Group Practice

Get a life–go flextime

Extended office hours please busy patients and—surprise!—create more time for you. Here's how primary care colleagues manage.

By Anita J. Slomski

FP Michael Pendleton was willing to sacrifice some shut-eye in the mornings for pool time in the afternoons. Although his two partners in the Hood River, OR, practice thought he was nuts, Pendleton began seeing patients at 7 am so he had afternoons free to swim laps with his kids and train for Masters swim competitions.

Within a year, his partners were vying for the early-morning shift. "It was with reluctance that I had to start sharing my schedule," says Pendleton. "My partners finally saw the upside of saying 'adios' at 3 pm."

Doctors everywhere are finally catching on that flexible scheduling not only pleases patients—it can result in a less stressful work and home life. When office hours at the five-physician Lansing (MI) Pediatric Associates were 8 to 6 with an hour break for lunch, the doctors chronically ran late and the 11- and 12-hour days exhausted the staff and the physicians.

"We kept adding patients to the end of the day, and we didn't know how long we'd have to work," says office manager Dee Flower. The pace also slowed before and after the lunch break, causing more backlogs. This year, the practice added another doctor and opened the office 12 hours a day with doctors working six-hour shifts without meal breaks. The group also kept its existing 8-to-12 Saturday hours.

Although the new flex schedule meant that the doctors could no longer take their customary weekday off, pediatrician Mark Israel finds the six-hour office day to his liking. "When I work from 8 to 2, I get to spend time with my kids in the afternoon and make an occasional dinner," he says. "And when I work the afternoon shift, I spend my mornings relaxing, reading, running errands, or doing things around the house. Under the old schedule, I would leave for work at 7 in the morning and not get home until 7 or 7:30 in the evening."

Hospital rounds—the Lansing doctors take rounds for a week on a rotating basis—also became less hectic. The doctor who's doing hospital duty isn't scheduled to see patients until 2 pm, unlike before, when he had to race back to the office by mid-morning.

Even soloists are finding ways to flex their hours. Family practitioner Derrick Sorweide in Grants Pass, OR, the father of three preschoolers, works from 7:30 to 4 two days a week and from 10 to 7 the other two days. The office is also open from 8 to 1 on Saturday. "When we opened the office two years ago, the other doctors in town told Dr. Sorweide that people don't want to go to the doctor at 6 pm or on Saturdays," says office manager Donna Duval. "Some of those practices lost patients to us, and two doctors have since added Saturday hours."

Are your patients larks or owls?

Besides giving doctors more mornings and afternoons off during the week, extended hours can eliminate middle-of-the-night phone calls and trips to the ER. Pediatrician David Smalley sees sick kids in his office until 9 pm instead of heading off to the ER after talking to an anxious parent on the phone.

"Before we had extended hours, we were always trying to decide if a child needed to come to the ER or if the parent simply needed some reassurance," says Smalley, who is in a 10-pediatrician group in Opelika, AL. "Now we can see them in the office, which is less stressful for everyone. And we have fewer 3 am phone calls." Another advantage is that there's always a doctor available to call patients with lab results. "If I'm working the day shift, I can go home at 5 instead of waiting around for my last patient's lab work to be done," says Smalley.

The practice is unusual in that it's open every day of the year: 12 hours Mondays through Fridays, 9 to 5 Saturdays, and 1 to 5 Sundays and holidays. Doctors typically work weekdays from 8 to 5. But the on-call doctor might work in the clinic from 1 to 9 pm with an hour for dinner, and the next day from 9 to noon—meaning that, basically, he's on call for 24 hours. Still, "if the doctor is in the ER during the night, he won't have to put in a full day of clinic the next day as the doctors used to do," says Jerry Haynes, the group's administrator.

For some groups, offering extended hours simply makes good business sense. Northlake Pediatrics, a three-doctor practice in Truckee, CA, expanded its hours to compete with a group of FPs, who also offered evening hours. "We were afraid we might lose patients if we didn't," says pediatrician Deborah Brown. Within three months, the evening appointments, which run until 8, were booked. "We're always busy in the evenings, summer or winter," says Brown, who often sees more patients after dark than during daylight. Brown uses her mornings off to ski at nearby Tahoe and "to get things done. For me flextime has been great, because I'm single and don't have anyone to help with daytime chores."

But it isn't a given that if you extend your hours patients will come. FP Michael Pendleton's group quit offering evening hours because few patients wanted appointments between 5 and 7 pm. "Also, the doctors and staff didn't like working until 7 because we couldn't have dinner with our families," says Pendleton.

Sherry Migliore, a consultant with PMSCO in Harrisburg, PA, recalls an ob/gyn practice that cut the number of evenings it stayed open from three to two for lack of patient interest. "Patients may say they want evening hours, but if the office is close to their workplace and they can get the time off, they'll see the physicians during work hours," she says. She advises groups to stay open late one or two nights a week at first to see if the schedule fills.

Ob/gyn Steven Thompson of Truckee, CA, finds that patients especially like the 8 to 9 am slots, though working women usually get their Pap smears during lunch hours. Because the practice of two OBs and a nurse midwife added eight hours per week, patients have to wait only two to three weeks for routine appointments instead of six.

The payoff in productivity

Float the idea of extended hours by polling your patients, suggest consultants. You may not have to keep your office open 12 hours a day, but hours beyond the usual 9 to 5 can give your practice a competitive advantage. "Patients feel they are getting special treatment when doctors try to accommodate them," says Curt Nurenberg, a consultant with Rehmann Robson in Lansing, MI. Adds Jerry Haynes of the Pediatric Clinic in Opelika, AL: "It's a great way to market our practice, and it's profitable for us."

Patient relations aside, groups often develop flextime arrangements out of economic necessity. Lansing Pediatrics didn't have enough exam rooms to accommodate the new doctor it was hiring. But by opening the office 12 hours a day and splitting the six doctors and four nurse practitioners into two six-hour shifts, the group found its 16 exam rooms adequate.

Edmonds Family Medicine Clinic, a 25-physician family practice group north of Seattle, requires its part-time physicians—those doctors who fall 10 percent below the group averages in production, patient visits, and hours—to flex their hours so the group can add full-time physicians without renting additional space. "Where economics and flex scheduling come together, we create space sharing," says group administrator Marcy Shimada.

Not only does the space sharing defray overhead expenses, but the eight flextime physicians cover more of the evening clinics so each full-time physician has to work only one evening each week. Initially, Lansing Pediatrics' Mark Israel and his colleagues worried that the four fewer hours they work per week would translate into lower incomes. (Although the practice is open longer, the addition of another doctor and flex scheduling means each doctor works less.) But so far this year, the five partners are averaging a more than 10 percent increase in production. "Working a six-hour shift instead of dragging through a 12-hour day keeps the doctors energized and much more efficient," says Curt Nurenberg, the consultant who helped the practice extend its hours.

Selling extra hours to your staff

The doctors at Lansing Pediatrics offered employees an extra $2 per hour as an incentive to work at least one evening per week. "The last thing you want is to open your office longer and then have staff quit," says Nurenberg. "I can't tell you how much time it took for the office manager and nurse scheduler to get the staff comfortable with extended hours. In the end, we asked them to give it a chance."

Staff members were given the choice of working three 12-hour days, six-hour shifts, or eight-hour shifts. The group also hired three additional business-office employees and four nurses (some part time), but required some experienced staff to be present during office hours.

The staff adjusted, and no one quit. But, since patients are seen continually through the 12-hour day, the doctors and staff no longer eat lunch together. "This is something we really miss," says office manager Dee Flower.

Assembling staff and physicians for meetings is also more difficult when work shifts are staggered. Depending on the size of your group, you may have to hold two meetings.

At the Pediatric Clinic in Opelika, AL, each doctor has his or her own nurse, and they rotate together through day, evening, and weekend shifts. During evenings and weekends the business office is staffed by a separate crew, often college students working part time, who earn time-and-a-half pay on Sundays and holidays.

But Amanda W. Smith, a consultant with Gamble Givens & Moody in Charleston, SC, advises against letting locum tenens or moonlighters take your practice's evening and weekend shifts. "It's hard to keep communication flowing, especially on compliance issues and record-keeping," says Smith. "Having staff doctors and their nurses rotate through these times allows for continuity of patient care and a more cohesive practice."

The appointment schedulers at groups that flex their hours may initially have to be more vigilant about who's working when, but eventually a set schedule of alternative hours becomes as routine as the standard 9 to 5. Varying work hours may pose some challenges for two-career couples in terms of dividing child care responsibilities. But as consultant Sherry Migliore points out, "With call and trips to the hospital at odd hours, doctors are already pretty used to irregular work schedules." Adds Amanda Smith: "We're talking about flextime; if you can't be flexible, you're not living up to the potential of the concept."

The author is the former Group Practice Editor of Medical Economics.

 

Anita Slomski. Get a life--go flextime. Medical Economics 2001;18:62.