ABSTRACT
Physician reentry into the workforce can be defined as returning to professional activity/clinical practice for which one has been trained, certified or licensed after an extended time period away. Little data and information on this topic exist; however, the American Academy of Pediatrics, in conjunction with the Association of American Medical Colleges, sent a survey to 1,600 pediatricians aged 50 and older that included information on extended leaves of absence from clinical practice, retirement patterns, and considerations/preparation to reenter the workforce. Data from this group showed that extended leaves of absence are not tied to generalist or specialist practice, career satisfaction, or desire for a part-time practice arrangement. Women were more likely than men to take extended leaves of absence from clinical medicine, and these leaves were longer than those for men. Additionally, very few reentering pediatricians had any retraining before returning to practice. In the future, policymakers, educators, state medical and osteopathic boards and others will need to collaborate to design a reentry system that addresses physician readiness to return to the workforce — as well as patient safety issues — and to tailor education to the needs and focus of individuals reentering physician's practice.
Keywords:
Introduction
Many physicians leave practice and then wish to reenter the physician workforce after a significant period of time away from clinical medicine. Physician reentry into the workforce can be defined as returning to professional activity/clinical practice for which one has been trained, certified or licensed after an extended time period. This issue, which was first examined in detail by Mark and Gupta in JAMA in 2002,1 cuts across genders and specialties. There are a myriad of stated reasons for leaving and reentering the workforce, ranging from child rearing or caring for elderly relatives to career dissatisfaction and the high cost of medical liability insurance premiums. Another category of reentry physicians includes those who initially retired from practice and later, for reasons ranging from financial to personal preference, seek to return to the workforce.
Reentry is to be differentiated from remediation, which is a disciplinary intervention to address a departure from practice due to a breach of medical ethics, substance abuse, loss of one's medical license, or similar issue. Reentry is also different from retraining, which may not be part of the reentry process, as in the case of physicians who train in a new discipline, such as a subspecialty, without leaving their current practice. Jacoby et al, for example, explored the possibility of retraining specialist physicians to deliver primary care during the managed care push of the mid to late 1990s.2 There is little information and data on physician reentry in the medical literature. The American Medical Association (AMA) Masterfile notes that in 2008, there were 119,238 inactive physicians in the United States, which accounts for 12% of the 954,224 physicians in the Masterfile.3 At present, it is unclear how many of these physicians left the workforce with the desire or intention of returning at some point in the future. Those who do wish to return are likely to face systemic barriers, including educational needs, state licensure, board certifica-tion restrictions, financial constraints, and verifica-tion of clinical competence. Even physicians who have remained active in the medical profession in research, teaching, or administration are likely to face challenges if they seek to return to clinical practice.
Few state- or specialty-specific studies have been conducted to document the trends of physician reentry, including the reasons and demographic characteristics of those who leave and attempt to reenter the workforce. In a study of Arizona physicians between 2003 and 2006 conducted by Rimsza et al, it was noted that of the 604 physicians reentering clinical practice, 62 (10%) had changed the specialty focus of their practice since the last time they were clinically active. More than half of these physicians changed their specialty designation from obstetrics to gynecology, but there was also some migration among primary care specialties and from primary to subspecialty care.4
Public policy discussions have increasingly focused on physician reentry in recent years, because of its impact on many elements of health care, ranging from education to patient safety to the regulatory system. Physicians who exit the workforce represent a loss of the costly public investment in medical education, as well as a loss to the health care system of the clinical and intellectual capital of these physicians. When these physicians seek to return to practice, a host of questions are raised about assessing their clinical competence, their need for some kind of reentry education, the ability of state medical and osteopathic boards to document reentering physicians' readiness to resume practice, and a wide range of liability issues. With no formal or centralized reentry system, however, such questions remain largely unanswered.
Methods
The American Academy of Pediatrics (AAP), in conjunction with the Association of American Medical Colleges and eight medical associations, conducted a cross-sectional survey examining physician reentry in 2006. Questionnaires were mailed to 1,600 pediatricians aged 50 and over up to three times between February and May of 2006. Members of the AAP Senior Section — which is open to AAP members over the age of 55 (N = 730) — and 870 randomly selected good-standing members of the AAP who were over the age of 55 but not members of the senior section were surveyed. This project received approval from the Institutional Review Board (IRB) at the AAP. No remuneration was provided to respondents. Valid responses were collected from 72% (N = 1158) of the pediatricians surveyed.
Tests comparing sample respondents with all members in the sample, and comparing sample respondents with all AAP members over the age of 50 revealed that the respondent population is older (mean age = 68) than the AAP over-50 population (mean age = 60) (t(23107) = 24.81, p < .000).
The respondents are also more likely to be male (73%) than the target population (66%) χ2 (1, N = 22917) = 29.47, p < .001. Therefore, sampling weights were calculated to reflect the appropriate proportional representation of AAP members over the age of 50. These weights were used for all analyses reported here.
This survey asked questions regarding work status, work history, education, and demographic information. Leave of absence was measured by asking respondents whether they ever took a six-month or longer leave of absence from medicine. Those who reported having taken a leave of absence were asked how long it lasted and the reasons for taking a leave. They were also asked whether the leave was to care for children or other family members and whether they received any retraining prior to reentering medicine.
Desire for part-time work was measured by asking respondents whether they would prefer to work part time if part-time hours were available. Respondents rated their satisfaction with medicine as a career on a five-point scale. They were asked to indicate whether they owned their practice and whether they practiced primary care pediatrics or a pediatric medical or surgical subspecialty.
Respondents who reported their current work status as “retired” were asked whether they ever considered reentering medicine, their reasons for considering reentry, and whether they retired earlier than planned or expected.
Statistical Analyses
A series of t-tests were performed to reveal group differences in extended leave. A series of chi-square comparisons examined group differences in extended leave and reentry. One logistic regression was conducted to predict extended leave taking. For all analyses a p value under .05 was considered statistically significant.
Results
Overall, 2% of the sample described their current status as “temporarily inactive from medicine,” and 11% reported having taken an extended leave at some point in their career. Length of leave ranged from 6 months to 13 years with an average duration of 22 months and a median duration of 12 months.
Women (23%) were more likely than men (5%) to report that they had ever taken a leave of absence from medicine χ2(1, N = 1109) = 87, p < .001. The average leave was longer for women (27 months) than it was for men (11 months; t(104) = 3.953, p <.001).
Taking a leave of absence was less common among practice owners (5%) than among non-owners (15%) χ2(1, N = 908) = 24, p < .001, but was equally as likely for specialists and generalists χ2(1, N = 1086) = 0, p = .98.
These differences remain significant when tested in a multivariate framework. A logistic regression examined the associations between taking a leave of absence and gender, ownership status and specialist status. As depicted in Table 1, women have higher odds of taking an extended leave, and practice owners have lower odds of taking an extended leave. Of those who took an extended leave of absence, 54% reported that they took time off “to care for children or other family members,” and 23% reported having retrained before reentering medicine.
Logistic Regression Predicting Extended Leave
Women were more likely than men to use their time off for family care χ2(1, N = 121) = 42, p < .001, but were equally as likely as men to retrain prior to reentering medicine χ2(1, N = 113) = 0.98, p = .321.
Pediatricians who reported having taken a leave of absence are not different from other pediatricians over the age of 50 in terms of satisfaction with medicine as a career (t(939) = 0.240, p =.810) or in terms of desiring but having no access to part-time hours in their current work setting χ2(1, N = 883) = 3.13, p = .077. Among the retired pediatricians in this sample, 37% expressed interest in reentering medicine. Those who retired earlier than they had planned or expected were more likely to express interest in reentering medicine (50%) than those who retired at their planned age or later (30%) χ2(1, N = 154) = 5.68, p = .022. When asked to endorse reasons they considered reentering, retirees selected “miss caring for patients” more than any other reason. Other reasons for interest in reentering among retirees are listed in Table 2.
Reasons for Interest in Reentering Medicine Among Retired Pediatricians
Discussion
The data from this survey clarifies a number of trends regarding physician reentry, particularly regarding the demographic attributes of those who take an extended leave of absence. It is logical that practice owners were less likely to take extended leaves of absence than non-owners. Practice owners' responsibility to attend to the administrative aspects of the practice, provide adequate coverage for service demands, and ensure the continuity and quality of patient care would make it difficult for them to take substantial time away from practice. It is noteworthy, however, that extended leaves of absence were not tied to either generalist or specialist practice, career satisfaction, or the desire for a part-time practice arrangement.
Perhaps most significant for pediatrics are the find-ings related to gender differences. Data from the American Academy of Pediatrics demonstrates that in 2009 women constituted almost 55% of nonresident pediatrician members. In the same year, approximately 72% of all pediatric residents were women.5 These are highly significant statistics in light of this survey's results, which document that women are more likely to take extended leaves of absence, and that these leaves of absence are longer than those for men. From a workforce perspective, the number of pediatricians required to meet workforce needs will depend on the clinical intensity of those working and the patterns of their exit and reentry into practice.
In order to accommodate the needs of the growing number of women pediatricians, particularly those relating to caring for other family members, it will be necessary for both pediatric training and practice to become more flexible. In particular, educators, employers, professional associations, and others should develop strategies to assist women pediatricians in continuing at least a minimal level of clinical and professional activity while they are caring for family members to obviate the need for a full-scale reentry experience. For those pediatricians who do choose to leave the workforce altogether, resources to help them reenter the workforce will need to be developed and, of greater importance, promoted.
Interest in reentering the workforce, however, is not uniquely related to gender. The survey data also demonstrated that retired physicians were moderately to highly interested in returning to practice. For these physicians, interest in returning to practice was not related to financial need or some other market driver. Vocational or identity issues of being a physician, such as missing caring for patients, wishing to respond to a need in the community, and missing colleagues or the practice environment, proved to be highly determinative in their interest to return to practice. Reentry is, therefore, an issue not only of the public's or health care system's investment in the education and formation of the pediatrician, but also of the pediatrician's investment in the practice of medicine and the provision of patient care. Policymakers and state medical and osteopathic boards should embrace the idea that leaving and reentering the workforce is part of many physicians' career trajectories and not an odd or unusual situation. Any structured reentry system will, therefore, need to provide a portal for pediatricians who have retired to contribute to the profession and the needs of the pediatric patient population in a meaningful way.
One area of serious concern identified by the survey was the lack of reentry training before returning to practice. This is likely due to the absence of any standardized and accepted reentry pathway, and consequently, the administrative, financial, logistical and other barriers involved in crafting a personally tailored and relevant reentry experience. Nonetheless, this finding is concerning in an era when the public demands accountability for health care quality and safety. This may, in fact, put an additional burden on state medical and osteopathic boards, which, in turn, may need to aggressively develop plans to address reentry issues. Of equal importance, these state boards will need to proactively communicate policies to the physicians in their state. State medical and osteopathic boards could provide easy access to up-to-date information on changes in policies and/or procedures (theirs and possibly those of other regulatory groups in their state) that may affect physicians seeking to reenter the workforce, perhaps by being able to opt-in for electronic alerts when changes occur. Physicians who are contemplating leaving the workforce, as well as those who are planning to reenter clinical practice, will need guidance from their state boards.
This study has several limitations. Because only pediatricians aged 50 or over were surveyed, the gender differences may be greatly reduced for younger generations of pediatricians. Indeed, lifestyle issues may be more determinative for younger generations than the respondents in this study. Professional satisfaction, the clinical demands of subspecialty practice, the desire for part-time practice, and other lifestyle considerations have been demonstrated to be very important to younger physicians. These factors may likely prove to be decisive in the future as reasons for extended leaves of absence.6
Conclusion
The need for physician reentry pathways is apparent as many physicians, including those over the age of 50, choose to leave clinical medicine for a period of time and then desire to reenter clinical practice. It is also clear that different physicians — and indeed, pediatricians — will need different types of education, depending on time away from practice, general versus subspecialty practice, academic versus community-based practice, and other factors. This education will have to meet the requirements for maintenance of licensure, maintenance of board certification, gaining of hospital privileges, and other regulatory challenges. A growing number of state medical and osteopathic boards, for example, issue limited licenses for physicians who have left the workforce (i.e., clinical practice) and/or have specific rules for physicians seeking to reenter the workforce.7 For these reasons, medical specialties and their societies, in partnership with state medical and osteopathic boards, will need to play a key role in determining the criteria for specialty-specific competency needs of physicians who desire to reenter clinical practice. They will also need to develop the tools and resources needed to assist these reentry physicians.
State medical and osteopathic boards could serve as the conveners and facilitators of several organizations and groups (e.g., state medical societies, state hospital associations, and the state chapters of specialty societies) that are all working on various aspects of physician reentry.
The concept of lifelong learning will play an important role in physician reentry. Physicians who have left the workforce should be encouraged or required to continue to maintain and expand their medical knowledge so as to better facilitate their return to clinical practice. For example, Adams et al (2008) described an innovative retraining program to refresh the skills of obstetrician-gynecologists who have taken an extended voluntary leave of absence and wish to return to active clinical practice.8 State medical and osteopathic boards are in a unique position to collect and share information about “best practices” that will both inform and facilitate the efforts of many.
It is hoped that state medical and osteopathic boards, and indeed, all interested parties, will be willing to move forward to address physician reentry in the face of a paucity of data. As noted earlier, although some studies have been conducted, they are certainly not comprehensive. State medical and osteopathic boards are also in a unique position to ameliorate this situation. Working in collaboration with the Federation of State Medical Boards (FSMB) to develop a comprehensive and combined approach, they can collect uniform data across states and over time that will inform the planning at the state level and contribute to a national study of physician reentry.
Developing a standardized reentry pathway that meets diverse needs and situations will pose many challenges and require input and collaboration from a wide range of stakeholders, including reentering physicians, reentry training programs, assessment and evaluation experts, licensing and regulatory authorities, workforce policymakers, and others. This, however, is a challenge that must be met if we wish to ensure public safety and inspire public confidence.
Acknowledgment
The authors would like to acknowledge the guidance provided by the late Avrum L. Katcher, M.D., FAAP, as well as his colleagues in the AAP Section for Senior Members for their efforts in developing, and later responding to, the “Over 50” survey. Their support for this endeavor is gratefully acknowledged.
References
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- 5.↵Adams KE , AllenR, CainJM. Physician reentry: a concept whose time has come. Obstet Gynecol. 2008May;111(5):1195–8.
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- 8.↵American Academy of Pediatrics, Division of Health Services Research. Table 8. Percent of Pediatricians by Gender (Post-residents and Residents). Periodic Survey of Fellows #74 and # 75(2009). http://www.aap.org/research/periodicsurvey/ps_practice_characteristics.htm#Table8. Accessed July 9, 2010.
