Kamei, Robert K. MD; Chen, H Carrie MD, MSEd; Loeser, Helen MD, MSc
Part-time residency training options were pioneered in Great Britain in the 1960s, and subsequently introduced in isolated programs in both the United States and Canada.1 The stimuli for developing flexibly scheduled training options included the growing proportion of women, older students, and dual-career couples in medical training.2 There is a continuing demand for more flexible career structures in which doctors can follow a variety of different routes through their careers and vary their time commitments according to their needs at particular stages of their lives.3 However, despite the apparent successes of these programs, and continued increase in the number of trainees for whom these programs would seem to be attractive,4 flexibly scheduled training options have not been increasingly embraced or even sustained.5
This situation does seem to provide an excellent opportunity to meet the challenges of defining reasonable options for supporting healthy families.6 Additionally, offering a flexible scheduling option can be a powerful recruiting and retention tool,7 which may be useful with the current trend of diminishing interest in primary care training.
For more than ten years, the University of California, San Francisco, (UCSF) School of Medicine Department of Pediatric Residency Training Program has offered to its residents the option of proceeding through residency training on an extended schedule, called the Flexible Option (FO). Several national trends stimulated the development of the FO: the shift to a majority of women in pediatric residencies, an increasing number of residents with expanded family responsibilities, and the development of new expectations and guidelines prompted by regulations such as the Family and Medical Leave Act of 1993 (FMLA). Thus we explored the potential of applying other innovative solutions in support of resident’s interests and needs. We found that this flexibility created a supportive culture for the residency program, and we recognized the FO as an asset in recruiting and retaining the residents our program seeks.
Residents in our large, university-based training program staff five different sites: a university medical center, a county medical center, two community-based medical centers, and one full-service health maintenance organization. FO residents work six to eight months each year and can take up to five years to complete the 33 months of training required by the American Board of Pediatrics. The specific four to six months away from the program are determined each year by request of the resident combined with the scheduling needs of the program. The FO is available to residents only after they successfully complete the first year of residency training, and the schedule is neither part-time nor shared. Since continuity clinic is a fundamental component of pediatric residency education, we feel it is important to sustain that aspect of training. During the four to six months off each year, the FO residents maintain their Primary Care Continuity Practices, except for the few residents who travel outside of the local area. Those residents cluster their expected continuity clinics just before or immediately after their time away. No residents had medical illnesses that prevented them from continuing their continuity clinics.
The residency program covers disability insurance, workman's compensation, and medical malpractice for the full year, but does not supply salary during the “off” months. Residents choosing the FO for reasons of maternity or care of a dependent are continued on medical insurance as required by FMLA. Other FO residents go off the payroll, and ensuring continuity of health insurance coverage is a challenge for them. The availability of alternative coverage through a partner provides solutions for some; for others, obtaining health benefits under the Consolidated Omnibus Budget Reconciliation Act (COBRA) must suffice. On average, we support two or three residents per year to participate in the FO. We have constructed a mechanism to combine salaries covering multiple FO residents, even across different years, which affords the program administration the capacity to support the FO. However, beyond the increased direct costs of maintaining benefits for nonsalaried months, the program also accrues additional indirect costs in administrative and faculty time to support the FO residents.
We have acquired more than ten years’ experience with the Flexible Option program. It is well established in the residency program, and 24 individuals participated from 1992–2002, the period of our study. Although we continue to feel that our initial reasons for developing the program remain compelling, we wished to evaluate the outcomes of the program and to assess the balance between costs and benefits. Furthermore, we thought it was important that this evaluation include not only the effects on the FO resi-dents, but on all of the “regular schedule” (RS) residents as well. Substantiating and disseminating our long-term program experience might encourage other programs to consider flexible options for their own residencies, and permit residents and faculty to advocate for alternative training program schedules.
Between 1992 and 2002, 284 pediatric residents entered the UCSF Pediatric Residency Program. Of these, 24 (20 women) participated in the FO. Our goal was to interview these 24 residents by telephone regarding their perspectives about extending their training. In February 2002, an independent research consultant conducted the structured interviews and the recorded responses were anonymous. In addition, at the end of 2001–02, we administered an anonymous Web-based questionnaire that asked for RS residents’ perceptions regarding the impact of the FO program on their training experience. RS residents were informed of the study by means of the electronic listserv used for all residency communications. A neutral party administered the online questionnaire, kept track of the participants, and provided us with coded, aggregated data. Responses were given on a five-point scale: 1 = “strongly agree,” 3 = “neutral,” 5 = “strongly disagree.” Participation in the questionnaire was voluntary and no incentives were offered for participating. We obtained no funding for this study. The Institutional Review Board of UCSF approved the study protocol.
We analyzed quantitative and qualitative data for this report. Data from the American Board of Pediatrics certifying examination were analyzed comparing the aggregate scores of FO residents with those of all residents who graduated from the UCSF Pediatric Residency Training Program and took the examination in 2001. Statistics for continuous variables, including means and standard deviations were calculated and one-way factorial analysis of variance (ANOVA) was applied. The confidence interval for the pair-wise analysis of differences was determined. The qualitative analysis of the structured interview data consisted of categorizing recorded answers into common themes and documenting frequency.
Flexible Option Resident Interviews
Of the 24 residents who participated in the FO between 1992 and 2002, the independent research consultant was able to contact all but three; all 21 residents (19 women) who were contacted agreed to participate in the telephone interviews.
At the time of this study, 15 of the FO residents had completed the residency program, and nine were still in training. Residents’ most commonly stated reasons for selecting the FO were to care for a child or parent and to work on a significant personal relationship. Other reasons included time to perform research, to pursue international health work or other educational interests, to supplement income, and for mental health care. Administratively, the program accepts a broad range of intended reasons for selecting the FO. In practice, most residents’ reasons for selecting the FO did account for how they used their flexible time, and all of their activities fell within acceptable categories (See Table 1).
When asked what choice they would have made had the Flexible Option not been available, 52% of FO residents reported that they would have simply completed the residency program on time, 48% reported that they would have asked for a personal leave of absence, and no FO residents reported that they would have left the program or pediatrics altogether.
When the FO residents were asked how important the Flexible Option was to their success as a resident, 57% reported that it was critical to their success, 43% reported it to be very helpful, and none felt that it was disadvantageous for their residency education or detrimental to their careers. Two of the FO residents competed successfully to become chief residents in our program.
For 45% of the FO residents, taking time off was of great importance. Two representative comments were: “I can give better during my work … knowing that I have time off to refocus on family, friends and other personal interests” and “My mother was sick with cancer, and I was able to take better care of her and my own health.” Additional advantages reported about the FO included using the time to figure out career options; participating in activities helpful to career development, such as research or other clinical work; and learning another language.
One of the most common disadvantages stated by the FO residents was the delay in their “graduation” and finishing out of sync with their class (45%). As one resident said, “I wouldn't graduate with my class, and I wondered [how] everyone else was handling it [while] I needed the time off.” The other commonly stated disadvantage was financial (36%): the concern of taking time off without pay, and the need to pay for one's own health insurance during the time off. Some noted the concern of transitioning in and out of the residency: “I was concerned that I would be ‘rusty’ after being away,” commented one resident.
We analyzed data from the American Board of Pediatrics certifying examination and compared the aggregate scores of FO residents with those of residents who graduated from the UCSF Pediatric Residency Training Program and took the examination in 2001. At the time of the study, 15 FO residents were board eligible; all took the examination and passed on the first attempt. The FO residents’ scores (mean = 512, SD = 58.8) were compared to scores of all the UCSF Pediatric Residency Training Program graduates who took the exam in 2001 (mean = 524, SD = 79), and the published ABP reference group (mean = 500, SD = 100). There was no significant difference between the three groups (p < .76). The difference between the means of FO residents’ board scores and all U.S. residents’ board scores is 12 (95% confidence interval [CI], −38 to 62) and the difference between the means of UCSF residents’ 2001 board scores and FO residents’ board scores is 12 (95% CI, −36 to 60).
Regular Schedule Resident Questionnaire
A total of 81 residents were enrolled in the UCSF Pediatric Residency Program during the 2001–02 academic year. Of those, nine had participated or were current participants in the Flexible Option program. The 72 remaining RS residents were asked to complete an anonymous, secure, online questionnaire. Forty-two (58%) RS residents each completed a questionnaire. The characteristics of the RS residents who completed the questionnaire are summarized in Table 2.
Of the RS respondents, 43% had considered taking the FO. Most thought they would use the time to pursue four major activities (listed in decreasing order of frequency): international work, family, research, and additional degrees in areas such as public health. The major reason these residents reported for ultimately opting against the FO was financial. Many felt they could not afford to take the time off without pay. Other reasons included the wish to finish residency in the least amount of time, to remain with their class, or to be fair to other residents.
Seventeen percent of the RS respondents felt the availability of the FO was an important factor in selecting the UCSF residency program, but none chose the program mainly because of the FO. The majority, 52%, considered it a nice option but did not plan to use it. Nineteen percent did not know about the FO when they applied, and none felt the FO negatively influenced their decision. Twenty-eight percent felt that knowing about the availability of the FO helped them continue in residency but only 7% regretted not taking advantage of the FO personally. Forty-three percent felt the effect of the FO on their personal overall residency experience was strongly or somewhat positive, 33% cited no effect, and 24% cited a somewhat negative effect on their experience. Overall, 12% somewhat resented the participation of other residents in the FO (see Figure 1).
When questioned about potential negative effects of having residents in the FO, 43% agreed or strongly agreed, and 31% disagreed that the FO increases the work load for fellow residents; 52% agreed or strongly agreed, and 24% disagreed that the FO creates scheduling problems for fellow residents. When asked about the FO's effect on general morale of the residency program, 79% cited either a strong or somewhat positive effect, 5% thought it had no effect, while 17% thought it had a somewhat negative effect (see Figure 2).
Despite the perceived negative effects, 88% of RS respondents agreed or strongly agreed that the residency program should continue to offer the Flexible Option. Only two residents disagreed or strongly disagreed. One resident wrote in a comment, “Honestly the flex option does make it hard on the residents who don't flex. We really carry the load. But, I wouldn't want to take the option away. It is good for those who need it and allows for people to further pursue options in their lives—which is an important value to keep in a residency.” Yet another wrote
I think this is an essential option for a family-friendly residency. Residents could always do the activities they planned during flexible time after residency. However, you cannot always plan certain life events, and the opportunity to stay home with your infant is an important one. I think it says a lot about our residency that this is a viable option for us. It reminds us that all our life choices are supported by the program. I won't need to flex, but it's nice to know it's there.
In our residency program, the benefits accrued by the FO residents are substantial, and center on well-being, support for individual needs by a structure (i.e., residency program) usually perceived to be both rigid and demanding, and validation of the value of family and other interests as fundamental to personal success and additive to residency training. We believe this is a notable finding for an established program that has existed for over ten years.
Participating in the Flexible Option also resulted in perceived costs to the FO residents. Most often, they noted decreased collegial relationship with peers, as FO residents often felt part of neither the class they began internship with nor the subsequent class they joined as they extended their time in the residency. Financial concerns also loomed large for many participants, including covering health insurance premiums through COBRA, and lack of income during the second year of residency as a result of the local market preference for “moonlighters” who have completed their second year of training. There were also associated opportunity costs, as it took more time to complete residency training.
Our results concur with published findings regarding consequences of flexibly scheduled training options for residents: a sense of dislocation from the “class”; concerns about competence and about how others perceive them; and issues around salary and insurance coverage. Our findings are also consistent with those of Carling et al.,8 demonstrating that objective outcomes do not differ between flexibly scheduled residents and full-time residents. In addition, Carling et al. report that faculty attribute certain strengths in greater measure to flexibly scheduled residents than to full-time residents.
Unique to our study was the evaluation of the impact of the FO on RS residents. RS residents perceived costs and benefits, both as individuals and to the residency. When asked about the effects on their own residency experiences, significant numbers of RS residents felt that having FO residents both increased the workload and created scheduling problems for fellow residents. Remarkably, the vast majority of RS residents strongly endorsed the importance of the FO to the residency as a whole.
We had a good overall response rate for this study: 88% of the FO residents and 58% of the RS residents responded. We believe that we elicited all substantive issues. Our residents are generally outspoken, especially regarding issues they feel strongly about, and are empowered within the residency to participate in discussions regarding their educational experience and work conditions. However, it is certainly possible that the proportions weighing in on certain features and factors might have varied if we could have improved our response rate. In fact, we believe that, if anything, we have captured an overestimate of concern because the survey of RS residents occurred during a year of unusual constraints: for unanticipated reasons, the program was short two residents; two of four chief residents took maternity leave; and the total number of FO residents in the program at one time (five residents) reached a historic peak.
Although many RS residents expressed concern that their schedules were affected by the needs of others in the program, including FO residents, it is difficult to determine whether the FO truly put RS residents at a scheduling disadvantage. We had other unanticipated schedule changes not related to the FO but instead driven by needs on the part of both the program and individual residents. These changes may have caused the perceived inequities that were attributed to the FO. From the program perspective, the RS residents did not bear an increased burden placed on the program by the FO either in schedule of rotations or quantity of call. In fact, the FO was used to advantage to provide coverage of several residents who were unexpectedly on leave for protracted periods of time (leave under the FMLA, unanticipated illness, etc.) by negotiating to rearrange the timing of the flex months, or renegotiating the total number of months away from the residency with an individual FO resident. In these circumstances, the RS residents might not have been aware when and how the FO contributed to resolving RS schedule and coverage issues.
We recognize that the specifics of our experience may not be applicable to other residency programs’ context and/or constraints. For example, ours is a large program, with multiple sites, numerous full-time, paid faculty, and an extensive network of support services for patient care. In addition to the FO, our residency regularly supports varied schedules for a wide array of trainee outcomes, such as the American Board of Pediatrics Special Alternative Pathway (fast tracking into subspecialty fellowships) and a research pathway. And, because our local economy and regulatory environment have afforded opportunities for off-service residents to earn additional income, this perhaps permits greater flexibility with resident income than others may enjoy.
For those who may be daunted by the proposition of overwhelming numbers of residents choosing a flexible option, our experience indicates otherwise. The balance between benefits and consequences of the FO effectively limits interest, which appears fairly stable over time. Even when allowed to choose for personal reasons, only a small number of our residents (24 of 284 over ten years) actually made this choice.
The Flexible Option is an important aspect of our residency program. Despite negative consequences perceived by RS residents, the overwhelming sense from all residents is that the Flexible Option provides an important opportunity for residents to support one another. Its existence also makes an important statement about the values of the entire residency program. This structured program gives residents the strong message that it is indeed “permissible” to take personal time during residency training and that it is supported by their colleagues and residency administration. The Flexible Option permits us to provide a humanistic and family-friendly context in which to learn to practice medicine and support the well-being of our resident physicians.9 All residency programs should consider this model or other alternatives to accommodate the complicated lives of our trainees and better help them balance career and individual and family needs.
We thank Carol Hodgson, PhD, Director of Education Research and Evaluation, UCSF, School of Medicine, for her helpful suggestions on the survey instruments and assistance with data reporting.