Part-Time Medicine

by Danielle Ofri
JAMA

It was 8:00 a.m. on Tuesday morning and I listened to my phone messages in my office. “This is Sharon S.,” the first message played, “calling on Thursday. I think I’m having a urinary infection. Please call me back.”

“It’s Sharon S.,” the next message played, “calling on Friday. I’m having a lot of burning when I urinate and wonder if I should be on antibiotics.”

With a sinking feeling in my stomach, I quickly dialed Sharon’s number and unfortunately got an answering machine. I apologized for not getting her message sooner, explaining that the clinic was closed for a federal holiday on Thursday, and that Fridays and Mondays were the days that I didn’t work at the clinic. All of these were true statements, but as I recounted them before Sharon’s answering machine they sounded pathetic.

I didn’t hear back from Sharon and felt worse. Although I later learned that she’d obtained appropriate treatment from her university health services, I still felt terrible. If Sharon had been less educated or didn’t speak English or was homebound, an untreated urinary infection could have progressed to pyelonephritis, even sepsis. Even though my voicemail greeting clearly states—in two languages—which days I’m not in the clinic (and specifically states that I won’t be getting messages on these days and to please dial the following number to get immediate attention, etc) it is not unusual for me to find messages with real urgency waiting on my machine when I get back to the office several days later.

It is at these times that being a part-time doctor feels I’m somehow shirking the Hippocratic Oath: I’m not there for my patients all the time like a doctor should. During my “on” days, I work furiously like my colleagues, seeing all of my patients, squeezing in anyone who calls or shows up, supervising residents and students, following up on test results, returning phone calls, filling out medical forms, writing letters for disability, housing, school and work.

But on my “off” days, I am officially off. I don’t go to the hospital, don’t check my voicemail, though I do carry my beeper for emergencies. If my patients need medical attention on those days, they have to be seen by in our walk-in clinic, or to go to the emergency room if it is after-hours or on weekends. When this happens, I feel terribly guilty about being a part-timer, but I often wonder whether this guilt is misplaced. Is there anything inherently wrong with working in medicine part-time?

Between 10% and 20% of doctors define themselves as “part-time,”[i],[ii],[iii]and pediatrics leads the pack for specialties conducive to part-time work. Patient trust and satisfaction with part-time doctors appear to be similar to that with full-time doctors. Part-time physicians report less burnout, higher satisfaction, and a greater sense of control than full-time physicians.[iv] The small studies that have been done on clinical outcomes suggest that part-time physicians are more efficient and productive, achieving better outcomes in cancer screening and diabetes management than their full-time counterparts.[v]

But, not surprisingly, part-time academic physicians fall behind t heir full-time colleagues in terms of promotion and tenure.[vi] Academic physicians view part-timer faculty members as less committed, though they concede that part-timers ought to be considered for promotion and even given extra time, if needed, to achieve tenure.[vii]

Conventional wisdom has it that most physicians choose part-time work so that they can balance work with family, and that these physicians are women. The statistics largely support this. But should part-time medicine be solely viewed as the hodge-podge mess that is leftover when women cut their hours to have children? Perhaps part-time medicine is its own entity. Could it be the part-time physician be seen as is another type of clinician—laboring alongside hospitalists, intensivists, pulmonologists, and nephrologists.

Unlike most of my colleagues, I did not become part-time phsysician as a result of children. My career “choice” came about with more bureaucratic banality—a New York City budget crisis that caused a hiring freeze just as I was poised to begin my academic medical career. When the freeze unfroze, there was only a part-time spot available. Working part-time had never once crossed my mind when I had envisioned my career, but there it was: a three-day-a-week offer, nothing else. I was single, unemployed, fresh out of residency with fourteen years worth of student loans coming due. I did the only pragmatic thing and snapped it up, hoping that maybe a full-time position would open up later.

What happened next was entirely unplanned and unexpected. With two days available each week, I suddenly had time to devote my other interests in life—ones that had been decisively extirpated by medical training. I took up dance at a professional school, I began reading literature—not the medical kind—again, and I was finally able to pursue that nagging desire to write down some of the memorable experiences in medical school and residency. I didn’t plan to become a writer, but having those two days away from medicine allowed me to take writing classes and invest serious energy into these efforts.

Some time later, the much-coveted full-time position opened up. Due to the inequities of how part-timers are prorated, my salary stood to double for adding on these two extra days. The thought of instantly having twice as much money was admittedly appealing. But I as I gave thought to what I might want to buy with this extra cash, I realized that the only thing that I would truly wish to purchase, would be the one thing that I could not buy with money—time. So I “bought” myself the time to continue writing by turning down the full-time offer.

To this day, I continue my three-day-a-week schedule. In the interim, I’ve also had three children, and frankly this has usually caused me to consider working more hours rather than less. (Kids aren’t cheap!) But I’ve maintained the part-time schedule and this allowed a second career in writing to have room to develop.

Part-time medicine allows physicians to be a part-time something else, and perhaps this is something that should be recognized in its own right. Obviously, it’s not for everyone, but then again, neither is obstetrics, inpatient medicine, hospital administration, locum tenens, and a host of other options in medicine. In a survey of group practices, 30% of female physicians and 90% of male part-time physicians offered reasons other than family for choosing part-time work.[viii] Some of those doctors may simply be seeking a few extra rounds of golf, but there are others who pursue second careers in law, business, and education. Others are pursuing advanced degrees, and some are investing intense efforts in music, art, and other pursuits.

I am always honest with my patients about my part-time status. I tell them immediately on the first visit that I work part-time; that I am only present in the clinic on three days, and that calls on the other days will not be returned immediately. I explain how to see another doctor in the clinic if their needs can’t wait until I return. And if this is not something they are comfortable with, I offer a referral to a full-time colleague.

I used to preface this little speech with an apology, as though anything less than full-time doctoring was dereliction of duty. But I no longer do that. This is not because I’ve finally achieved the much heralded states of self-justification, rationalization, or even denial. It’s more that I no longer feel that being in medicine part-time is any sort of cop-out. It’s also not any sort of heroism either. It simply is one of the many possible career paths.

I have to be honest with myself and my colleauges that I can’t be—and truthfully don’t wish to be—that doctor who is available 24 hours a day, seven days a week. It’s not necessarily easy to admit this, as it conflicts with our deeply-ingrained image of what doctors are. It also seems, prima facie, to be in conflict with our current situation of a national shortage of primary care doctors. But perhaps more physicians would be willing to take on the grind of primary-care medicine if they knew there was respite on some days of the week.

Of course I have my pangs of guilt—especially when I hear tales of patients unable to find me, resorting to the ER, or another doctor with a conflicting management plan, or waiting too long to seek help. I cringe as these stories of piecemeal medical care unfold, even though I’m aware that my part-time status is only part of the cause. Nevertheless, I have to take responsibility and put in the extra effort to ensure that my patients understand how to obtain care when I’m not available.

Occasionally I will have a patient who politely—or not so politely—takes me up on my offer of another colleague. But that tends to be the exception. Perhaps patients are okay with—or even happy with—a doctor who has a different life outside of medicine. Or maybe they are just appreciative that someone is honest about the realities and limitations of modern medicine and modern life. After all, their lives are also pulled in many directions, and perhaps this is a reassuring admission that we are in the same boat.

When I finally saw Sharon in my office a few weeks later, she just smiled and waved her hand when I reiterated my apology for the missed phone calls. As we proceeded through the visit, I realized that we’d been together for almost seven years, since before she started college, and though the years when she had worked part-time and taken classes part-time, through her hectic nursing training.

That very morning, in fact, had come from a job interview at a prestigious New York hospital. They had offered her a job on the spot, and Sharon was still glowing.

“The best thing about it,” she told me, “is that they’ve done away with the daily 8-hour shifts. Now it’s 12-hour shifts, and I can do three or even two per week.”

I nodded my head as I filled out her pre-employment physical form.

“It’s great,” she said, “because I’ll only have to work two or three days per week.”

“What will you do on the other days?” I asked, signing and stamping the form.

She took the form from me and folded it into her purse. “I don’t know yet,” she said, giving me a thoughtful look. “But there’s a lot of stuff out there besides nursing.”

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[i] Gallagher T . Survey highlights SGIM’s vitality and opportunities for improvement . SGIM Forum . 2004;27(11):1–6 .

[ii] Mulvey H, et al, Abstr Acad Health Serv Res Health Policy Meet. 2002; 19: 9.

[iii] AMGA and Cejka Search 2007 Physician Retention Survey (www.cejkasearch.com)

[iv] Mechabar, H. et al, Part-time physicians…prevalent, connected, and satisfied. Journal of General Internal Medicine. 23(3):300-3, 2008

[v] Parkerton, PH, et al. J Gen Intern Med. 2003 September; 18(9): 717–724

[vi] Socolar RR. Kelman LS. Lannon CM. Lohr JA. Institutional policies of U.S. medical schools regarding tenure, promotion, and benefits for part-time faculty. Academic Medicine. 75(8):846-9, 2000

[vii] Kahn, J. et al., Academic Medicine. 80(10):931-939, October 2005.

[viii] AMGA and Cejka Search 2007 Physician Retention Survey (www.cejkasearch.com)