Dr. Helitzer is professor, Family and Community Medicine, and assistant dean for research education, University of New Mexico School of Medicine, Albuquerque, New Mexico.
Correspondence should be addressed to Dr. Helitzer, University of New Mexico School of Medicine, MSC 09-5040, Albuquerque, NM 87131; e-mail: (email@example.com).
Editor’s Note: This is a commentary on Linzer M, Warde C, Alexander RW, et al. Part-time careers in academic internal medicine: A report from the Association of Specialty Professors Part-Time Careers Task Force on behalf of the Alliance for Academic Internal Medicine. Acad Med. 2009;84:1395-1400.
Several recent articles in this journal, including the article by Linzer and colleagues in this issue, discuss and promote the concept of part-time careers in academic medicine as a solution to the need to achieve a work-life balance and to address the changing demographics of academic medicine. The article by Linzer and colleagues presents the consensus of a task force that attempted to address practical considerations for part-time work in academic internal medicine. Missing from these discussions, however, are a consensus on the definition of part-time work, consideration of how such strategies would be available to single parents, how time or resources will be allocated to part-time faculty to participate in professional associations, develop professional networks, and maintain currency in their field, and how part-time work can allow for the development of expertise in research and scholarly activity. Most important, the discussions about the part-time solution do not address the root cause of dissatisfaction and attrition: the ever-increasing and unsustainable workload of full-time faculty. The realization that an academic full-time career requires a commitment of 80 hours per week begs the question of whether part-time faculty would agree to work 40 hours a week for part-time pay. The historical underpinnings of the current situation, the implications of part-time solutions for the academy, and the consequences of choosing part-time work as the primary solution are discussed. Alternative strategies for addressing some of the problems facing full-time faculty are proposed.
The article by Linzer and colleagues1 in this issue presents a consensus statement and recommendations developed by the Association of Specialty Professors (ASP) Part-Time Careers Task Force about how to incorporate part-time work as a legitimate approach to careers in academic medicine. The topic of part-time careers in internal medicine is also a focus of a recent research study by Harrison and Gregg2 and is addressed in an accompanying commentary by Palda and Levinson3 in an earlier issue of this journal. All of these authors are to be congratulated for their thoughtful exploration and deliberation of the issues that create the need for a broad range of alternative approaches to full-time work for both genders. A recent analysis of retention rates of full-time faculty members showed that 38% left their careers in academic medicine between 1987 and 1997. This attrition was worse for women (40%-47%) compared with men (36%-39%).4 In addition, a recent report of satisfaction survey results showed that “only 36% of all (male and female) respondents agreed or strongly agreed that the workplace culture at their medical school cultivates a supportive climate for balancing home and work responsibilities.”5 A more recent survey of graduate students in the University of California system found that similar concerns might steer their career choices away from tenure-track academic positions.6 However, I question whether incorporating more part-time work would dramatically improve the situation. The recommendations proposed in these articles do not address the root cause of the problem, which is the ever-increasing workload of full-time faculty. In fact, by providing the academy with an alternative to reducing the exhaustion experienced by full-time faculty, these recommendations may accelerate the high attrition rather than lead to meaningful change.
As a professor and academic leader at my institution, and as a faculty member at the Association of American Medical Colleges Early Women in Medicine program, I receive self-reports by women (and men) indicating that to fulfill the expectations of a productive faculty member requires, at a minimum, 60 hours per week, and more typically 80 hours. This is confirmed by Harrison and Gregg.2 Many faculty members report that they work a 10-hour day at their workplace and continue to work at home after their familial responsibilities are completed; they report working an additional four to eight hours on the weekends, or on days off. I send and receive e-mails late at night, and often in my inbox in the morning I find e-mails sent at 1:00 am or later. That these untenable schedules lead to burnout is inevitable.
Many factors have contributed to this situation. Early paradigms of successful careers in academic medicine were created for men who were able to work long hours because their wives stayed at home, cared for the children and other family members, ran errands, and took charge of managing the upkeep of the home. Some of the men, in turn, made significant clinical, research, and educational advances and were nationally and internationally renowned. It is not uncommon for a description of a faculty member from the prior generation to include the statement, “He has over 100 publications in high-impact journals.” Today, productivity of academic faculty is judged by these same standards. For many such men, however, this remarkable productivity occurred at the expense of close relationships with their wives and families. This in particular has led to this generation’s desire for work-life balance and the challenges that the ASP task force attempted to address.
What has changed in the last 30 years in academic medicine? The proportion of women in academic medicine has steadily increased. In 1965, women represented 8% of medical school graduates and medical school faculty; by 2004, the statistics were 45% and 28%.7 Today, financial debt incurred from medical school tuition is so burdensome so that it requires two incomes to maintain an upper-middle-class lifestyle. More families are headed by single parents. Expectations for clinical productivity and revenue generation in the academic environment are now commensurate with private practice. Disparities between the salaries of academic physicians and those in private practice are no longer seen as acceptable trade-offs for the benefits provided by an academic career. Education of medical students and residents cuts into productivity measured by relative value units. Documentation requirements by the Commission on Medicaid and Medicare Services for clinical physician billing with residents are onerous. Research grants are more difficult to obtain than they were in the past.8 Manuscripts require more revisions, and peer-reviewed journals have less available space. Research grants support a smaller proportion of a researcher’s time. Clinician-researchers face additional challenges to attain sufficient support for salaries above the National Institutes of Health cap ($191,300 in 2008). Bureaucratic and regulatory requirements overwhelm time for creative activity, which was the original impetus drawing faculty to academic careers.
Several issues that were not addressed by the task force’s recommendations, the previously published research study, or the related commentary led me to question whether part-time work is an acceptable alternative for many faculty members. For example, no clear consensus on the definition of part-time work is provided. Given the current estimates of full-time work by faculty at 80 hours per week, is it reasonable to imagine that part-time faculty would be willing to work 40 hours per week and be compensated with half-time pay? Harrison and Gregg’s2 study suggests not. Also, part-time work and salaries commensurate with shorter hours are not viable alternatives for single-parent families or those in which only one of the couple works outside the home. It seems unfair to advocate alternative strategies of which only some faculty might be able to take advantage. No consideration is given in the task force’s recommendations to how time or resources will be allocated to part-time faculty to participate in professional associations, develop professional networks, and maintain currency in their field.
The notion of part-time work, “working less” or “working differently,”2 seems on the surface to be mostly a matter of hours. It is concerning that none of these articles address the impact of part-time work on competency. Ericsson9 demonstrated the connection between hours of deliberate practice and expertise in many areas of human performance. Physicians who practice fewer hours are less efficient and may have difficulty maintaining and improving clinical skills. Researchers who have inadequate “protected” time also have limited success. The recommendation that federal agencies should provide research career development awards to part-time faculty suggests that these faculty members will be able to build research expertise part-time—either requiring twice as long to attain a similar level of expertise or depriving that individual of 50% of the necessary training. It is unlikely that any funding agency would reward part-time faculty by setting aside scant research funds to the detriment of those who choose to work full-time. Educators who teach less may become out of touch with advances in education. For all academics, the imperative to stay abreast of developments in our fields, reviewing information which proliferates in technology available at the touch of a button 24/7, presents increasing challenges to our ability to retain accreditation and complete required certifications.
Certainly, there is a role for part-time work within an academic environment, but we must be realistic about the challenges that accompany the choice to work part-time. Perhaps in this context, the term “working differently” used by faculty and division directors in Harrison and Gregg’s study is a euphemism for compromise. A clinician educator who can limit his or her clinical hours to that which is required for service and teaching would be most likely to find a part-time configuration workable. The Society of General Internal Medicine Horn Scholars Program10 is designed to encourage internal medicine clinician educator faculty to balance part-time (defined as 20-25 hours) work and family responsibilities. However, part-time clinician educators may not have the flexibility to fully participate in educational programs3 and may be relegated to mostly clinical duties; unless this is understood as a precondition to part-time work choices, such limitations may ultimately lead to dissatisfaction and disillusionment with an academic career. Part-time leadership positions may also seem possible, given that many midlevel administrative positions support only a fraction of the faculty member’s time. The challenge for part-time leaders will be learning how to be available to solve organizational problems on a part-time basis and in a timely manner. Researchers with no other responsibilities could also work part-time, but research is often hard to schedule and to limit to specific hours. Furthermore, engaging in a research career implies additional administrative responsibilities outside the actual conduct of research, and successful researchers enhance their skills by serving on proposal review study sections, participating on human or animal subject protection review committees, and acting as peer reviewers for journals.
We must attain work-life balance for all faculty members—there is no question about that. The part-time solution is one approach, but for an individual who desires to attain expertise in research, clinical practice, and education, I submit that within the current environment, recommendations for part-time work would serve to prevent these individuals from having productive academic careers. The elephant in my office—that is, the time required to meet the expectations for successful faculty—must be addressed if we are to hope for a healthy future for academic medicine. There are obvious solutions—for example, reducing internal and external bureaucratic requirements; limiting meetings and e-mails only to those that are essential; relaxing or extending the seven-year limit for promotion “up or out” and requiring less evidence of productivity; appreciating multidisciplinary team work that gives equal credit to each member of the research team; making improvements in the environment to accommodate the everyday needs of faculty members, such as co-located child and elder day care and services (i.e., laundromats, dry cleaners, food markets); accessible health care (expanded hours and days); and broadening forgiveness of student loans for those pursuing academic careers. These strategies and others must be considered if we are to stem the tide of substantial attrition facing academic medical institutions today. I believe it will be through improving the work environment for all full-time faculty that we will discover many different opportunities to help faculty become and stay productive throughout their academic careers. I look forward to working together with my colleagues to further this goal. The elephant in my office is taking up too much space, and we’re going to have to let him go.
1 Linzer M, Warde C, Alexander RW, et al. Part-time careers in academic internal medicine: A report from the Association of Specialty Professors Part-Time Careers Task Force on behalf of the Alliance for Academic Internal Medicine. Acad Med. 2009;84:1395–1400.
2 Harrison RA, Gregg JL. A time for change: An exploration of attitudes toward part-time work in academia among women internists and their division chiefs. Acad Med. 2009;84:80–86.
3 Palda VA, Levinson W. Commentary: The right time to rethink part-time careers. Acad Med. 2009;84:9–10.
4 Alexander H, Lang J. The long-term retention and attrition of U.S. medical school faculty. AAMC Analysis in Brief. June 2008.
5 Bunton SA. Differences in U.S. medical school faculty job satisfaction by gender. AAMC Analysis in Brief. November 2008.
7 Magrane D, Lang J. An overview of women in U.S. academic medicine, 2005-06. AAMC Analysis In Brief. October 2006.
8 National Institutes of Health, Office of Extramural Research. NIH Extramural Data Book. Bethesda, Md: National Institutes of Health; May 2008.
9 Ericsson KA. Deliberate practice and the aquistion and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79(10 suppl):S70–S81.