Published in the May 2014 issue of Today’s Hospitalist
ASK Thomas McIlraith, MD, how he feels about part-time hospitalists, and he’ll admit to a recent 180-degree about-face.
In his first hospitalist practice more than a decade ago, Dr. McIlraith found that the “special deals” offered to part-timers were toxic to group dynamics, and that having part-timers raised too many fairness issues. He vowed that he would never make the same mistake: Everyone would work the same number and type of shifts, see the same number of patients, and contribute equitably to the group.
Plus, he worried about clinical competence. “I’ve often wondered if you can do this job part time and stay on top of all the changes that constantly come through the pipeline,” Dr. McIlraith says. “Practicing hospital medicine as an occasional thing, you aren’t going to be as effective. Everything changes all the time: the two-midnight rule, the latest core measures, corporate initiatives, the EMR. Everything.”
But last year, in his role managing more than 60 hospitalists as chair of hospital medicine at Dignity Health’s Mercy Medical Group in Sacramento, that philosophical bias ran headlong into reality. That’s when several senior physicians who had been with the group for more than a decade wanted to cut back on their hours.
“They have contributed so much for so long, and they deserve an accommodation,” he explains. “I wanted to show these people respect.”
Dr. McIlraith did reduce their hours, but on the condition that the newly part-time hospitalists agreed to pick up a number of extra shifts during the busiest months of the year. During peak times, the physicians will work full time on a temporary basis.
While working part time may be growing in popularity, part-time hospitalists can present significant management challenges. Dr. McIlraith’s solution “asking part-timers to compromise on their preferred schedule to meet coverage needs “is just one way programs around the country are trying to make part-time staff work for them.
Part-time ground rules
According to the 2013 Today’s Hospitalist Compensation & Career Survey, 11% of respondents work part-time “and hospital medicine has the reputation of being particularly attractive to part-timers. (See “Who works part time?” on page 31.)
But being attractive to doctors and effective for groups aren’t always one and the same. While part-time arrangements may be great for doctors who can forgo full-time incomes, they can cause problems for groups, hospitals and even patient care.
Some hospitalist programs schedule part-timers only when continuity is less of an issue, like during nights, weekends or admitting-only shifts. Or they make part-timers work a disproportionate number of weekend shifts. Nearly all say that part-timers work best when they are onsite several days in a row.
Working contiguous days, explains Edward Ma, MD, a hospitalist at the Coatesville, Pa., Veterans Affairs Medical Center, allows hospitalists to “get into the zone.” Despite working fewer hours, they get to know patients, practice efficiently, minimize handoffs and maximize continuity of care.
Sources say that another problem is that part-time physicians may act more like moonlighters or per-diem hospitalists than salaried employees. The difference can mean lower levels of team commitment, suboptimal communication and less investment in improving the hospital system.
“Some of that is physician-dependent, based on a doctor’s personality,” explains David Handin, MD, director of the hospital medicine service at Emerson Hospital in Concord, Mass. “The question of engagement and investment is the biggest challenge of having a lot of part-timers.”
In 2012, for instance, his group adopted a financial incentive for participating in a committee and attending meetings over the year. But one part-time staff member decided to ignore the extra compensation she could have earned. “She didn’t want to do it, and she didn’t get a bonus for doing it,” Dr. Handin says. Instead, that incentive went to other members of the group.
And “one of my frustrations is people who don’t read their e-mail or they are not around,” he notes. While Dr. Handin points out that those problems aren’t exclusive to part-timers, “it seems that they are less engaged in the day-to-day processes and may treat the job a little more like shiftwork.”
Part-timer, not per-diem
The challenge, says Albert Langou, MD, interim director of hospital medicine at the Eastern Connecticut Health Network and a hospitalist at ECHN’s Manchester Memorial Hospital in Manchester, Conn., is “making sure a part-timer doesn’t become a per-diem”-type hospitalist, who works only random shifts and tends not to be a true team member.
To that end, part-time hospitalists in his group commit to working as a 0.75 full-time equivalent (FTE) instead of only half time. They also agree to work a minimum of three shifts in a row.
“You have to have a structured schedule. That’s the secret,” says Dr. Langou. “For instance, our 30-hour part-time hospitalists work Friday-Saturday-Sunday or Saturday-Sunday-Monday, so they can be paired with someone who works four 10-hour shifts.” That way, he adds, “there are no issues about continuity of care and no length-of-stay issues.” It becomes like a job-share.
In his experience, hospitalists who work only two days a week “say, a weekend “”aren’t as vested in the program” as hospitalists who are around more. “They don’t attend staff meetings, and they may not use the same communication tools as the rest of us.”
Dr. Langou gives this example: Because part-timers are not in the hospital that much, some prefer to use their personal e-mail accounts rather than the hospital’s. “That can make them harder to communicate with,” he explains.
And having too many part-timers, he adds, ironically can cause a group to need more per-diems. As Dr. Langou explains, when a part-timer is away on vacation or sick, per-diem coverage is usually the only recourse.
Like Dr. Handin in Massachusetts, Dr. Langou has also seen part-time hospitalists blow off incentives that encourage extra work and improve quality.
“A tendency that I have seen is that our part-timers are not as interested in hitting our incentive bonus as our full-timers are,” Dr. Langou says. “They ask, ‘Is it really worth my time and effort to go after a couple thousand dollars?’ ”
The more, the better
While some program directors express concerns about part-timers, others happily depend on a growing number of them. In Albany, N.Y., for instance, the hospitalist group at St. Peter’s Hospital consists of 12 full-time doctors and 12 part-timers.
“I find advantages to having lots of part-timers,” says Thea Dalfino, MD, chief of hospital medicine. For one, part-time hospitalists “tend to be happier. They are not overworked.” That means that part-timers are more likely to say “yes” when the group is short-staffed and they are called to come in.
“The part-timers are our go-to people,” says Dr. Dalfino. “When you are off after working full time, if you are asked to do any more, you are going to scream. But if you have had a couple of days off, you will do it.”
That’s not to say there shouldn’t be any limits or that some part time is too part time.
“If you are working less than 20 hours a week, are you really providing the best patient care?” she asks. That question came up recently when one group member announced his intention to retire. While he had been working a 0.7 FTE, Dr. Dalfino tried to convince him to further cut back on his hours but stay with the practice.
“He didn’t want to work less than that because he didn’t think he would be able to keep up on the medicine well enough. I have been thinking about that lately.”
Moreover, she says, she can imagine fairness problems popping up “not to mention scheduling hassles “if an even greater proportion of group members switched to part time.
“It’s hard to have all our doctors want to cut back because that means they work fewer nights and weekends,” she says. To encourage people to work full time, her group this year implemented what it is calling a “retention bonus.” Doctors who worked full time the preceding year earn a significant bonus in addition to their quality and productivity incentives.
While part-timers may be happier, she points out, “I still have to have people work full time, and people truly committed to our program should be rewarded. This is a thank you for not cutting back.”
The question of group morale
Dr. Dalfino also explains that paying attention to full-timers’ perceptions of fairness is critical for group morale.
Group members realized, for instance, that they could earn more as a part-timer earning overtime for working extra shifts than as a full-timer working the same number of shifts. When she figured out what was happening, “we changed our compensation structure so that you can’t make the overtime rate until you work a certain number of hours in a pay period,” she notes. “Most of my job is trying to outsmart very smart people.” She herself has always worked part time and is currently a 0.9 FTE, giving herself a little extra time at home with her four young children.
William T. Ford Jr., MD, director of the hospitalist program at Abington Health in suburban Philadelphia, oversees hospitalists at both Abington Memorial Hospital and Lansdale Hospital. He believes that part-timers enrich hospital medicine.
“I am a large proponent of hiring part-time physicians because there are a lot of good people out there who want to work part time,” says Dr. Ford.
In his view, groups that close themselves off from that pool of potential candidates hurt their ability to recruit and retain great doctors. Not only are part-timers a “valuable commodity,” he notes, but “whatever reason they want part time usually goes away over time, and then you are looking at a good partner who you can make full time again.”
Having a roster of part-timers reduces his need to hire doctors when his group is short-staffed. And part-timers are a necessary adjunct to full-time hospitalists who work seven-on/seven-off and who never want to work during their days off.
“If you call a part-timer who just did three shifts last week, he or she will say, ‘OK, I can work two extra days,’ ” Dr. Ford points out. “It’s not because they are better people. It’s because seven-on/seven-off is brutal, and part-timers are not suffering from that brutality.”
The only reason his group doesn’t have more part-timers on staff, Dr. Ford says, is because many of them have academic appointments, and the residency program prefers its supervising attendings to work full time to provide continuity for trainees.
Like California’s Dr. McIlraith, Dr. Ma at the Coatesville VA Medical Center took a while to warm to the idea of part-time hospitalists. That change happened in large part, he says, because part-timers provide “a welcome break for the full-timer” “a benefit that usually outweighs their limited working hours and lower level of engagement.
This is particularly true, he says, when it comes to weekends. Not only can part-timers provide more dependable, higher quality weekend coverage than moonlighters due to their psychological investment in the group, but having them around increases the pool of physicians available to cover weekends.
Dr. Ma points out that the majority of full-time community hospitalists work every other “or, at best, every third “weekend, which is really tough on personal and family life. By adding part-timers, a practice can reduce that weekend burden and improve retention.
“At my former practice, I recruited a fantastic doc to work five shifts every two weeks “and three of those five shifts were weekend nights, the absolute least desirable shifts,” he says. “That was a huge boon to our physicians.”
Moreover, bulking up staff with part-timers paid off in political dividends. It made “our group look bigger,” he says, “and arguably more powerful” in the hospital.
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
Who works part-time?
ACCORDING TO A SURVEY by the American Medical Group Association and the recruiting firm Cejka Search, about 36% of women physicians (across all specialties) and 13% of men in 2010 practiced part time. Survey results indicated that women doctors overwhelmingly chose part-time positions because of “family responsibilities.” Men said they did so largely because they were “preparing for retirement” or because of “unrelated professional or personal pursuits.”
About 11% of those responding to the 2013 Today’s Hospitalist Compensation & Career Survey reported working part time. That included 16% of female respondents and 8% of men.
The Today’s Hospitalist survey also found that part-time hospitalist careers can be quite lucrative. Part-timers treating adults reported working on average only two-thirds the number of hours as their full-time colleagues. However, they earned on average 75% of what full-timers reported. Part-time hospitalists responding to the survey worked an average of 11.6 shifts per month and earned a mean compensation of $197,200.
In addition, survey results indicated that part-timers were much more likely to report working daytime shifts. In addition to being female, they were also more likely to be found at larger hospitals, to be older and to not work in the South. They also reported being slightly more satisfied with their career and their current compensation than their full-time colleagues.