of your patients in your absence, that you have full confidence in your colleagues' ability to deal with emergent situations that may arise, and that there is adequate coverage for acute visits on days off."

Keeping up with all the work related to patient care (e.g., phone messages, refill requests and lab results) that accumulates while a part-time physician is out of the office can be a little more difficult. Harmon, who works three days a week with Lincoln Health Care Specialists, part of a large multispecialty group in Lincoln, Ill., checks in with the practice's phone nurse at various times on her days off to try to minimize the work that accumulates in her absence.

Phillips' practice has a coverage system in place to deal with the problem: "Our secretaries and nurses initially screen calls to determine if it is a same-day concern or if it can wait until the next day when we are in the office." When the system doesn't work, Phillips says she occasionally goes into the office on her days off to complete undone work. (See "How part time is part time, really?")

Participating in call. Whether a part-time physician participates in call varies by the physician's and the practice's needs. For Knapp, it isn't possible. "My husband is an ER physician, so unless we had a live-in nanny, it would be too difficult to arrange our schedules to allow for me to take hospital call," she says. Knapp is not alone. Smith says that a number of part-time physicians do not participate in hospital call, which can make adequate hospital coverage difficult for some practices. (See "More part-time physicians, less coverage.")

Some part-time physicians participate in a call schedule that reflects their reduced number of hours. Phillips, who practices obstetrics, participates in inpatient and obstetric call 50 percent of the time and practice call (which has a much higher volume of calls) 10 percent of the time. All of the physicians in her practice take equal weekday and holiday call, but weekend call is prorated by each physician's FTE status. The Lockes, who rotate through their practice's call schedule just as one physician would, split the call between them: "Our office manager plugs us into the schedule as 'The Lockes.' We then decide how to divvy up the call days for which we are responsible."

Still some physicians, such as Harmon, who is on call every Wednesday night and every fourth weekend, participate in a full call schedule regardless of their part-time status.

HOW PART TIME IS PART TIME, REALLY?

According to Kelly Locke, MD, a half-time physician will typically end up working more than half time to keep up with paperwork, etc. "Clinics have a tendency to want to get their money's worth out of a truly half-time doc," says Locke. Eve A. Knapp, MD, has experienced this. "I currently have a full patient load for a full-time physician but am trying to manage it in a part-time schedule, which leads to waits for appointments and more paperwork," says Knapp. Susan Harmon, MD, has seen the extra hours pile up as well: "Only in medicine is working 40 to 50 hours a week considered part time," she says. Why can't part time really be part time? According to Lindsay Phillips, MD, who says she probably ends up working 15 percent more than her scheduled part-time hours, one reason is that even though a part-time physician's hours may be cut back, the requirements for CME, credentialing, board exams, office meetings and committee work essentially remain the same. This means even less time is left in the part-time physician's schedule for seeing patients. For example, Phillips points out that two hours a week spent on these activities is 5 percent of the full-time physicians' schedules and 7 percent of her part-time schedule. But she says working more than the scheduled hours is not unique to part-time physicians: "The average full-time physician works 125-percent time, not 100-percent time. Full-time physicians work more than a 'regular full-time' job too." For a part-time physician to keep his or her hours in check, Harmon says the patient load needs to be cut back and patient visits should be done earlier in the day to allow time for post-visit paperwork to be completed. Knapp suggests that job-sharing may be the solution. "On the days you are not in the office, the other person would cover some of the paperwork and see the patients," she says.

Dealing with financial/benefits issues. "The basic trade-off for the part-time physician is less money for more free time," says Smith. In his experience, which is mostly with hospitals, part-time physicians are most often hired as independent contractors and offered an income guarantee with some benefits. "The guarantee for a physician working part time will be less than for a full-time physician, and once the guarantee period expires the physician's income will be self-determined - the fewer hours the physician chooses to work, the less income he or she will likely earn," says Smith.

The next two most common financial/benefits arrangements Smith has seen offered to part-time physicians are per diem, which means the physician receives a fixed amount per day, and production-based. The salaries for part-time physicians in Shenkel's practice are mostly production-based, but the vacation, sick and CME time they receive are the same as the full-time physician's. "This may be to the detriment of our bottom line, but it's to the betterment of our mental health," says Shenkel, adding that the practice has seen only one divorce in 31 years and 25 physicians.

In Phillips' practice, all physicians are paid with a productivity formula, which is applied equally to part-time and full-time physicians. Since full-time physicians see more patients in a week, they earn more than the part-time physicians. CME funds are prorated by FTE, and all physicians have four weeks of vacation.

The Lockes' one-FTE-physician status means that, between the two of them, they receive the same vacation and are given the same overhead as any other physician in the practice, with one big exception - malpractice insurance. Although some practices will pay all of a part-time physician's malpractice insurance costs (which are often less but not half as much as full-time physician's costs), many will leave some or all of these costs to the part-time physician. "In the past, our partners were subsidizing this extra malpractice cost by absorbing it into the practice overhead. In the future, we have agreed to personally cover malpractice costs exceeding one FTE so the expense is more equitable," says Locke. The AMA has identified some professional liability companies that offer reduced premiums to part-time physicians (see http://www.ama-assn.org/ama/pub/category/7118.html).

Handling partnership issues. Whether partnership is available to part-time physicians can depend on the part-time physician and the practice. Harmon, Shenkel and the Lockes are all partners in their practices. Harmon was already a full partner in her practice's limited liability corporation when she switched to part-time work, and her part-time status didn't change that. She says that each physician in the clinic has to buy a minimum share of ownership, which comes with one full vote on partnership issues. For the Lockes, the partnership privileges of one FTE physician are shared equally between them. Each has half of a vote and half of an FTE share in the corporation.

The rewards

Despite some of the financial and other challenges associated with part-time work, these physicians say the benefits are well worth it -- personally and professionally. "At times, I wish I had more money," says Phillips. "New cars and fancy vacations aren't part of our family budget. I would never trade in what I have though. We eat together as a family four nights a week, and I arrange play dates, supervise homework and talk to my husband." Knapp agrees, saying she made the best decision for her family: "I will never regret cutting back my hours so that I could watch my children grow and play a more involved role as a parent than I could if I worked full time."

Shenkel says that cutting back to part-time work has allowed him more energy, time and emotional involvement with his family. "They have more of my undivided attention, whereas for years my work had most of it," he says.

Phillips has discovered some unanticipated benefits as well. "I have realized that working part time leaves me with more time for reading medical literature, volunteering at school and in my community and taking care of myself - all of which enrich me as a person and a physician," she says.

In addition to affording physicians the flexibility they need to be more fulfilled, offering part-time positions can benefit a practice in many other ways, says Smith. "Part-time work is a good recruiting draw and an effective retention tool; practices will increase their chances of being successful by offering flexible hours. It also may allow the group to expand their hours to evenings or weekends, thereby gaining a competitive advantage and creating a service patients really like," says Smith.

MORE PART-TIME PHYSICIANS, LESS COVERAGE

As more physicians begin working part time, maintaining adequate access may become difficult, says Mark Smith, vice president of recruiting for Merritt, Hawkins & Associates, a national physician recruiting firm based in Irving, Texas. "The gross number of doctors in the work force is increasing, but the net number is decreasing because physicians are changing their practice styles," he says. "This trend is changing the way we look at physician supply and it will have to be reckoned with by groups, hospitals and patients throughout the country." With growing numbers of physicians (full-time as well as part-time) opting out of inpatient work, hospitals may have a particularly difficult time finding coverage for inpatient care, says Kelly Locke, MD. "It doesn't matter how many docs you have in a community, if none of them want to be on staff, the remaining inpatient physicians will have to work that much harder to provide coverage," he says. To maintain adequate coverage among many part-time physicians, the hospital system Lindsay Phillips, MD, works for is actively encouraging part-time physicians to job-share. "This creates a full-time office presence for staff and patients to access," says Phillips.

Making choices

Part-time work isn't for everyone and it's not always easy, but it is an option some physicians find rewarding. Phillips suggests that physicians think about where they want to be in five years. "Make sure you are making choices that support your goals," she says. The right choices will be different for every person; for Phillips, it was clear that part-time work was right for her: "I want to remain connected to my children and my community while being an excellent physician. Part-time work lets me do that."

1. American Academy of Pediatrics Department of Health Policy Research. Pediatrics leads specialties in number of part-time physicians. AAP News. 2002;21(3):126.

2. Murray A, Safran DG, Rogers WH, Inui T, Chang H, Montgomery JE. Part-time physicians: physician workload and patient-based assessments of primary care performance. Arch Fam Med. 2000;9:327-332.

Olivia Maresh is an associate editor for Family Practice Management. Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.

---

Copyright © 2004 by the American Academy of Family Physicians. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact fpmserv@aafp.org for copyright questions and/or permission requests.