Effect of part-time practice on patient outcomes

The Evolution of Board-Certified Emergency Physicians and Staffing of Emergency Departments in Israel

Introduction

Emergency medicine (EM) was recognized as a specialty in Israel in 1999. Fifty-nine of the 234 (25%) attending physicians working in emergency departments (ED) nationwide in 2002 were board-certified emergency physicians (EP). A 2012 study revealed that 123/270 (45%) of ED attendings were EPs, and that there were 71 EM residents. The EPs primarily worked midweek morning shifts, leaving the EDs mostly staffed by other specialties. Our objective in this study was to re-evaluate the EP workforce in Israeli EDs and their employment status and satisfaction 10 years after the last study, which was conducted in 2012.

Methods

We performed a three-part, prospective cross-sectional study: 1) a survey, sent to all EDs in Israel, to assess the numbers, level of training, and specialties of physicians working in EDs; 2) an anonymous questionnaire, sent to EPs in Israel, to assess their demographics, training, employment, and work satisfaction; and 3) interviews of a convenience sample of EPs analyzed by a thematic approach.

Results

There were 266 board-certified EPs, 141 (53%) of whom were employed in EDs full-time or part-time. Sixty-two non-EPs also worked in EDs. The EPs were present in the EDs primarily during weekday morning shifts. There were 273 EM residents nationwide. A total of 101 questionnaires were completed and revealed that EPs working part-time in the ED worked fewer hours, received higher salaries, and had more years of experience compared to EPs working full time or not working in the ED. Satisfaction correlated only with working part time. Meaningful work, diversity, and rewarding relationships with patients and colleagues were major positive reasons for working in the ED. Feeling undervalued, carrying a heavy caseload, and having complicated relationships with other hospital departments were reasons against working in the ED.

Conclusion

Our study findings showed an increase in the number of trained and in-training EPs, and a decrease in the percentage of board-certified EPs who persevere in the EDs. Emergency medicine in Israel is at a crossroads: more physicians are choosing EM than a decade ago, but retention of board-certified EPs is a major concern, as it is worldwide. We recommend taking measures to maintain trained and experienced EPs working in the ED by allowing part-time ED positions, introducing dedicated academic time, and diversifying EP roles, functioning, and work routine.

The Perceived Influence of the COVID-19 Pandemic on the Medical Education of Residents in 2021 and 2022

Background Recent studies reported how the COVID-19 pandemic influenced the medical education community. However, little is known about the further influence of the pandemic over time and about the impact across the different medical disciplines. Objective Our objective was to investigate how residents working in different disciplines and on different tracks (full- vs part-time) perceived the influence of the COVID-19 pandemic in 2021 and 2022 on their education. Methods The data were collected with a questionnaire (developed by the Swiss Federal Institute of Technology and the Swiss Institute for Medical Education) as part of the Swiss national annual survey on medical education. We assessed the influence of the pandemic on medical residents from different specialties in 2021 and 2022 with 3 items: global effect on education, available time for education, and effect on teaching. Results The questionnaire had a response rate of 70% (8496 of 12 137) in 2021 and 2022 (8823 of 12 604). In 2021, residents reported that the pandemic had a negative influence (3.5 of 5; P<.001; 95% CI 0.49, 0.53) and impaired their education. The negative influence declined (t=7.91; P<.001; 95% CI 0.07, 0.11) but remained noticeable in 2022 (3.4 of 5; P<.001; 95% CI 0.41, 0.44). This pattern of results was similar among the different medical specialties. In both years, residents working full-time reported a more severe influence of the pandemic than those working part-time (eg, in 2021 impaired education: 3.1 of 4 vs 2.9 of 4; P<.01; 95% CI -0.26, -0.14). Conclusions The negative influence of the pandemic declined across all medical disciplines.

Impact of primary care physicians working part-time on patient care: A scoping review

BACKGROUND

Increasing numbers of primary care physicians (PCPs) are reducing their working hours. This decline may affect the workforce and the care provided to patients.

OBJECTIVES

This scoping review aims to determine the impact of PCPs working part-time on quality of patient care.

METHODS

A systematic search was conducted using the databases PubMed, CINAHL, Embase, and the Cochrane Library. Peer-reviewed, original articles with either quantitative, qualitative or mixed methods designs, published after 2000 and written in any language were considered. The search strings combined the two concepts: part-time work and primary care. Studies were included if they examined any effect of PCPs working part-time on quality of patient care.

RESULTS

The initial search resulted in 2,323 unique studies. Abstracts were screened, and information from full texts on the study design, part-time and quality of patient care was extracted. The final dataset included 14 studies utilising data from 1996 onward. The studies suggest that PCPs working part-time may negatively affect patient care, particularly the access and continuity of care domains. Clinical outcomes and patient satisfaction seem mostly unaffected or even improved.

CONCLUSION

There is evidence of both negative and positive effects of PCPs working part-time on quality of patient care. Approaches that mitigate negative effects of part-time work while maintaining positive effects should be implemented.

Burnout and work-privacy conflict - are there differences between full-time and part-time physicians?

Background

Changes in everyday work with regard to working time models have reached the medical profession. The number of physicians working part-time is steadily increasing. At the same time, however, the population's need for care is also rising. This can reinforce the impending shortage of doctors in the future. The aim was to investigate differences in work-privacy conflict and burnout among physicians working full-time or part-time.

Method

The present study includes data from a baseline survey of the long-term study of physicians with different medical backgrounds. The analysis focused on a sub-sample of 598 physicians (not self-employed). The two main outcomes under investigation—burnout and work-privacy conflict—were measured using the Copenhagen Burnout Inventory adapted for health care professionals, as well as the associated subscale of the Copenhagen Psychosocial Questionnaire (COPSOQ). Data analyses included descriptive statistics followed by regression models.

Results

Descriptive analyses show, that 31.8% of physicians are working part-time, whereas 68.2% are working full-time. The part-time subsample is significantly older, and female physicians are more likely to work part-time. With regard to workload and work-privacy conflict, significant differences between part-time and full-time physicians were only observed in terms of work-privacy-conflict. However, regression analysis underline the importance of possible confounding variables (such as medical setting) within the relationship between job size and job-related well-being.

Discussion

Differences in working hour arrangements (full-time or part-time work) are only accompanied by less work-privacy conflict. No differences with regard to burnout (patient-related, work-related or personal) could be obtained. Rather, the data suggests that other job-related variables may play a role and should be further investigated.

Analysis of Variation in Organizational Definitions of Primary Care Panels: A Systematic Review

IMPORTANCE

Primary care panel size plays an increasing role in measuring primary care provider (ie, physicians and advanced practice providers, which include nurse practitioners and physician assistants) workload, setting practice capacity, and determining pay and can influence quality of care, access, and burnout. However, reported panel sizes vary widely.

OBJECTIVE

To identify how panels are defined, the degree of variation in these definitions, the consequences of different definitions of panel size, and research on strengths of different approaches.

EVIDENCE REVIEW

Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, MEDLINE, Web of Science, Embase, and Dissertations and Theses Global databases were searched from inception to April 28, 2021, for subject headings and text words to capture concepts of primary care panel size. Article review and data abstraction were performed independently by 2 reviewers. Main outcomes reported included rules for adding or removing patients from panels, rules for measuring primary care provider resources, consequences of different rules on reported panel size, and research on advantages and disadvantages of different rules.

FINDINGS

The literature search yielded 1687 articles, with 294 potentially relevant articles and 74 containing relevant data. Specific practices were identified from 29 health care systems and 5 empanelment implementation guides. Patients were most commonly empaneled after 1 primary care visit (24 of 34 [70.6%]), but some were empaneled only after several visits (5 [14.8%]), enrollment in a health plan (4 [11.8%]) or any visit to the health care system (1 [3.0%]). Patients were removed when no visit had occurred in a specified look-back period, which varied from 12 to 42 months. Regarding primary care provider resources, half of organizations assigned advanced practice providers independent panels and half had them share panels with a physician, increasing the physician's panel by 50% to 100%. Analyses demonstrated that changes in individual rules for adding patients, removing patients, or estimating primary care provider resources could increase reported panel size from 20% to 100%, without change in actual primary care provider workload. No research was found investigating advantages of different definitions.

CONCLUSIONS AND RELEVANCE

Much variation exists in how panels are defined, and this variation can have substantial consequences on reported panel size. Research is needed on how to define primary care panels to best identify active patients, which could contribute to a widely accepted standard approach to panel definition.

Association Between Physician Part-time Clinical Work and Patient Outcomes

IMPORTANCE

Despite the growing number of physicians who reduce clinical time owing to research, administrative work, and family responsibilities, the quality of care provided by these physicians remains unclear.

OBJECTIVE

To examine the association between the number of days worked clinically per year by physicians and patient mortality.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis was completed on a 20% random sample of Medicare fee-for-service beneficiaries 65 years and older who were admitted to the hospital with an emergency medical condition and treated by a hospitalist in 2011 through 2016. Because hospitalists typically work in shifts, hospitalists' patients are plausibly quasirandomized to hospitalists based on the hospitalists' work schedules (natural experiment). The associations between hospitalists' number of days worked clinically per year and 30-day patient mortality and readmission rates were examined, adjusting for patient and physician characteristics and hospital fixed effects (effectively comparing physicians within the same hospital). Data analysis was conducted from July 1, 2020, to July 2, 2021.

EXPOSURES

Physicians' number of days worked clinically per year.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day patient mortality, and the secondary outcome was 30-day patient readmission.

RESULTS

Among 392 797 hospitalizations of patients treated by 19 170 hospitalists (7482 female [39.0%], 11 688 male [61.0%]; mean [SD] age, 41.1 [8.8] years), patients treated by physicians with more days worked clinically exhibited lower mortality. Adjusted 30-day mortality rates were 10.5% (reference), 10.0% (adjusted risk difference [aRD], -0.5%; 95% CI, -0.8% to -0.2%; P = .002), 9.5% (aRD, -0.9%; 95% CI, -1.2% to -0.6%; P < .001), and 9.6% (aRD, -0.9%; 95% CI, -1.2% to -0.6%; P < .001) for physicians in the first (bottom), second, third, and fourth (top) quartile of days worked clinically, respectively. Readmission rates were not associated with the numbers of days a physician worked clinically (adjusted 30-day readmissions for physicians in the bottom quartile of days worked clinically per year vs those in the top quartile, 15.3% vs 15.2%; aRD, -0.1%; 95% CI, -0.5% to 0.3%; P = .61).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, hospitalized Medicare patients treated by physicians who worked more clinical days had lower 30-day mortality. Given that physicians with reduced clinical time must often balance clinical and nonclinical obligations, improved support by institutions may be necessary to maintain the clinical performance of these physicians.

A neglected issue in hospital emergency and disaster planning: Non-standard employment in hospitals

Work organization and relationships have changed over recent decades. Following the recent COVID-19 pandemic, the norms concerning work-related standards will likely change even more significantly. There has been a shift away from standard employment to non-standard employment (NSE), which includes fixed-term, part-time, on-call, agency-related employment, dependent self-employment, dispatch, and temporary employment, etc. In nearly every sector. The health sector is no exception. However, the effects of non-standard employment on the disaster preparedness of health systems, particularly on hospitals' emergency and disaster plans, have not yet been adequately studied. Most crucial themes are engagement of non-standard employees in emergency and disaster planning and response, and the impact of non-standard employees in expanding hospitals' capacity in large-scale events. This short communication paper aims to discuss this neglected issue in hospital emergency and disaster planning. In order to see whether NSE is considered in hospital disaster and emergency plans, two hospital disaster and emergency planning guidelines-the Hospital Incident Command System, and the Hospital Emergency Response Checklist developed by the World Health Organization-were assessed regarding NSE in their respective contexts. Although these guidelines are comprehensive tools for hospital preparedness, NSE is not specifically considered in any of them. However, it is essential that NSE, with its trade-offs, is considered in disaster plans to maintain an effective implementation of them. Further research and actions are necessary, especially after the COVID-19 pandemic, to identify how this reflection should be conducted and to supply evidence for further measures and revising emergency and disaster planning guidelines.

The Role of Physician and Practice Characteristics in the Quality of Diabetes Management in Primary Care: Systematic Review and Meta-analysis

BACKGROUND

Despite evidence-based guidelines, high-quality diabetes care is not always achieved. Identifying factors associated with the quality of management in primary care may inform service improvements, facilitating the tailoring of quality improvement interventions to practice needs and resources.

METHODS

We searched MEDLINE, EMBASE, CINAHL and Web of Science from January 1990 to March 2019. Eligible studies were cohort studies, cross-sectional studies and randomised controlled trials (baseline data) conducted among adults with diabetes, which examined the relationship between any physician and/or practice factors and any objective measure(s) of quality. Studies which examined patient factors only were ineligible. Where possible, data were pooled using random-effects meta-analysis.

RESULTS

In total, 82 studies were included. The range of individual quality measures and the construction of composite measures varied considerably. Female physicians compared with males ((odds ratio (OR) = 1.07, 95% CI: 1.04, 1.10), 8 studies), physicians with higher diabetes volume compared with lower volume (OR = 1.24, 95% CI: 1.05-1.47, 4 studies) and practices with Electronic Health Records (EHR) versus practices without (OR = 1.43, 95% CI: 1.11-1.84, 4 studies) were associated with a higher quality of care. There was no association between physician experience, practice location and type of practice and quality. Based on the narrative synthesis, increasing physician age and higher practice socio-economic deprivation may be associated with lower quality of care.

DISCUSSION

Identification of physician- and practice-level factors associated with the quality of care (female gender, younger age, physician-level diabetes volume, practice deprivation and EHR use) may explain differences across practices and physicians, provide potential targets for quality improvement interventions and indicate which practices need specific supports to deliver improvements in diabetes care.

Part-time practice in healthcare: Impact on operational versus medical performance

We explore how reliance on part-time medical staff affects operational and medical outcome performance in two general surgery departments Whereas prior research has indicated that operational performance is positively associated with medical performance, we find that heavier reliance on part-time practice may deteriorate operational performance but not necessarily medical-outcome performance. For so-called "complex" patients, reliance on part-time practice may even override the effect of patients' characteristics on medical-outcome performance. This result calls into question common perceptions in behavior marketing literature regarding part-time employees' working patterns and efficiency, and thereby provides a new perspective regarding current labor-market trends.

Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout

These are challenging times for health care executives. The health care field is experiencing unprecedented changes that threaten the survival of many health care organizations. To successfully navigate these challenges, health care executives need committed and productive physicians working in collaboration with organization leaders. Unfortunately, national studies suggest that at least 50% of US physicians are experiencing professional burnout, indicating that most executives face this challenge with a disillusioned physician workforce. Burnout is a syndrome characterized by exhaustion, cynicism, and reduced effectiveness. Physician burnout has been shown to influence quality of care, patient safety, physician turnover, and patient satisfaction. Although burnout is a system issue, most institutions operate under the erroneous framework that burnout and professional satisfaction are solely the responsibility of the individual physician. Engagement is the positive antithesis of burnout and is characterized by vigor, dedication, and absorption in work. There is a strong business case for organizations to invest in efforts to reduce physician burnout and promote engagement. Herein, we summarize 9 organizational strategies to promote physician engagement and describe how we have operationalized some of these approaches at Mayo Clinic. Our experience demonstrates that deliberate, sustained, and comprehensive efforts by the organization to reduce burnout and promote engagement can make a difference. Many effective interventions are relatively inexpensive, and small investments can have a large impact. Leadership and sustained attention from the highest level of the organization are the keys to making progress.

Parental satisfaction of U.S. physicians: associated factors and comparison with the general U.S. working population

BACKGROUND

Physicians work considerably longer hours and are less satisfied with work-life balance than U.S. workers in other fields. There is, however, minimal data on physicians' parental satisfaction.

METHODS

To evaluate differences in parental satisfaction among physicians and workers in other fields, we surveyed U.S. physicians as well as a probability-based sample of the general U.S. working population between August 2014-October 2014. Parental satisfaction and the perceived impact of career on relationships with children were evaluated.

RESULTS

Among 6880 responding physicians (cooperation rate 19.2 %), 5582 (81.1 %) had children. Overall, physicians were satisfied in their relationships with their children, with 4782 (85.9 %) indicating that they were either very satisfied [n = 2738; (49.2 %)] or satisfied [n = 2044 (36.7 %)]. In contrast, less than half believed their career had made either a major [n = 1212; (21.8 %)] or minor positive [n = 1260; (22.7 %)] impact on their relationship with their children, with a slightly larger proportion indicating a major (n = 2071 [37.2 %]) or minor (n = 501 [9 %]) negative impact. Women physicians were less likely to believe their career had made a positive impact as were younger physicians. Hours worked/week inversely correlated with the belief that career had made a positive impact on relationships with children. Both men (OR: 2.75; p < 0.0001) and women (OR: 4.33; p < 0.0001) physicians were significantly more likely to report that their career had a negative impact on relationships with their children than the sex-matched U.S. working population.

CONCLUSIONS

U.S. physicians report generally high satisfaction in their relationships with their children. Despite their high satisfaction, physicians have a more negative perception of the impact of their career on relationships with their children than U.S. workers in general.

Longitudinal Study Evaluating the Association Between Physician Burnout and Changes in Professional Work Effort

OBJECTIVE

To longitudinally evaluate the relationship between burnout and professional satisfaction with changes in physicians' professional effort.

PARTICIPANTS AND METHODS

Administrative/payroll records were used to longitudinally evaluate the professional work effort of faculty physicians working for Mayo Clinic from October 1, 2008, to October 1, 2014. Professional effort was measured in full-time equivalent (FTE) units. Physicians were longitudinally surveyed in October 2011 and October 2013 with standardized tools to assess burnout and satisfaction.

RESULTS

Between 2008 and 2014, the proportion of physicians working less than full-time at our organization increased from 13.5% to 16.0% (P=.05). Of the 2663 physicians surveyed in 2011 and 2776 physicians surveyed in 2013, 1856 (69.7%) and 2132 (76.9%), respectively, returned surveys. Burnout and satisfaction scores in 2011 correlated with actual reductions in FTE over the following 24 months as independently measured by administrative/payroll records. After controlling for age, sex, site, and specialty, each 1-point increase in the 7-point emotional exhaustion scale was associated with a greater likelihood of reducing FTE (odds ratio [OR], 1.43; 95% CI, 1.23-1.67; P<.001) over the following 24 months, and each 1-point decrease in the 5-point satisfaction score was associated with greater likelihood of reducing FTE (OR, 1.34; 95% CI, 1.03-1.74; P=.03). On longitudinal analysis at the individual physician level, each 1-point increase in emotional exhaustion (OR, 1.28; 95% CI, 1.05-1.55; P=.01) or 1-point decrease in satisfaction (OR, 1.67; 95% CI, 1.19-2.35; P=.003) between 2011 and 2013 was associated with a greater likelihood of reducing FTE over the following 12 months.

CONCLUSION

Among physicians in a large health care organization, burnout and declining satisfaction were strongly associated with actual reductions in professional work effort over the following 24 months.

Patients report better satisfaction with part-time primary care physicians, despite less continuity of care and access

BACKGROUND

The growing number of primary care physicians (PCPs) reducing their clinical work hours has raised concerns about meeting the future demand for services and fulfilling the continuity and access mandates for patient-centered care. However, the patient's experience of care with part-time physicians is relatively unknown, and may be mediated by continuity and access to care outcomes.

OBJECTIVE

We aimed to examine the relationships between a physicians' clinical full-time equivalent (FTE), continuity of care, access to care, and patient satisfaction with the physician.

DESIGN

We used a multi-level structural equation estimation, with continuity and access modeled as mediators, for a cross-section in 2010.

PARTICIPANTS

The study included family medicine (n = 104) and internal medicine (n = 101) physicians in a multi-specialty group practice, along with their patient satisfaction survey responses (n = 12,688).

MAIN MEASURES

Physician level FTE, continuity of care received by patients, continuity of care provided by physician, and a Press Ganey patient satisfaction with the physician score, on a 0-100 % scale, were measured. Access to care was measured as days to the third next-available appointment.

KEY RESULTS

Physician FTE was directly associated with better continuity of care received (0.172% per FTE, p < 0.001), better continuity of care provided (0.108% per FTE, p < 0.001), and better access to care (-0.033 days per FTE, p < 0.01), but worse patient satisfaction scores (-0.080% per FTE, p = 0.03). The continuity of care provided was a significant mediator (0.016% per FTE, p < 0.01) of the relationship between FTE and patient satisfaction; but overall, reduced clinical work hours were associated with better patient satisfaction (-0.053 % per FTE, p = 0.03).

CONCLUSIONS

These results suggest that PCPs who choose to work fewer clinical hours may have worse continuity and access, but they may provide a better patient experience. Physician workforce planning should consider these care attributes when considering the role of part-time PCPs in practice redesign efforts and initiatives to meet the demand for primary care services.

The volume-quality relationship in antibiotic prescribing: when more isn't better

For many surgeries and high-risk medical conditions, higher volume providers provide higher quality care. The impact of volume on more common medical conditions such as acute respiratory infections (ARIs) has not been examined. Using electronic health record data for adult ambulatory ARI visits, we divided primary care physicians into ARI volume quintiles. We fitted a linear regression model of antibiotic prescribing rates across quintiles to assess for a significant difference in trend. Higher ARI volume physicians had lower quality across a number of domains, including higher antibiotic prescribing rates, higher broad-spectrum antibiotic prescribing, and lower guideline concordance. Physicians with a higher volume of cases manage ARI very differently and are more likely to prescribe antibiotics. When they prescribe an antibiotic for a diagnosis for which an antibiotic may be indicated, they are less likely to prescribe guideline-concordant antibiotics. Given that high-volume physicians account for the bulk of ARI visits, efforts targeting this group are likely to yield important population effects in improving quality.

A comprehensive analysis of dyslipidaemia management in a large health care system

RATIONALE, AIMS AND OBJECTIVES

Dyslipidaemia is a cardiovascular risk factor, and national screening and treatment guidelines have been established, but achievement of these remains inadequate. Multidisciplinary approaches, such as the chronic care model, have been applied to other chronic diseases and likely would be applicable to the management of dyslipidaemia. We therefore aimed to comprehensively study the different components of a multidisciplinary management approach to dyslipidaemia in a large health care system for patients at a high risk for cardiovascular events.

METHODS

All patients at a Veterans Affairs Medical Center in the United States over 3 years with diabetes and/or coronary artery disease were included. Various clinical and demographic variables were collected and achievement of national cholesterol goals was determined. Univariate and multivariate analyses were conducted to determine the association of different health care variables with improved patient cholesterol guideline achievement.

RESULTS

There were 3559 patients in the study population and 51.0% had achieved national cholesterol goals. Multivariate analyses showed that patients who had achieved goals were more likely to have attended cardiology clinic [odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.3-2.01] and nutrition clinic (OR = 1.3, 95% CI = 1.04-1.7) and were more likely to have primary care providers who were nurse practitioners (OR = 1.6, 95% CI = 1.2-2.0), practicing full-time (OR = 1.8, 95% CI = 1.5-2.1) and at the main hospital-based clinics (OR = 1.5, 95% CI = 1.3-1.9).

CONCLUSIONS

Our study identifies different components of a multidisciplinary approach to management of dyslipidaemia that are efficacious and these results may help guide future investment in this area.

Role of physician gender in drug therapy

There is evidence that female patients receive less intensified drug therapy in many medical conditions than male patients. However, there are only limited data regarding the influence of physician gender on drug therapy. It has been shown, for example, that female physicians tend to adhere more closely to guideline-recommended pharmacotherapy compared to their male counterparts. In some medical conditions where drug therapy is only one among various components of a complex interplay of therapeutic regimes (e.g., diabetes, cardiovascular diseases, depression, pain management), female physicians seem to achieve better overall intermediate outcomes and some studies suggest that "better" drug therapy is provided by female compared to male physicians. The reasons for the overall better outcomes may be superior communication skills of female physicians, participatory decision making, and consequently improved drug adherence in addition to or in combination with more effective non-pharmacologic treatment results. It is impossible to distinguish between the individual contributions of drug- and nondrug-related influence on such improved outcomes and thus to determine whether they are due to unconfounded physician gender effects on drug therapy. There is until now in no area of medicine evidence to suggest that a patient will consistently receive higher quality of drug therapy by switching to a physician of a specific gender.

Implementation of electronic medical records: effect on the provision of preventive services in a pay-for-performance environment

OBJECTIVE

To study the effect of electronic medical record (EMR) implementation on preventive services covered by Ontario's pay-for-performance program.

DESIGN

Prospective double-cohort study.

PARTICIPANTS

Twenty-seven community-based family physicians.

SETTING

Toronto, Ont.

INTERVENTION

Eighteen physicians implemented EMRs, while 9 physicians continued to use paper records.

MAIN OUTCOME MEASURE

Provision of 4 preventive services affected by pay-for-performance incentives (Papanicolaou tests, screening mammograms, fecal occult blood testing, and influenza vaccinations) in the first 2 years of EMR implementation.

RESULTS

After adjustment, combined preventive services for the EMR group increased by 0.7%, a smaller increase than that seen in the non-EMR group (P = .55, 95% confidence interval -2.8 to 3.9).

CONCLUSION

When compared with paper records, EMR implementation had no significant effect on the provision of the 4 preventive services studied.

Graduating med-peds residents' interest in part-time employment

OBJECTIVE

As part-time work is becoming more popular among the primary care specialties, we examined the demographic descriptors of med-peds residents seeking and finding part-time employment upon completion of residency training.

METHODS

As part of the 2006 annual American Academy of Pediatrics (AAP) Graduating Med-Peds Residents Survey, we surveyed the graduating residents of all med-peds programs about their interest in and plans for part-time employment. A total of 199 (60%) of the residents responded.

RESULTS

Of the resident respondents applying for nonfellowship jobs, 19% sought part-time positions and 10% actually accepted a part-time position. Female residents were significantly more likely than male residents to apply for part-time jobs (26% vs. 7%, P = .034). Sixty percent of female residents immediately seeking work and 58% of those going on to fellowship reported an interest in arranging a part-time or reduced-hours position at some point in the next 5 years.

CONCLUSIONS

Part-time employment among med-peds residents applying for nonfellowship positions after graduation is similar to the current incidence of part-time employment in other fields of primary care. A much higher percentage of med-peds residents are interested in arranging part-time work within 5 years after graduation. This strong interest in part-time work has many implications for the primary care workforce.

Part-time work among pediatricians expands

OBJECTIVE

The objective of this study was to track trends in part-time employment among pediatricians from 2000 to 2006 and to examine differences within subgroups of pediatricians.

METHODS

As part of the Periodic Survey of Fellows, national random samples of American Academy of Pediatrics members were surveyed in 2000, 2003, and 2006. These surveys shared questions concerning working part-time and other practice characteristics. Roughly 1600 pediatricians were included in each random sample. Totals of 812 (51%), 1020 (63%), and 1013 (62%) pediatricians completed the surveys in 2000, 2003, and 2006, respectively. Analyses were limited to nonretired, posttrainee pediatricians.

RESULTS

The number of pediatricians who reported that they work part-time increased from 15% in 2000, to 20% in 2003, to 23% in 2006. The pattern of increased part-time work from 2000 to 2006 held for many subgroups, including men, women, pediatricians who were younger than 40 years, pediatricians who were aged >or=50 years, pediatricians who worked in an urban inner city, pediatricians who worked in suburban areas, general pediatricians, and subspecialist pediatricians. Those who were working part-time were more satisfied within their professional and personal activities. Part-time pediatricians worked on average 14.3 fewer hours per week in direct patient care.

CONCLUSIONS

Increases in part-time work are apparent throughout pediatrics. The possible continued growth of part-time is an important trend within the field of pediatrics that will need to be monitored.

Part-time clinical anesthesia practice: a review of the economic, quality, and safety issues

Part-time clinical practice in anesthesia is increasing due to the feminization and the aging of the medical workforce, as well as the arrival of generations X and Y to the health care workforce. Recruiting the best and brightest physicians requires accommodating their needs and interests, as well as retaining older workers who wish to reduce their hours as they approach retirement. This article discusses steps to help departments or groups optimally manage the part-time anesthesia workforce.

Influence of gender of physicians and patients on guideline-recommended treatment of chronic heart failure in a cross-sectional study

AIMS

Clinical outcomes of patients with chronic heart failure (CHF) have improved, but evidence-based treatment appears to be imbalanced depending on patients' and physicians' gender. We aimed to determine the interactions of gender with medical treatment of CHF.

METHODS AND RESULTS

Consecutive patients with CHF (n = 1857) were evaluated regarding co-morbidities, New York Heart Association classification, current medical treatment, and dosage of angiotensin-converting enzyme-inhibitors (ACE-Is) and beta-blockers. Gender of patients and treating physicians was recorded. Baseline characteristics of patients and physicians were comparable for males and females. Female patients were less frequently treated with ACE-Is, angiotensin-receptor blockers, or beta-blockers. Achieved doses were lower in female compared with male patients. Guideline-recommended drug use and achieved target doses tended to be higher in patients treated by female physicians. There was no different treatment for male or female patients by female physicians, whereas male physicians used significantly less medication and lower doses in female patients. In multivariable analysis, female gender of physicians was an independent predictor of use of beta-blockers.

CONCLUSION

Treatment of CHF is influenced by patients', but also physicians' gender with regard to evidenced-based drugs and their dosage. Physicians should be aware of this problem in order to avoid gender-related treatment imbalances.

A time for change: an exploration of attitudes toward part-time work in academia among women internists and their division chiefs

BACKGROUND

Increasing numbers of clinicians desire part-time work, and many will opt out of academic medicine if the barriers to part-time work are too great.

METHOD

Purposeful sampling was used to investigate the experiences of part-time academic physicians and their division leaders to understand (1) how each identified the negative and positive consequences of part-time work, and (2) how each conceptualize part-time work. In 2004, the authors interviewed the Society of General Medicine Horn Scholars Program applicants and their division chiefs from the 2001 and 2004 award cycles and performed a qualitative analysis of the one- to two-hour audiotaped interviews.

RESULTS

Seven out of nine eligible applicants and six of seven division chiefs participated. All applicants were female junior faculty clinician educators in academic internal medicine from seven institutions. All division chiefs were male full-time faculty members. Both applicants and division chiefs identified multiple specific negative and positive consequences of part-time work. Analysis of interviews suggested that both groups tended to frame part-time work as a decision to "work less" or to "work differently." Self-reflection and articulation of values helped some faculty determine where they derive the greatest happiness and fulfillment personally and professionally.

CONCLUSIONS

As more academics seek work-life balance and consider part-time work as a tool to achieve that balance, academic medicine will be challenged to develop creative models for integrating successful part-time physicians, or it will lose that segment of the workforce. This study's findings suggest that one such model may require that physicians and their leaders reconceptualize work altogether.

Professional characteristics and job satisfaction among SGIM members: a comparison of part-time and full-time physician members

BACKGROUND

As more physicians work part-time (PT), the faculty, institutions, and organizations that represent them should understand the factors that motivate and satisfy these physicians.

OBJECTIVE

Compare factors associated with job satisfaction among PT and full-time (FT) academic physicians.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Members of the Society of General Internal Medicine (SGIM), a national, academic Internal Medicine organization.

RESULTS

Fifty percent (1,396 of 2,772) of SGIM members responded, 11% work PT. Compared to FT, PT physicians were more often female (85% vs 38%, p < .001), clinicians (Cs) or clinician-educators (CEs) (84% vs 56%, p < .001), and of a lower rank (77% vs 61%, p = .001). Job satisfaction was similar between PT and FT Cs and CEs. For PT Cs and CEs, record of publication (11% vs 21%, p = .04) and local and national recognition (24% vs 36%, p = .03) were less important to overall job satisfaction compared to FT Cs and CEs. In multivariate analysis, academic rank (odds ratio [OR] = 7.18, 95%CI = 1.40-36.50) was associated with higher satisfaction among PT Cs and CEs.

CONCLUSIONS

PT and FT C and CE SGIM members report similar satisfaction, but different factors contribute to satisfaction. Knowing what motivates and satisfies PT physicians may allow medical centers to retain faculty and create positions to help them to fulfill their potential.

Part-time physicians...prevalent, connected, and satisfied

OBJECTIVE

The health care workforce is evolving and part-time practice is increasing. The objective of this work is to determine the relationship between part-time status, workplace conditions, and physician outcomes.

DESIGN

Minimizing error, maximizing outcome (MEMO) study surveyed generalist physicians and their patients in the upper Midwest and New York City.

MEASUREMENTS AND MAIN RESULTS

Physician survey of stress, burnout, job satisfaction, work control, intent to leave, and organizational climate. Patient survey of satisfaction and trust. Responses compared by part-time and full-time physician status; 2-part regression analyses assessed outcomes associated with part-time status. Of 751 physicians contacted, 422 (56%) participated. Eighteen percent reported part-time status (n = 77, 31% of women, 8% of men, p < .001). Part-time physicians reported less burnout (p < .01), higher satisfaction (p < .001), and greater work control (p < .001) than full-time physicians. Intent to leave and assessments of organizational climate were similar between physician groups. A survey of 1,795 patients revealed no significant differences in satisfaction and trust between part-time and full-time physicians.

CONCLUSIONS

Part-time is a successful practice style for physicians and their patients. If favorable outcomes influence career choice, an increased demand for part-time practice is likely to occur.

Many pediatric residents seek and obtain part-time positions

OBJECTIVE

The goal was to monitor the number of pediatric residents seeking part-time employment after graduation and to examine the difficulty of their job searches, compared with residents seeking full-time employment.

METHODS

As part of the American Academy of Pediatrics Graduating Resident Survey, national random samples of 500 graduating, categorical pediatrics residents were surveyed from 2003 through 2005, between May and August of each year. Responses were pooled to examine resident interest in and experience with part-time employment. Totals of 308 (62%), 307 (61%), and 281 (56%) residents completed the survey in 2003, 2004, and 2005, respectively. Analyses focused on residents who applied for nonfellowship jobs.

RESULTS

A total of 51% of residents applied for nonfellowship jobs. Of those who applied for such jobs, 38% reported that they applied for part-time positions and 21% actually accepted part-time positions. Residents who applied for part-time positions were more likely to report moderate or considerable job search difficulty (part-time: 36%; full-time: 25%). The average starting salary for residents who accepted part-time jobs was almost $34,000 less than that for residents working full-time (part-time: $71,615; full-time: $105,598). Residents who accepted part-time positions expected to work 15 hours less per week in practice (38 vs 23 hours) and were more likely to accept a position in the same city/area as their residency (part-time: 60%; full-time: 47%).

CONCLUSIONS

Approximately 4 of 10 pediatric residents seek part-time employment after graduation, and 2 of 10 accept part-time positions. Strong interest in part-time positions is likely to continue, and this important trend has implications for the pediatric workforce.

Internal medicine specialists' attitudes towards working part-time: a comparison between 1996 and 2004

Background

Although medical specialists traditionally hold negative views towards working part-time, the practice of medicine has evolved. Given the trend towards more part-time work and that there is no evidence that it compromises the quality of care, attitudes towards part-time work may have changed as well in recent years. The aim of this paper was to examine the possible changes in attitudes towards part-time work among specialists in internal medicine between 1996 and 2004. Moreover, we wanted to determine whether these attitudes were associated with individual characteristics (age, gender, investments in work) and whether attitudes of specialists within a partnership showed more resemblance than specialists' attitudes from different partnerships.

Methods

Two samples were used in this study: data of a survey conducted in 1996 and in 2004. After selecting internal medicine specialists working in general hospitals in The Netherlands, the sample consisted of 219 specialists in 1996 and 363 specialists in 2004. They were sent a questionnaire, including topics on the attitudes towards part-time work.

Results

Internal medicine specialists' attitudes towards working part-time became slightly more positive between 1996 and 2004. Full-time working specialists in 2004 still expressed concerns regarding the investments of part-timers in overhead tasks, the flexibility of task division, efficiency, communication and continuity of care. In 1996 gender was the only predictor of the attitude, in 2004 being a full- or a part-timer, age and the time invested in work were associated with this attitude. Furthermore, specialists' attitudes were not found to cluster much within partnerships.

Conclusion

In spite of the increasing number of specialists working or preferring to work part-time, part-time practice among internal medicine specialists seems not to be fully accepted. The results indicate that the attitudes are no longer gender based, but are associated with age and work aspects such as the number of hours worked. Though there is little evidence to support them, negative ideas about the consequences of part-time work for the quality of care still exist. Policy should be aimed at removing the organisational difficulties related to part-time work and create a system in which part-time practice is fully integrated and accepted.

The view of surgery department chairs on part time faculty in academic practice: results of a national survey

BACKGROUND

Reduced resident work hours sparked debate regarding lifestyle of clinical faculty. We hypothesized surgery department chairs would not be supportive of part-time clinical faculty (PTF) and would be reluctant to grant requests to reduce total institutional commitment (TIC) or total professional effort.

METHOD

A 16-question survey was mailed to 202 surgery chairs requesting department demographics, and perception of PTF. Chairs were given the option of identifying themselves. PTF referred to full-time equivalent clinicians who reduce their TIC for personal/family reasons and did not include clinicians with research or teaching commitments limiting clinical responsibilities.

RESULTS

A total of 112 of 186 (61.2%) delivered surveys were returned. Of these, 48.2% of respondents indicated clinicians had requested reduced TIC and 40.2% of departments had PTF. Only 1 chair was unable to grant a request to reduce TIC. A total of 42.8% of respondents indicated that PTF receive reduced salary-linked benefits but (58.9%) no change in either academic status or (52.7%) eligibility for promotion/tenure. The percentage of women faculty was 12.0% in departments with PTF and 10.5% in departments without PTF. A total of 42.8% of chairs agreed facilitating PTF would improve faculty retention versus 24.1% who disagreed (P<.0001). When compared with departments without PTF, chairs with PTF were more supportive that facilitating PTF would improve faculty retention (53.3% vs 32.7%, P<.001) and would be beneficial to their departments (57.8% vs 22.4%, P<.001). Sixty-two percent of respondents volunteered their names and contact information for follow-up.

CONCLUSIONS

Contrary to our hypothesis, surgery department chairs appear to be supportive of PTF and were interested in discussing this further.

The generation and gender shifts in medicine: an exploratory survey of internal medicine physicians

Background

Two striking demographic shifts evident in today's workforce are also apparent in the medical profession. One is the entry of a new generation of physicians, Gen Xers, and the other is the influx of women. Both shifts are argued to have significant implications for recruitment and retention because of assumptions regarding the younger generation's and women's attitudes towards work and patient care. This paper explores two questions regarding the generations: (1) How do Baby Boomer and Generation X physicians perceive the generation shift in work attitudes and behaviours? and (2) Do Baby Boomer and Generation X physicians differ significantly in their work hours and work attitudes regarding patient care and life balance? Gen Xers include those born between 1965 and 1980; Baby Boomers are those born between 1945 and 1964. We also ask: Do female and male Generation X physicians differ significantly in their work hours and work attitudes regarding patient care and life balance?

Methods

We conducted exploratory interviews with 54 physicians and residents from the Department of Medicine (response rate 91%) and asked about their perceptions regarding the generation and gender shifts in medicine. We limit the analyses to interview responses of 34 Baby Boomers and 18 Generation Xers. We also sent questionnaires to Department members (response rate 66%), and this analysis is limited to 87 Baby Boomers' and 65 Generation Xers' responses.

Results

The qualitative interview data suggest significant generation and gender shifts in physicians' attitudes. Baby Boomers generally view Gen Xer physicians as less committed to their medical careers. The quantitative questionnaire data suggest that there are few significant differences in the generations' and genders' reports of work-life balance, work hours and attitudes towards patient care.

Conclusion

A combined qualitative and quantitative approach to the generation shift and gender shift in medicine is helpful in revealing that the widely held assumptions are not necessarily reflective of any significant differences in actual work attitudes or behaviours of Boomer and Gen X physicians or of the younger generation of women entering medicine.

The pediatric subspecialty workforce: public policy and forces for change

Policy has not adequately addressed the unique circumstances of pediatric subspecialties, many of which are facing workforce shortages. Pediatric subspecialties, which we define to include all medical and surgical subspecialties, are discrete disciplines that differ significantly from each other and from adult medicine subspecialties. Concerns about a current shortage of pediatric subspecialists overall are driven by indicators ranging from recruitment difficulties to long wait times for appointments. The future supply of pediatric subspecialists and patient access to pediatric subspecialty care will be affected by a number of key factors or forces for change. We discuss 5 of these factors: changing physician and patient demographics; debt load and lifestyle considerations; competition among providers of subspecialty care; equitable reimbursement for subspecialty services; and policy to regulate physician supply. We also identify issues and strategies that medical and specialty societies, pediatric subspecialists, researchers, child advocates, policy makers, and others should consider in the development of subspecialty-specific workforce-policy agendas.

Generation X: implications for faculty recruitment and development in academic health centers

Differences and tensions between the Baby Boom generation (born 1945-1962) and Generation X (born 1963-1981) have profound implications for the future of academic medicine. By and large, department heads and senior faculty are Boomers; today's residents and junior faculty are Generation X'ers. Looking at these issues in terms of the generations involved offers insights into a number of faculty development challenges, including inadequate and inexpert mentoring, work-life conflicts, and low faculty morale. These insights suggest strategies for strengthening academic medicine's recruitment and retention of Generation X into faculty and leadership roles. These strategies include (1) improving career and academic advising by specific attention to mentoring "across differences"--for instance, broaching the subject of formative differences in background during the initial interaction; adopting a style that incorporates information-sharing with engagement in problem solving; offering frequent, frank feedback; and refraining from comparing today to the glories of yesterday; to support such improvements, medical schools should recognize and evaluate mentoring as a core academic responsibility; (2) retaining both valued women and men in academic careers by having departments add temporal flexibility and create and legitimize less-than-full-time appointments; and (3) providing trainees and junior faculty with ready access to educational sessions designed to turn their "intellectual capital" into "academic career capital."Given the trends discussed in this article, such supports and adaptations are indicated to assure that academic health centers maintain traditions of excellence.

Career Satisfaction and Retention of a Sample of Women Physicians Who Work Reduced Hours

OBJECTIVE

To better understand the career satisfaction and factors related to retention of women physicians who work reduced hours and are in dual-earner couples in comparison to their full-time counterparts.

METHODS

Survey of a random sample of female physicians between 25 and 50 years of age working within 25 miles of Boston, whose names were obtained from the Board of Registration in Medicine in Massachusetts. Interviewers conducted a 60-minute face-to-face closed-ended interview after interviewees completed a 20-minute mailed questionnaire.

RESULTS

Fifty-one full-time physicians and 47 reduced hours physicians completed the study; the completion rate was 49.5%. The two groups were similar in age, years as a physician, mean household income, number of children, and presence of an infant in the home. Reduced hours physicians in this sample had a different relationship to experiences in the family than full-time physicians. (1) When reduced hours physicians had low marital role quality, there was an associated lower career satisfaction; full-time physicians report high career satisfaction regardless of their marital role quality. (2) When reduced hours physicians had low marital role or parental role quality, there was an associated higher intention to leave their jobs than for full-time physicians; when marital role or parental role quality was high, there was an associated lower intention to leave their jobs than for full-time physicians. (3) When reduced hours physicians perceived that work interfering with family was high, there was an associated greater intention to leave their jobs that was not apparent for full-time physicians.

CONCLUSIONS

Women physicians in this sample who worked reduced hours had stronger relationships between family experiences (marital and parental role quality and work interference with family) and professional outcomes than had their full-time counterparts. Both career satisfaction and intention to leave their employment are correlated with the quality of home life for reduced hours physicians.