Harrison, Rebecca A. MD; Gregg, Jessica L. MD, PhD
Increasing numbers of physicians now work part-time,1 and studies suggest that in comparison with their full-time colleagues, part-time physicians have higher job satisfaction and productivity,2,3 equal or higher-quality performance,4 and similar patient satisfaction.5,6 Yet despite these trends, and benefits, academic physicians seem less likely to work part-time than are community physicians.1 In a 2005 study, 13% of U.S. respondents worked part-time, with the highest numbers in health maintenance organizations (22%) in comparison with academic physicians, where part-time practice was reported less than 11%.1 In 2003, only 11% of the Society of General Internal Medicine (SGIM) membership, a largely academic medical organization, reported working part-time.2,7
Barriers to part-time work include negative perceptions about part-time individuals’ work ethic and commitment to medicine, lower rates of promotion and tenure, less effective mentoring, and less research support compared with full-time physicians.2,8–11 Yet, part-time career opportunities are increasingly critical for recruitment and retention in internal medicine and other primary care specialties. In a 2002 survey of women pediatrics residents, close to 60% stated that they would be interested in working part-time within five years after graduation,12 and data suggest that the perception of controllable lifestyle accounts for recent career choice trends among medical students, who are choosing to stay away from primary care and are moving toward specialty choices such as ophthalmology, radiology, and dermatology.13 Furthermore, when students, particularly female students, do choose a primary care specialty, they often avoid or leave academic careers because of concerns about family and work balance in the academic milieu.14 This decreases workforce diversity and compromises the financial health of academic institutions; the loss of a clinician to a practice is estimated to cost the institution between $250,00 and $400,000 per individual lost.15
Thus, academic medicine is at a crossroads: increasing numbers of clinicians desire part-time work and will opt out of academics if that option is not available, or if the barriers to part-time are too high. Yet, while many are opting out of academia altogether, a small but growing proportion of part-time physicians have opted in,16 and their experiences will help determine whether and how part-time work is accepted in academic medicine in the future. Therefore, it is important that we document those experiences and build models of part-time work that will further the success of both part-time physicians and their academic divisions.
Our goal was to use qualitative methods to better understand the decision-making process surrounding part-time careers and the experience of part-time work in academia. More specifically, our aim was to understand the experiences of a purposeful sample of academic physicians and their division chiefs, all of whom had undergone a rigorous process (the Horn Scholars application, discussed below) refining their understanding of part-time work and the role of part-time work in their lives and for their divisions.
To our knowledge, this is the first qualitative study exploring experiences with part-time work for individuals and their division chiefs in academic medicine. We are unaware of any such qualitative study exploring part-time work experiences among internal medicine physicians or any other specialty. As such, our study does not attempt to quantitatively measure beliefs, behaviors, or experiences, and it does not assume that the experiences of this purposeful sample are “average.”17,18 Instead, we have tried to tap into the expertise of a sample that has been through a process requiring them to articulate and defend their reasons for beginning part-time work (or for having part-time workers) and their experiences as part-time workers (or with part-time employees). We then use their insights to begin the process of documenting or “mapping” experiences, identifying trends and ideas that will warrant further exploration in future research.
Design and participants
In 2005, we conducted in-depth qualitative interviews with a purposeful sample of physician applicants to the SGIM Horn Scholars Program from the 2001 and 2004 award cycles, and their division chiefs at the time of the application. This program is a three-year career development award open to any SGIM member intended “to foster a new career track for physicians centering on successful balance of career, family, and social responsibilities.”19 Currently, there are funds for one scholar every three years of up to $37,500 per year made to sponsoring institutions to support the scholar and the scholar’s work. The sponsoring institution must agree to at least match the award. Scholars must be dedicated to working half of a full-time academic position as a clinician educator in general internal medicine (approximately 2.5 days/week or 20–25 hours) and spend the other half focusing on family. The scholar’s patient-care responsibilities include serving the medically indigent and comprise no more than two half-day clinic sessions per week in direct patient care. The application contains in-depth, focused questions regarding career and personal goals (List 1) and requires an endorsement letter by the applicant’s division chief. We therefore purposefully targeted this sample of part-time physicians and their division chiefs because they were a group who, through the application process, had the opportunity to actively reflect on the benefits and drawbacks of part-time work in academic medicine. Although the Horn Scholars Program is not limited to women, all applicants thus far have been women.
We performed in-depth, face-to-face or telephone interviews with applicants lasting one to two hours. With their permission, we invited applicants’ division chiefs for interviews lasting from 30 minutes to an hour and a half. We transcribed audiotapes, and the two authors independently analyzed transcriptions. Given that little is known about our study topic (subjective experiences with part-time work in academic medicine), our interview questions were not developed with the goal of testing specific hypotheses derived from the literature. Rather, we used a grounded theory approach, asking general questions (such as “Why did you consider working part-time, and how has that been?” to the faculty, or “How has having a part-time division member been?” to the division chief) that would allow us to develop theoretical frameworks from our primary data.20–22
Each of us read each of the transcripts in their entirety and identified general themes. We then met to discuss those themes, rereading the transcripts when there was doubt or disagreement. Our themes were validated by the participants after reviewing copies of our results in slide presentation format. The results were presented as separate presentations at the Northwest regional SGIM meetings in March 2006 and 2007, the national SGIM meetings in April 2006 and 2007, and at Association of American Medical Colleges annual meeting in November 2006. IRB approval was received from Oregon Health & Science University. During the process of analysis, each participant was identified as HA (Horn applicant) or DC (division chief) followed by a number; applicants and their division chiefs were not paired numerically in order to protect identity. We have maintained those identifiers in reporting our results. In this article, we document specific drawbacks and benefits to part-time work noted by the participants. However, because it was such a striking and potentially important finding, we have chosen to focus the bulk of our analysis and discussion on participants’ conceptualizations of the idea of part-time work itself.
Seven of nine eligible applicants (77%) participated. They were all junior faculty women, clinician educators in academic internal medicine, from seven major academic institutions; their approximate ages based on graduation from residency ranged from 30 to 45. All had dependent children (one to three children). Six of seven had a spouse employed full-time (three spouses were physicians). The range of hours worked was 0.5 to 0.8 FTEs (one participant was 1.0 FTE at the time of the interview but 0.5 FTE for three years prior). One participant had a PhD.
Six out of seven (87%) eligible division chiefs were interviewed. Their ages based on graduation from residency ranged from approximately 50 to 62. One refused an interview. All division chiefs were male senior faculty members who trained in internal medicine, were full-time workers, and had families.
Consequences of part-time work
Lists 2 and 3 highlight the negative and positive consequences of part-time work identified by physicians and division chiefs. Interviewed participates cite part-time work career benefits to include more research time and ability to focus on career goals, potentially resulting in career transitions or pursuit of scholarship. Personal benefits centered largely on time for family, community, or self-care activities. Career drawbacks include working more hours while being paid less, or working more than allotted FTE. Some cited a slower promotion trajectory or even demotion, being overlooked for career opportunities, given less desirable work, or being marginalized within the division.
Division chiefs describe several benefits to having part-time faculty in their divisions including recruitment and retention of high-quality faculty members and creation of more “balanced” career paths. Some described these faculty having more time available for scholarship and presentations, which increases division visibility.
Challenges of having part-time faculty in a division include equity of pay, work, and defining part-time and full-time hourly equivalents. From the perspective of division chiefs, negative consequences of part-time work for the worker include the potential loss of benefits and health insurance, but they also highlight the potential to be viewed as a less committed worker or one who is not fully integrated into the division.
Framing the decision to become part-time
Though both physicians and division chiefs identified multiple specific negative and positive consequences of part-time work, more generally, both groups tended to conceptualize part-time work in one of two ways. In the process of analysis, we termed those concepts “working less” and “working differently.” We found that three of the applicants and three division chiefs framed the decision to work part-time in terms of working less, and four applicants and three division chiefs framed the decision in terms of working differently.
Women whom we identified as “working less” continually stressed the impossibility of successfully meeting conflicting demands of home and work:
I really love what I do; I just need to do less of it. It’s such a huge conflict to me…. I can’t get up at 3:00 in the morning anymore and chart for four hours before the kids get up. I physically can’t do that anymore! And I am stepping back and looking at myself and saying okay, I am 35 years old, and I cannot keep up this pace. It’s absolutely impossible that I’ll be able to keep this up at 45 or 55, and I’m looking at how many more years I’ve got to work. I must work. So I can’t afford to kill myself now. (HA2)
My husband always says, well this is too much …. My dad said he was just exhausted after reading my [Horn] application. I described everything I was already doing, which was way too much, but then I had come up with a couple of new projects that I was going to work on if I had more time. I am always thinking of things to do. (HA7)
The pressures of trying to do full-time parenting and full-time working were making me miserable. I was finding that I needed to relieve the babysitter; I wasn’t even done with my dictations, if I was going to give complete patient care. Then suddenly my child was hungry, so dinner needed to be make, groceries needed to be gotten …. Just too many things kind of squishing at the end of the day and making me feel very stressed and unhappy. (HA1)
For these women, less work seems to be just that—less—and thus perhaps not as good. Thus, even as part-time workers, each sought to squeeze more work into their days:
I already see patients over lunch. I double book and cram these people into my already truncated day. (HA2)
I answer my phone calls while I’m with my children’s activities in the afternoon, and I answer e-mail often when I have gotten home or in the evening, every day. (HA1)
I always feel guilty playing with my kids and then wondering, boy I hope I get a little time to work today. Being happy that they both take a nice long nap. It’s awful, but it’s true…. (HA 7)
By contrast, women whom we identified as “working differently” described working part-time as a decision to fundamentally alter how they spend their time:
It was like a new stage in my life [when she decided to begin part-time work]. I did not want to cram everything into one week. I wanted to just change it all together. (HA3)
I said that I’m not going to do this. There needs to be a change, like a real change! (HA4)
These women conceived of part-time work in an entirely different way; not simply as less than full-time work, but as a fundamental change from full-time work.
One participant contrasted her part-time career to her father’s full-time career in medicine:
For my dad, being a doctor is totally different. He’s of that generation where if your patient calls you in the middle of the night, you’re like, no problem; you got up and went to the hospital …. I don’t think me being available in the middle of the night makes me a better doctor or more professional. I really love work, but it is not the amount of work, it’s the quality of work that’s important to me. (HA6)
She went on to say,
I love being at work because I know on Tuesday afternoon when I am seeing patients and running behind, I know my husband is going to pick up my son, I know I’ll see him all day Wednesday and I’m going to wear jeans and we’ll go for a walk…. So I feel I’m really much more pleasant for patients. I just talk and spend time with them. I don’t feel out of control or overwhelmed. (HA6)
I’m much happier at work than I was when I was full-time. But I’m no less busy…. I’m a mom on Sundays and back to work on Mondays. I’m totally not a physician 100% on the days I’m at my daughter’s school in shorts and a T-shirt. I’m totally removed from the work environment. I can focus at work more…. I can be completely devoted to both separately and it’s wonderful! (HA4)
Another discussed her commitment to protecting time away from work and the clarity she experiences in her work and home life:
They [department chiefs] know my choices are because of the children, but I have also heard their response back that we all have children and we all have families…. Sometimes I have been able to protect it [time] just having discussions with the section chief. Sometimes I have to go to the chairman level to settle the issues. (HA5)
Interestingly, participants who discussed part-time work as an opportunity to work differently also spoke extensively about the important roles that self-reflection and value articulation played in their ability to shift their thinking about work:
I never thought that I would have to sit, think, prioritize, and negotiate what’s important to me, all that came when I started thinking about becoming part-time. Most full-time academicians just work and work, that’s it…. When I went part-time, clearly I became so much more self-aware of my needs and professional and personal desires. (HA6)
I really thought hard about how I wanted to work and how I wanted to balance, so I just decided I’m going to do this part-time. I’m going to say this is what is important to me. (HA3)
That process of reflection continued when women began part-time work:
Being part-time helped me slow down to think about what I really wanted to do, then allowed me to work on an advanced degree, which took three years. I did it really slow so that I didn’t stress the family unit too much. I think it worked to my advantage. (HA5)
Another describes how working part-time provided the chance to reflect on and focus her career goals, becoming more ambitious while embracing a longer career trajectory:
While I’m more ambitious with career goals because I’ve been able to define them better, I certainly recognize that it will take longer to reach those academic goals. I don’t see that as being less ambitious. I think I’ve become more realistic with the phrase, “you can have it all but you can’t have it all at the same time.” (HA4)
For one of the participants, defining her values and priorities in a structured way through the Horn application process gave her the opportunity to think about work differently and to transition successfully to part-time work:
The [Horn application] process was so good for me. Even though I had all of these ideas, actually forcing me to write them down was unbelievably helpful. I continually ask what am I willing and not willing to give up. Defining this helped me focus. After that, I was like, “Yes, I’m not doing this anymore!” Before, I would have been wiggling away and dropping one seminar again and again.
In turn, this individual’s time away from full-time work gave her the ability to transition back to full-time time, but with a different sense of how that work would fit into the rest of her life:
It was a very conscious decision returning to full-time and no one was saying that you have to do this. I didn’t want to pass up this career development opportunity … an investment in me…. Now my full-time is nothing like the full-time before … the number of hours, control, and flexibility are all totally different. Even though on paper I’m 100%, it feels in every single way different. (HA4)
For both the women who remained working part-time, and for the participant who went back to full-time, self-reflection on values and priorities seemed to provide the opportunity to more consciously align career goals and personal choices. Importantly, long-term career ambitions or aspirations to leadership positions did not differ between the two groups, except that those who viewed part-time as reconceptualized work seemed more comfortable having a longer career trajectory in terms of when they reach these goals.
Notably, division chiefs also reflected these two frameworks for thinking about part-time academic work in medicine. All division chiefs described the struggle to find a way to balance individual division members’ needs with the needs of the division as a whole. However, it seemed that some division chiefs conceptualized part-time work primarily as a desire to do the same work but less of it, whereas others understood part-time work as different work altogether and seemed more aware of fitting work to individuals’ needs and talents.
Three division chiefs stressed that when individuals approached them about part-time work, their primary concern was that time and division of labor remain equitable in the division:
The conflicts are that those who work 1.0 full-time want to see the 0.5 equivalent take at a prorated share of weekend work and nights. They want to see her do 0.5 equivalent of the type of work that nobody wants to do, i.e., nights and weekends. (DC1)
After being asked how he deals with the conflict, this division chief went on:
I make sure things are equally assigned and just let them go with it. There are 52 weekends, and 12 FTE and 52 divided by 12 is “x,” and if we have 12.5 then we divided it out and that’s “y,” and therefore this is what you get. (DC1)
A third division chief emphasized the importance of prorating every aspect of a full-time job worked by a part-time division member to keep salary fair:
If an individual wanted to be a 0.5 FTE once they had already been in the division I would have no problem with that, as long as everything was written in a 0.5 scale; the work and salary expectations, everything else. If you’re going to be a 0.5 FTE then everything is going to be 0.5, as long as it is equally done. You don’t get a 1.0 salary for doing 0.5 work. (DC2)
Another division chief described the challenge of defining what is meant by full-time work to determine the number of hours a part-time worker should work to remain fair to all division members:
Usually the biggest problem with it is with fairness issues: How do you define part-time? Do you work 80% of what you usually work? Do you have a patient panel that is 80% of what you would otherwise have? When you talk about preceptoring, how do you cut those hours down? (DC3)
This same individual noted the difficulty transitioning from a more traditional model of medicine to one that takes account of lifestyle and personal priorities:
Traditionally I don’t think that part-time has been something that, in medicine really, that you traditionally do. We trained to be a professional and work the whole FTE and do everything you had to do for your career. (DC3)
Although he said that he supported part-time work in his division, he noted that he was much more supportive of that choice if the individual physician had no other options:
I think you need to be more careful about having somebody go part-time because they want to versus someone who has to. If they want to, I think they are more likely to take advantage of it. If they have to, I think they are less likely [to take advantage of it]. (DC3)
Similarly, another division chief stated clearly that individual, personal issues not directly related to the job at hand were not relevant to the workplace:
We usually leave the things outside of work outside of work. I ask people how things are for them, but I don’t come down and ask them their personal goals about whatever they are trying to do at home or in their personal life. (DC1)
By contrast, other division chiefs described an approach where “things outside of work” such as personal priorities and values were integral to decisions regarding the type and quantity of work a division member should do. One chief stressed that for a person to begin part-time work, he or she must clarify personal priorities first:
For them to ask for it [part-time work] in the first place, they had to have thought about what they wanted and have their goals together. So I, always in a mentoring capacity, always encouraged people to think them through, to figure out who they are and what their mission and goals are. (DC4)
This person went on to emphasize the importance of identifying the individual’s work interest and the quality of work the individual performs rather than the quantity of work:
We have certain jobs we want done and pay for within the division. So what really matters is how good a person is and how able they are to accomplish the tasks that we want them to do. It’s important they want to do the tasks, too. Then I look at how we put a division together that works and accomplishes the division’s issues. Since our division is academic medicine, we have individual missions, our success as a division relates to the success of the individuals. All those things come together in balance. Whether I think a person is full-time or part-time, therefore, is less important than whether they are doing something that is of importance and doing it well. (DC4)
Another division chief noted the importance of having clearly established goals when considering and negotiating part-time work:
I think of the folks I talk with that they come in with very, very clearly articulated sort of goals and desires relative to the personal life work and balance. (DC5)
A third noted that if a member of his division was not able to articulate what he or she valued outside of work, he wouldn’t support them in choosing part-time work. Giving the example of someone in his division who had considered transitioning to part-time, but relied heavily on external validation from others, he discussed why he did not support her efforts to cut back her workload:
She has a poor self-image, which is something she and I have talked about for many, many years. I think she puts so much of her self-value into what other people say about her because she does her job very exceptionally well that she needs that feedback. If she doesn’t have the feedback, she can’t tell herself she’s doing a good job. (DC6)
Of note, there was no correlation in how the applicant and division chief dyad pair framed the decision to work part-time.
The academicians we interviewed experienced multiple positive and negative consequences from working part-time. Both part-time faculty and their division chiefs framed the decision to begin part-time work either as a decision to do less work or as a decision to work differently. In addition, self-reflection and articulation of values helped some of these physicians determine where in their personal and professional lives they derive the greatest happiness and fulfillment.
Part-time medical practice challenges the long-established cultural work values of medicine. McMurray et al1 note that physicians have traditionally emphasized productivity, indefatigability, and selfless dedication as markers of professional values. For academic clinicians facing the combined responsibilities of teaching, research, clinical care, and mentoring, dedication to work often means dedication to the 60-plus-hour workweek. The women faculty and men division chiefs we interviewed who framed part-time work chiefly as less time at work seemed to hold this more traditional understanding of the role of a physician. They seemed to focus more on what they, or their division staff, were not doing (devoting themselves completely to work) than on what they were gaining (balance, satisfaction, time to explore other scholarly options). By contrast, faculty and division chiefs who framed the decision to work part-time as an opportunity to reconceptualize work seemed to understand work in a fundamentally different way. We believe that although it is challenging, changing cultural attitudes in the academic medical community to embrace the part-time physician work force would be of clear benefit but would require a reconceptualization of work.
This reconceptualization of work has both practical and theoretical counterparts outside of academic medicine. For instance, studies among professional women in other domains have demonstrated that offering reduced work schedules that are a “good fit” with employee needs and values is a key weapon in retaining valuable professional employees, particularly women.23 To increase recruitment and retention of valued employees, some companies are moving toward the “new concept” part-time employment options, which are high-status, career-oriented, reduced-hours options that are crafted to the individual worker’s skills and interests while maintaining prorated professional salaries and benefits. By elevating the status of part-time work, the goal is to recruit and retain individuals as reduced-hour employees with enhanced job prestige, satisfaction, and income, yet allowing these individuals to more successfully integrate work and family responsibilities.24
On a more theoretical level, work by Suchman25 on healthy organizational environments suggests that organizations are “ongoing conversations” between employees, employers, customers, and all those who come into contact with them, and that organizations will function optimally when they respect the values and subjective experiences of their staff. Suchman argues that when leaders focus on appreciating and using the unique strengths and resources of individual workers, rather than expecting one-size-fits-all productivity, organizations are more successful and more productive on multiple levels.25–27 Notably, this model seems to support the idea articulated by some of our participants that value clarification and self-reflection are important steps in identifying the type and amount of work that will allow a physician to be most successful. Furthermore, recent discussions about the need for academic mentors in general medicine to help mentees clarify their values and make appropriate choices suggests that there is recognition in some academic circles that articulation of personal and professional values and goals may contribute to both academic success and satisfaction.28
There are several limitations to our study, including a small, preselected sample that may reflect a specific population of part-time physicians. Therefore, our results may not be generalizable to a broader population. There is also the risk of overinterpretation of positive or negative attributes of results. Finally, we recognize that while we categorized experiences and presented aggregate themes, individual experiences with part-time work occur across a spectrum of perspectives and understanding.
As increasing numbers of 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.
Our findings suggest that one such model may require that physicians and their leaders reconceptualize their work altogether, moving away from a model based primarily on hours and/or general concepts of productivity and toward a model based on organizational satisfaction and productivity determined through assessment of individual and organizational strengths, deficits, and needs. We acknowledge that recreating concepts of work would not be easy, and we are not suggesting that this model is the only or the best model for all physicians or all organizations. Rather, we are suggesting that for the health of academic medicine and academics, it may be worthwhile for academic medical centers to explore alternative options and ideas surrounding work in general. By doing so, academic medical centers may become more able to retain valuable workers who would otherwise leave to work elsewhere, and they may discover unexpected benefits in terms of patient and organizational satisfaction. Of course, before this can occur, more study is needed, including study of a larger spectrum of part-time physicians and their division chiefs or other leaders to determine the generalizability of our findings and to elucidate further approaches to part-time work in academic medicine.
The authors would like to thank Dr. Carol Warde, all study participants, and the Mary O’Flaherty Horn Scholars Program in General Internal Medicine.