Pulse
Scaling Back
For some physicians, reducing the number of hours they work has been the secret to finding a new enthusiasm for medicine.
New Ulm physician Ellen Vancura, M.D., was seeing a patient who was new to her—a developmentally disabled man who had been having repeated pneumonias—when she suddenly felt an uncontrollable sense of panic.
She finished the interview but walked out of the exam room knowing something was wrong. “I didn’t understand what was going on,” she says.
Vancura eventually recognized her problem as burn-out. After decades of working all day in the clinic, following patients in the hospital, then covering the emergency department or taking call at night, she realized she was exhausted. “After 31 years, it was getting to me.”
Vancura went to the medical center’s administrators and explained how she was feeling. She was granted a 12-week leave of absence in September of 2009, during which they worked out a way for her to lessen her load. “Retirement wasn’t an option for me,” she says, “so I had to negotiate my own slow-down.” Today, Vancura works three days a week and sees between 36 and 40 patients—the vast majority of whom are geriatric (“I have a lot of grandmas,” she says). She also makes rounds at the nursing home.
More physicians than ever are doing what Vancura did—cutting back hours or choosing to work part time. In its 2009 Physician Retention Survey, the American Medical Group Association and Cejka Search found that more physicians are choosing to practice part time than in the past. The practices that responded, which represent nearly 12,500 physicians in the United States, noted that 21 percent of their practitioners worked part time in 2009—up from 13 percent in 2005. The top reason cited by male physicians for cutting their hours was to take on administrative/leadership duties. The top reason for females: family responsibilities.
In early November, Minnesota Medicine asked physicians in an online survey about whether they had reduced their hours and why. Respondents cited numerous factors including wanting to spend more time with family, pursue hobbies and interests, take better care of themselves, and explore new career possibilities.
Digging Deeper
Although their motives vary, the physicians’ responses reveal a common theme: Changes in medicine and the economics behind those changes are affecting their lives—and not for the better. For Vancura, spending less and less time with her patients was wearing on her. “Geriatric patients are very complicated. You cannot get through their issues in 20 minutes,” she says. And the clinic’s move to an electronic medical record system several years earlier made it all the more difficult to see the required number of patients in a day. “It takes us all longer to do our work,” she explains.
Teresa Gurin, M.D., a physical medicine and rehabilitation physician in Minneapolis, wanted more time with her four children—ages 12, 10, and 7 (her youngest are twins). “I’ve always been very family-oriented,” she says. “I’ve had a lot of help over the years, but I decided I really needed to be there to make sure the kids felt loved, did their homework, and that things got done.” But she felt she couldn’t. Financial realities were already making it hard for her to maintain even a three-day-a-week schedule at a Twin Cities clinic, much less scale it back even more. In 2010, Medicare eliminated its codes for consultations. As a result, physicians were required to code such visits as office visits for new or existing patients—both of which paid less than consultations. “This was approximately a 50 percent reduction in my main source of reimbursement,” says Gurin. “When you work part time, your overhead is high compared with your income, and the overhead was going to be impossible to overcome. I would have had to increase my days at work to cover that overhead and still make a living.”
After working in a rural clinic for four years, family physician Troy Hanson saw a need to educate patients about how to prevent health problems. But he found it impossible to do so. The Belle Plaine, Minnesota, clinic, where he had worked since residency, was chronically understaffed. “I felt like I was putting out fires and running from one crisis to the next,” he says. “I felt depleted and unable to practice medicine the way I wanted to practice it.” Hanson decided to go back to school to earn a master’s degree in public health.
Redesigning Practice
For these physicians, getting what they wanted—whether it was time with family, time for school, or time for themselves—has meant charting a different path. For Hanson, it meant leaving his practice to do locum tenens work in rural clinics and emergency departments—an option that reduced his work hours by 25 percent.
The move allowed him to not only work on a master’s degree in public health at the University of Minnesota but also complete a certificate program in infant and early childhood mental health. Today, he serves on the state’s advisory council on mental health, is a member of the Great Start Minnesota early childhood development steering committee, is co-chair of the Minnesota Association for Infant and Early Childhood Mental Health, and works at Scott County’s mobile health clinic once or twice a month. “This is allowing me to take a more global perspective on health for my patients and focus more on issues like health promotion and prevention and integrating care from many different disciplines based on a person’s overall need,” he says.
Earlier this month, he began a part-time practice at Sibley Medical Center and Clinic in Arlington—one of the facilities at which he did locum tenens work. He’ll be working in the clinic and doing some emergency department call duty. The schedule will allow him to continue with his other commitments. In addition, the clinic’s administration agreed to let him work on setting up a system to screen kids for developmental concerns and help parents find resources for kids who are identified as having delays or other issues. “They had some interest in at least letting me pursue some of my public health ambitions,” he says.
Gurin also left her practice in order to find a better balance. With a mini MBA from the University of St. Thomas and an entrepreneurial streak (she started her own house cleaning business while in college), she decided to go into practice for herself after she learned about the pending Medicare changes, and in October of 2009 opened the Sports Orthopedic Advanced Rehabilitation (SOAR) Clinic in Minneapolis.
Today, she spends two days a week on patient care and also does independent medical exams for insurance companies. To keep expenses under control, she sublet space from a physical therapist, bought an electronic medical record system to automate as many administrative tasks as possible, and hired part-time employees to enter data for billing, do the filing and faxing, and run errands. “I took my costs down to as rock bottom as I could,” she says.
The move has allowed her to practice the way she wants. She treats a contingent of patients with complex musculoskeletal problems and chronic pain, whom she describes as “very loyal,” and she’s able to be home when her kids get out of school. “My youngest got home the other day and was upset because a kid threw a snowball at him. I was able to be there to comfort him,” she says. “That’s a great success.”
In Vancura’s case, the medical center started a hospitalist program about the time she took her leave of absence, so she is no longer expected to take call. She’s become the clinic’s de facto geriatrician and is allowed to spend more time (30 minutes) with her aging patients. “I’m now the lowest producer, but I maintain a niche,” she says.
Since coming back part time nearly a year and a half ago, Vancura says she feels like she has more emotional and physical energy. “I feel like I can take a deep breath and have some private time,” she says. “I’m not rushing as much through life, and I’m enjoying practice again.”
How Clinics Can Help
Physicians who’ve figured out for themselves that they needed to slow down say clinics could do a number of things to help prevent physicians from becoming burned out. One way they can help is by coming up with strategies to help long-time physicians ease into retirement, says Ellen Vancura, M.D., of New Ulm Medical Center.
Another is to hire more part-time physicians, especially in rural areas, where it’s often hard to find full-time providers. “There are a lot of medical groups where you work full time or you don’t work,” she says.
Another way clinics can help doctors maintain their enthusiasm for medicine is to tap into their strengths and interests. “By looking for ways to benefit from someone’s passions or interests or strengths, your facility can improve the environment for everyone,” says Troy Hanson, M.D., a family physician in Arlington, Minnesota.
Hanson also says clinics should allow physicians time for reflection. “You’re used to giving 110 percent effort 24 hours a day for a long time,” he says, adding that it’s important for physicians to step back and look at the big picture to see whether what they’re doing fits with what they value.
—Kim Kiser