Group Practice

Making part-time practice work—for all concerned

Doctors are embracing reduced schedules. But issues such as call, overhead, productivity, and partnership remain.

By Anita J. Slomski
Group Practice Editor

Fresh from residency and eager to launch his career in physical medicine, Jonathan Reeser, 40, wasn't exactly thrilled with the half-time job offer he got from Marshfield Clinic in Marshfield, WI. But he accepted, since his radiologist wife was already working there full time. When he was given the chance to increase his practice to 80 percent time, he jumped at it. A year and a half later, though, he voluntarily reduced his schedule to 60 percent.

"My 7-year-old son has really blossomed since I've been at home in the afternoons to help with homework and take him to sports practice," says Reeser. "The irony is, I can't imagine working any other way now." Since the birth of their second child in November, Reeser's wife has reduced her work schedule by 20 percent.

Brenda and Michael Holbert, both radiologists in their 40s, left the University of Pittsburgh after seven years in order to share a single radiology position. Their plan was well received at the 515-doctor Scott & White Clinic in Temple, TX, where an internist couple was already sharing a job and 31 other physicians were working part time. The Holberts alternate the days they work so one is always at home with their two children, ages 11 and 2. "I've known two-physician couples who have two nannies, a housekeeper, and a cook," says Michael Holbert. "Instead of working continuously, I find real pleasure in occasionally seeing the sunshine."

By moving to a smaller house and living in middle-income Temple, the Holberts had little trouble adjusting to their reduced income. There are advantages to both of them working part time instead of one spouse being the sole breadwinner, says Michael Holbert. For example, each gets to invest the maximum amount of $10,500 per year in the clinic's 403(b) plan, and if one of them becomes disabled or dies, the other is professionally current and can step into a full-time job immediately.

It's not just women or two-career couples who are opting to work less. FP Dan Fields of Tulsa, OK, reduced his schedule to 75 percent time so he and his wife could home-school their children. "Although I still work about 40 hours a week, I have four mornings each week to spend with my family," says Fields.

Doctors like Fields aside, there's little doubt that female physicians have taken the lead in saying No to 60-hour workweeks. And groups, eager for the patients that flock to women physicians, have had to figure out how to accommodate female part-timers.

"Now that 45 percent of medical students are women, there's no question that all groups will have to deal with part-time physicians," says internist Paul Liss, chief medical officer of the 610-doctor Marshfield Clinic. "Although our full-time primary care doctors have trouble breaking even because of low E&M reimbursement, we hire female part-time primary physicians because they fill their practices rapidly. The patient demand for female specialists more than justifies an overhead subsidy—and in specialties experiencing shortages, such as radiology, part-time contracts can be a real plus for recruiting."

Still, part-timers are a political hot potato for Marshfield. "We've granted part-time status to at least 40 physicians, but not everyone who asks gets it," says Liss. "In a short-staffed department such as anesthesia, a 55-year-old who wants to spend more time fishing won't be allowed to reduce his hours. We can't jeopardize the whole practice to give this privilege to everyone."

Other groups, like the 130-doctor CentraCare Clinic in St. Cloud, MN, tout their flexibility in accommodating part-timers in order to attract young physicians and retain older ones. "Part-time physicians aren't a drain on the organization," insists pulmonologist and CEO Terence Pladson. "Frankly, they work more than they're obligated to by coming in during their time off and staying late. I've seen other groups lose surgeons at 55 and younger because they weren't allowed to cut back their hours."

For the last three years, CentraCare cardiologist Marianne Serkland, 55, has shared a job with a 61-year-old colleague. Each doctor works full time for two months, then takes two months off. During her hiatuses, Serkland does medical volunteer work in Honduras, travels, and gardens.

"A traditional part-time schedule wouldn't have worked for me because my patients' problems—most notably, chest pains and shortness of breath—generally result in long days when I'm here," says Serkland. "The pace of this practice is quite intense, and you get to an age where you just can't keep it up. But after a two-month break, I'm excited to get back to work."

Two obstacles: Call and overhead

Since physicians join groups to make their call schedules more palatable, equal call is often expected from everyone. "Part-timers rarely complain about taking full call because they realize the group is making a pretty significant accommodation," says orthopedic surgeon Wallace Lowry, chairman of the board of directors at Scott & White Clinic.

Marshfield Clinic allows its part-time doctors to take partial call, but offers salary incentives to encourage them to do otherwise. A physician who works 60 percent and takes full call, for example, receives a 10 percent salary increase—2.5 percent more in salary for every 10 percent increment in call. At CentraCare Clinic, pediatricians and obstetricians are required to take full call, but other departments have more leeway in setting call schedules. Only senior doctors with 20 or more years of service are permitted to drop call altogether, and then at a cost of 22 to 30 percent of their pay.

"Shareholder and employment contracts usually provide an option for a doctor of a certain age to drop call, but I've seen groups practically disintegrate when that option is exercised," says Darrell Schryver, managing principal of Medical Group Management Association's consulting group. Contracts should spell out how part-time work will be compensated, how expenses will be allocated, and the cost of call. The penalties Schryver has seen for dropping call range from 10 to 50 percent of compensation—the latter imposed by an orthopedic group that treated trauma patients in the ER.

Overhead is the other potential deal-breaker for part-timers. Before green-lighting part-time doctors, your group must figure out how to apportion the overhead costs of a slot intended for a full-timer. Huge multispecialty groups have an advantage because large numbers of full-time specialists subsidize overhead clinic-wide. "We watch overhead closely, but we don't penalize people who work part time," says Liss of Marshfield Clinic. "Each department looks at its budget, decides how badly it wants the part-time person, then absorbs the higher overhead costs."

It's a different story in smaller groups, where partners are directly responsible for overhead. Robert McBride, 48, an ob/gyn in a 17-doctor practice in Richmond, spent six months devising a plan to split a practice with his colleague Pamela McGhee, 39. "We couldn't allow one person to go part time because revenue—but not overhead—would fall, and that would hurt the partners financially," says McBride. But with two doctors reducing their hours to two-thirds time, "we'll each generate 70 percent of the revenue we earned when we were full time, patients can see one of us in the office five days a week, the other partners won't have to see our patients, and we'll both take full call," says McBride. A newly hired nurse practitioner will help carry the patient load.

Some consultants recommend that every doctor pay an equal share of the overhead, no matter how many hours they work. "The practice is essentially holding a spot open for the physician to return full time, so the part-time doctor should contribute equally to overhead to avoid unfairly saddling the other physicians," says David Scroggins of Clayton L. Scroggins Associates in Cincinnati.

Consultant Judy Bee, a principal in the Practice Performance Group in Long Beach, CA, suggests the following formula for apportioning overhead: Part-timers pay a full share of fixed expenses, such as rent and utilities. Part-timers also pay a full share of the office manager's salary and benefits, "because we don't want the office manager doing favors for doctors that pay more of her salary," says Bee. Variable expenses, such as medical supplies, the phone bill, and other personnel's salaries are apportioned according to the number of patients the part-timer sees compared with the practice's total patient load. Bee then subtracts direct expenses, such as malpractice and health insurance, from the part-timer's compensation. An amount also may be deducted to compensate full-time doctors for absorbing the part-timer's workload when he isn't in the office.

Other consultants question the wisdom of asking part-timers to share equally in overhead. "That would kill part-timers financially," says attorney Dan Bernick, vice president at Health Care Law Associates in Plymouth Meeting, PA. "Full-time doctors need more staff and supplies, and they use the office more, so it makes sense for them to assume a greater portion of the overhead."

To prevent the overhead issue from driving a wedge between group members, Gray Tuttle Jr. of Rehmann Robson/PCI in Lansing, MI, favors sharing only practice profit. A portion of the profit—say, 25 percent—is divided according to how much each physician works. If a doctor works 60 percent time, he gets 60 percent of what he'd make working full time; the other 40 percent is apportioned among the full-time physicians. If someone drops call, the group can subtract another 20 to 35 percent. The rest of physician compensation is based on productivity. "I can march groups through this formula without a lot of consternation and gnashing of teeth," says Tuttle.

To reduce overhead, consultants recommend that the group pool nurse and clerical personnel. "You want to steer clear of the 'my girl' syndrome, which is not very efficient with part-time doctors," says Bernick. And by getting to know multiple nurses, patients don't feel so much at sea when the part-time doctor isn't in the office, agrees Bee.

Yet, some groups say individual nurses are critical to the part-time doctor's success. "In primary care, patients associate their doctor and nurse as a team," says FP Pat Bolding, CEO of the 23-doctor Family Medical Care of Tulsa [OK], where each of the 17 part-time doctors has a nurse. "When a part-time doctor isn't in the office, it's important for continuity of care for the patient to be able to talk to that one nurse." Although the group has resisted requiring part-time doctors to share equally in overhead, the idea is being considered. "Philosophically we understand that people want time with their families, but we have to balance that with economic realities," says Bolding.

Are part-timers fit to be partners?

FP Michelle Petrofes and her husband, Dale Harris, have worked 75 percent time for 15 years and both are partners of a five-doctor group in Reedsport, OR. "One of my partners said he doesn't think of us as part time because we're working all the time," says Petrofes. "Because of our more flexible schedules, we frequently fill in."

An admirable work ethic, but consultant David Scroggins doesn't put much stock in permanent part-time shareholders or owners. "Part-time doctors will vote against expanding the office or buying a new computer," he says. "They are not on the team and will destroy the group." He recommends making shareholder status contingent on the number of dollars each doctor brings to the practice. Set a benchmark—say 75 percent of the group's average established doctor's productivity. Doctors who don't achieve that benchmark aren't offered partnership and are either terminated or put on a year-to-year contract. Partners whose productivity falls below that amount must sell their shares back to the group. And if the group shares a portion of revenue equally, require doctors to reach, say, 90 percent of the average established doctor's productivity before they can participate in that pool.

"You don't want to give a permanent spot in the group to a part-timer and lock up space and salary when you can hire a full-time physician who will eventually become a partner," says Scroggins.

Doctors who work less than three-quarters time probably shouldn't be made partners, agrees Bernick, but he has a different view of more-involved part-timers having a shot at partnership "if the group wants them to be long-term players." He questions the notion that part-timers will vote against capital improvements. "They aren't anxious to make the organization function less well, thereby putting their own jobs in jeopardy," he says.

Indeed, long-term part-time employees are often exactly what a practice needs. Two full-time pediatricians in a small town in California hired a pediatrician, who worked four days a week. The two partners, who made $20,000 a year on the part-time doctor, were concerned that he wasn't eager to buy into the practice and work full time. When Judy Bee analyzed the practice, she found that there weren't enough patients to support a third full-time doctor. "If they fired this physician and got a very ambitious doctor to work five days a week, the two partners would have made much less money," says Bee. "The doctor they had was a godsend since he took equal call but didn't need a big practice to support him."

More productive than full-time doctors

Part-time doctors' hours may look enviable on paper, but the job frequently spills into their off hours. Jonathan Reeser is supposed to be seeing patients from 8 am until noon, but often squeezes in a patient in the early afternoon or does hospital rounds then. "I'm usually running out the door at 2:35 to pick up my son at school," he says.

Many report coming in on a day off to round on a patient or to catch up on paperwork. Michael Holbert keeps his beeper on during his nonwork days. "It's easier for me to take care of the problem right away than to wait until I'm back at the hospital. If it's too complicated to handle over the phone, I'll ask my wife to look at the case."

Ob/gyn Audrey Tool, who works three-quarter time with a group in Fort Collins, CO, adds: "It's hard not to overextend yourself. If a patient needs emergency surgery and the OR has an open slot on my day off, I'll say, 'Just this once I'll do it.' But I find myself doing that every other week."

Far from being a liability, part-time physicians can be a "very good cost benefit to a group," maintains Lisa Benson, a mother of three who works 60 percent time at Marshfield Clinic. "A physician who works 80 percent can be as productive as a full-time physician," she says. "We tend to work harder and get more done during the days we're in the office. Plus, if you have time to follow your outside interests, you'll probably be a happier person and, therefore, even more productive on the job."

That said, there nonetheless are times when part-time physicians must rely on colleagues to see their patients or return patient calls. None of the physicians we talked to said they sensed any resentment from fellow doctors. Generally, that's because the extra work is rarely onerous. In the seven years that internist Beatriz Hall has worked every other week at Scott & White Clinic, her colleagues have had to see an average of two to three of her patients during her off weeks.

"Ninety percent of phone calls and prescription refills can wait until I come in on Friday of my week off to do paperwork," says Hall. "And my secretary calls me four or five times a week with prescription requests. I think my schedule is harder on my colleagues than if I worked a portion of every day, but they've been very understanding. If they were unhappy, I would change my schedule."

Hall, who speaks Spanish, has many patients who come from Mexico for annual physicals. "By working a full week instead of half-days, I can save patients who travel long distances from having to spend a night in a hotel. And then I'm off for seven days. I can be a mom to my four children, I can be a wife, and I can be a doctor, too. It's worked marvelously."

"When you choose medicine as a career, you don't realize how much you have to give up," says cardiologist Marianne Serkland. "It's good for people's souls to have more time for themselves, their interests, and their families. Work shouldn't be our life."

 

Anita Slomski. Making part-time practice work--for all concerned. Medical Economics 2001;11:84.