Abstract
The increasing number of part-time physicians in pediatrics and other specialties has major implications for state medical boards. This study examines the demographic and practice characteristics of part-time pediatricians compared to full-time pediatricians and the implications of these characteristics on licensure requirements. An electronic survey on workforce topics was developed by the American Academy of Pediatrics' Committee on Pediatric Workforce. The survey responses of part-time pediatricians were compared to the responses of pediatricians working full-time. Approximately 31% of the part-time pediatricians plan to continue to work part-time for > 10 years. A small cohort of part-time pediatricians (4.7%) were working < 11 hours per week. The demographic and practice characteristics of part-time pediatricians differ significantly from full-time pediatricians but there was no difference in reported appointment availability between part-time and full-time pediatricians. These findings have implications for the regulatory community regarding the number of hours a physician must work to provide quality patient care and be considered an active physician in good standing. They also have important implications for projecting the number of pediatricians needed to ensure that all children have access to care in the United States.
Introduction
Part-time work schedules and periods of clinical inactivity have become more common among physicians today, especially in pediatrics, where almost one in eight pediatricians has suspended clinical care for more than a year and the percentage of pediatricians who work part-time has been increasing.1,2,3 However, there has been little research on physician clinical inactivity and part-time work and the implications for regulatory agencies. Because the medical practice characteristics of part-time pediatricians and clinically inactive physicians has major implications for the pediatric workforce and the policies of regulatory agencies, we conducted a focused analysis of the American Academy of Pediatrics (AAP) Committee on Pediatric Workforce's (COPW) State Pediatrician Workforce Survey on the work life of part-time pediatricians and compared these characteristics with pediatricians who are working full-time.
Patients and Methods
The Workforce Survey was developed by the COPW and consisted of 61 questions on a variety of workforce topics, including questions on part-time practice and clinical activity. The survey was sent electronically to 44,850 U.S. pediatricians who are members of their state AAP chapters. In this survey, a part-time pediatrician was defined as a pediatrician who worked 26 hours or less per week. We chose this definition of part-time practice because it is approximately half the number of hours that has been reported for full time pediatricians.4 The survey question used to define part-time was “Are you currently working in a reduced hour or part-time position?” A qualifier was added to this question as follows: “For the purposes of this survey, reduced hours or part-time position means working 26 hours or less per week in any combination of professional activities.” Respondents who answered “yes” to this question were included in the part-time cohort and those who answered “no” were included in the full-time cohort. Respondents who reported they were retired or in training (medical school, residency, or fellowship) were excluded from the cohorts.
...ALMOST ONE IN EIGHT PEDIATRICIANS HAS SUSPENDED CLINICAL CARE FOR MORE THAN A YEAR AND THE PERCENTAGE OF PEDIATRICIANS WHO WORK PART-TIME HAS BEEN INCREASING.
Data were analyzed using SPSS 18.0. Statistical significance of associations was tested using chi square for categorical data and Student's t-test or anova for continuous variables, as appropriate. Due to the large sample size, we restricted reporting of statistical significance to relationships with p < .01. This study was deemed exempt by the institutional review board of the AAP.
Results
The survey was completed by 8,867 pediatricians for an overall response rate of 19.8%. The background characteristics of all the respondents are shown in Table 1. The gender and age distribution of respondents was similar to the AAP membership. Respondents who were in training (n = 1,077), retired (n = 490) and those who did not answer this question (n = 193) were excluded from further analysis (Table 1). Of the remaining 7,107 respondents, 328 did not respond to the question on part-time status (Table 1). Table 2 compares the demographic and practice characteristics of these 6,779 respondents who reported working either full-time or part-time. There were 891 respondents who reported that they were currently working part-time. Twenty-five percent of these 891 pediatricians reported working 20 hours or less per week and 4.7% reported working < 11 hours/week.
APPROXIMATELY 31% OF THE PART-TIME PEDIATRICIANS PLAN TO CONTINUE TO WORK PART-TIME FOR > 10 YEARS. THE ANTICIPATED DURATION OF PART-TIME WORK VARIED SIGNIFICANTLY BY PHYSICIAN AGE.
Background Characteristics for All Respondents N = 8867a
Demographic and Practice Characteristics of the Full–time and Part–time Pediatricians N = 6779a,b
Eighty percent of the part-time pediatricians (n = 684) were women, whereas 53% of the full-time pediatricians (n = 2,975) were women (?2 = 222.1, p < .001). Part-time pediatricians were significantly more likely to report that they attended medical school in the United States (93% vs. 89%, ?2 = 12.2, p < .01). The age distribution of the part-time pediatricians was significantly different from the full-time pediatricians (?2 = 151.9, p < .001), most notably in the over-representation of pediatricians over the age of 65 in the part-time group. Part-time pediatricians reported being in practice significantly longer than full-time pediatricians (19.8 vs. 18.1 years, F = 17.7, p < .001) (data not shown).
Significantly fewer part-time pediatricians reported working in academic medicine (26% vs. 39%, ?2 = 51.1 p < .001) and these academic part-time pediatricians were significantly less likely to be on a tenure track than the full-time academic pediatricians (?2 = 9.6, p < .01, Table 2). The proportion of women working part-time in academic medicine was distributed across all age groups but 88% of the men who were working part-time in academic medicine were > 55 years old. The principal practice setting for part-time pediatricians was significantly different from the practice setting of the full-time pediatricians (?2 = 95.1, p < .001). There was no significant difference between part-time and full-time respondents in the wait times for existing patients for a non-emergency appointment (Table 2). There also was no significant difference between part-time and full-time respondents in the wait times for new patients or procedures.
THIRTY-SEVEN PERCENT OF WOMEN CURRENTLY WORKING PART-TIME ANTICIPATED WORKING PART-TIME FOR >10 YEARS WHEREAS ONLY 6% OF MEN CURRENTLY WORKING PART-TIME ANTICIPATED WORKING PART-TIME FOR > 10 YEARS.
Among the part-time physicians, 87.3% (n = 804) were in clinical practice. These part-time pediatricians were significantly more likely to be providing primary care services (e.g., general pediatric care) than the full-time pediatricians in clinical practice (F = 80.3, p < .001). The part-time pediatricians reported spending a significantly greater proportion of their time providing direct patient care (e.g., caring for patients) (82.4% vs. 75%, F = 52.1, p < .001) and a significantly lower proportion of their time on health care administration (9.2% vs. 13.5%, F = 27.3, p < .001) and research (2.9% vs. 7.4%, F = 39.3, p < .001) than full-time pediatricians. There was no significant difference in the proportion of time spent in teaching and precepting (7.6% vs. 7.8%, ns) (Table 2).
Approximately 31% of the part-time pediatricians plan to continue to work part-time for > 10 years. The anticipated duration of part-time work varied significantly by physician age (?2 = 203.1, p < .001). Among part-time pediatricians < 40 years, 46% anticipated working part-time for > 10 years and 52% of part-time pediatricians who were 41–50 years old anticipated working part-time for > 10 years. Among part-time pediatricians 51–60 years old, 28% anticipated working part-time for > 10 years and among pediatricians > 60 years old, 3% anticipated working part-time for > 10 years. The anticipated duration of part-time work also varied significantly by gender (?2 = 85.8, p < .001). Thirty-seven percent of women currently working part-time anticipated working part-time for > 10 years whereas only 6% of men currently working part-time anticipated working part-time for > 10 years.
Discussion
Our survey has identified several key findings regarding part-time physicians that have important implications for the pediatrician workforce and regulatory agencies. Part-time pediatricians are most likely to be providing primary care services and spend a greater portion of their time providing direct patient care but less time on health care administration and research than full-time pediatricians, perhaps because they are less likely to be working in academic medicine. Most (87.3%) are in clinical practice and therefore need to maintain their cognitive and procedural skills in order to provide high-quality care. We also found that many younger pediatricians are planning to continue to work part-time for much of their medical career but older part-time pediatricians are anticipating continuing to work part-time for only a few years, perhaps as a transition to retirement.
IN OTHER PROFESSIONS, REDUCING HOURS AS ONE NEARS RETIREMENT AGE IS COMMON AND OUR STUDY DEMONSTRATES THAT BOTH MEN AND WOMEN ARE REDUCING THEIR HOURS AS THEY AGE AND NEAR RETIREMENT.
Many previous studies have attributed the growth of part-time practice to the increasing number of young women in medicine.5,6,7 Our survey shows that women in all age groups are practicing part-time. While our findings confirm those of other surveys, which showed that part-time physicians are more likely to be women,2,3,5 we found that among older pediatricians the number of men and women working part-time is similar. In other professions, reducing hours as one nears retirement age is common and our study demonstrates that both men and women are reducing their hours as they age and near retirement.8 Thus, our findings support the conclusions of Cull that the increased number of part-time pediatricians is potentially due to demographic and social factors that are occurring across all age ranges.1
Although previous studies have suggested that part-time practice may be a temporary career choice,2 we found that a large percentage of part-time pediatricians < 56 years old anticipate continuing to work part-time for > 10 years. These findings suggest that part-time practice is a long-term career choice for many younger physicians that may have important implications for regulatory agency policies regarding continuing medical education requirements, patient follow-up, and maintenance of clinical skills. In order to appropriately develop these policies, regulatory agencies need to define part-time clinical practice and have policies in place that ensure that part-time physicians are working enough to maintain their clinical skills and provide quality care.
Although our survey did not include questions on satisfaction with part-time practice, previous studies have shown that part-time physicians are often more satisfied in both their personal and professional life than full-time pediatricians.1,5,9 There are many factors that might influence a physician's desire to work part-time, including family responsibilities, health reasons, and desired lifestyle.8,10 Additionally, the issue of reentry into clinical practice continues to be of interest to state medical boards. Among inactive physicians, a primary reason cited for returning to work is the availability of part-time work and flexible work schedules. In addition, the availability of part-time work may result in fewer active physicians leaving the workforce.6,10 Thus, availability of part-time positions may contribute to increasing the pediatrician workforce by encouraging those who may have considered leaving practice completely to instead maintain a sufficient level of their clinical activity and their medical licensure.
AMONG INACTIVE PHYSICIANS, A PRIMARY REASON CITED FOR RETURNING TO WORK IS THE AVAILABILITY OF PART-TIME WORK AND FLEXIBLE WORK SCHEDULES.
Factors that may influence an academic physician to work full-time include financial needs, availability of part-time positions, and concerns about career advancement. Further studies are needed to determine if the anticipated duration of part-time work reported by our respondents is accurate since financial, personal, and professional factors may cause pediatricians currently working part-time to increase their hours.
Our survey also revealed that academic pediatricians were less likely than non-academic pediatricians to be working part-time. A recent study reported that 6% of medical school faculty members reported that they were working part-time (0.5 FTE or less).11 The limited availability of part-time positions in academic settings and the failure of academic institutions to develop promotion or tenure policies that provide opportunities for part-time pediatricians to advance their careers have been cited as reasons for the small percentage of part-time academic physicians.9,12,13 Our survey found that full-time academic pediatricians were twice as likely to be on a tenure track than the part-time academic pediatricians. Because a large percentage of young physicians want to work part-time, academic institutions will risk losing the opportunity to hire and retain talented young physicians if they fail to develop flexible work schedules and promotion policies.3 In addition, flexible work schedules will help increase faculty diversity since women are especially interested in part-time careers and such schedules allow academic institutions to retain older, experienced pediatricians who might prefer a part-time position to full retirement.13
FACTORS THAT MAY INFLUENCE AN ACADEMIC PHYSICIAN TO WORK FULL-TIME INCLUDE FINANCIAL NEEDS, AVAILABILITY OF PART-TIME POSITIONS, AND CONCERNS ABOUT CAREER ADVANCEMENT.
One of the concerns often expressed about part-time physicians is that they will be less available to their patients.5 However, there was no significant difference between part-time and full-time pediatricians in reported appointment availability for new or existing patients and procedures reported in our survey. Our findings differ from those of Panattoni, who found that in a group multispecialty clinic, access to care was directly associated with physician full-time equivalents. However, the Panattoni study did not include pediatricians, and despite less appointment availability, patients in the study reported greater satisfaction with part-time physicians than full-time physicians.14
In our survey, we found that part-time pediatricians spent a significantly higher proportion of their time providing direct patient care than full-time pediatricians and proportionately less time on health care administration and research. These findings may be due to the lower percentage of part-time pediatricians who are working in an academic setting where research and hospital committee work may be expected and time allotted for this work. Further research is needed to determine if the higher proportion of time spent in direct patient care by part-time pediatricians is by choice or due to policies in their work setting that preferentially assign them to more direct patient care responsibilities and less administrative or research work. In addition, the higher proportion of time that part-time physicians spend in direct patient care may mean that they are more likely to maintain their clinical skills at a sufficient level to provide high-quality care than some physicians who are working more hours/week but spend less of their work hours on direct patient care. Since part-time pediatricians often provide more than half of the patient care workload of full-time pediatricians, these findings need to be considered when calculating the impact of part-time work on pediatrician workforce shortages. Advocating for increased opportunities for part-time work and flexible hours by those in the regulatory community as well as specialty societies may be one way to help pediatricians stay in the workforce. In its 2012 Report of the Special Committee on Reentry to Practice, the Federation of State Medical Boards noted that “All entities that depend on physicians to provide clinical care should be encouraged to accommodate individuals who are interested in returning to clinical practice but who may need flexible or part-time scheduling.” However, regulatory boards will need to assure the public that physicians who choose to work part-time are remaining clinically competent and thus can provide high-quality care despite their part-time work schedules.15 This important endeavor should be undertaken in collaboration with state and medical specialty associations and other relevant organizations.
ADVOCATING FOR INCREASED OPPORTUNITIES FOR PART-TIME WORK AND FLEXIBLE HOURS BY THOSE IN THE REGULATORY COMMUNITY AS WELL AS SPECIALTY SOCIETIES MAY BE ONE WAY TO HELP PEDIATRICIANS STAY IN THE WORKFORCE.
One of the strengths of this survey is the number and diversity of our respondents. This is one of the largest surveys of part-time physicians published to date and included primary care pediatricians, pediatric medical sub-specialists and pediatric surgical specialists from every state and practice setting. Further research is needed to determine if regulatory agencies need to develop different policies for part-time physicians than those who work full-time, especially if the percentage of time spent in clinical practice is limited to only a few hours per week.
There are some limitations to our study. Because our respondents included only pediatricians, our findings may not be generalizable to physicians in other specialties. It also may be difficult to compare our results with many previous surveys, because in most previous studies part-time practice was self-defined.1,3,9,10,11 Our response rate was not optimal, but it is within the expected range for a web-based survey of physicians, where response rates of under 20% are not uncommon.15 And, since our survey was anonymous, we are not able to compare respondents with non-respondents, which might impact findings. In spite of these limitations, it must be stressed that the overall numbers in this study represent a very large cohort of both part-time and comparison full-time pediatricians representing the entire age and geographic spectrum.
Conclusion
This analysis of the AAP COPW State Pediatrician Survey data on part-time pediatricians expands our understanding of the medical practices of part-time pediatricians in the United States today. Our survey demonstrates that part-time pediatricians are most likely to be providing primary care and are less likely to work in academic medicine or conducting research. Our findings also suggest that many younger pediatricians are planning to continue to work part-time for much of their medical careers and that among older pediatricians, part-time practice may be a part of eventual transition to retirement.
These findings have important implications for projecting the number of pediatricians needed to ensure that all children have access to care in the United States. The percentage of pediatricians working part-time, their practice locations and types of practice must be factored into our projections of the number of pediatricians our nation needs to be able to provide appropriate pediatric clinical care, conduct pediatric research, and train the future pediatric workforce. We can no longer simply count the number of active U.S. pediatricians to determine if our pediatrician workforce is sufficient to meet the health care needs of our children since so many pediatricians are currently working part-time.
Our study also has implications for pediatric practices and academic institutions. The increasing number of pediatricians seeking part-time work will require that more flexible work schedules, equitable personnel policies, and opportunities for advancement of part-time pediatricians be developed in order to recruit and retain pediatricians. For pediatricians who wish to work part-time, these findings also may be helpful in their career planning since part-time positions currently are more likely to be available in ambulatory settings and less likely to be available in academic centers. Many state medical boards have part-time, temporary, or limited licenses that would meet the needs of physicians who wish to work part-time. Our study provides a rationale for investing the time to provide guidance on part-time employment, and possibly part-time licensure. The state medical board is ideally suited to serve as a resource and to encourage communication with physicians who desire to continue to practice, but seek to work part-time or reduced hours.
OUR STUDY PROVIDES A RATIONALE FOR INVESTING THE TIME TO PROVIDE GUIDANCE ON PART-TIME EMPLOYMENT, AND POSSIBLY PART-TIME LICENSURE.
About the Authors
↵Mary E. Rimsza, MD, FAAP, is Immediate Past Chair of the American Academy of Pediatrics' Committee on Pediatric Workforce.
↵Holly Ruch-Ross, PhD, is Research Consultant, Division of Workforce and Medical Education Policy at the American Academy of Pediatrics.
↵William B. Moskowitz, MD, FAAP, is Professor, Pediatrics and Medicine, Chief, Pediatric Cardiology at The Children's Hospital of Richmond at Virginia Commonwealth University.
↵Harold K. Simon, MD, MBA, FAAP, is Marcus Professor of Pediatric Emergency Medicine and Faculty Development Vice Chair for Faculty Affairs, Department of Pediatrics at Emory University.
↵Kelly Towey, MEd, is Co-Director for the Physician Reentry into the Workforce Project at the American Academy of Pediatrics.
↵Holly J. Mulvey, MA, recently retired as Director, Division of Workforce and Medical Education Policy at the American Academy of Pediatrics.
- Copyright 2017 Federation of State Medical Boards. All Rights Reserved.
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