Productivity of Part-Time versus Full-Time Primary Care Physicians

This study was funded by grant number 947110-1107576 from the Sutter Medical Center Hospital Foundation.

Both male and female physicians are increasingly interested in part-time work, especially those raising families and in the latter stages of their careers.(1) The number of pediatricians who reported that they work part time increased from 15% in 2000 to 20% in 2003, to 23% in 2006. This pattern was consistent for both male and female pediatricians of all ages.(2)

However, the perception of physicians who work part time often is negative. These attitudes about part-time clinicians come from several perspectives. One is from the vocation of medicine itself, which prides itself on an unwavering commitment to patients over self, as a core value not usually found in other professions. Simply said, “Doctors who focus on a good lifestyle are bad news for patients. An 80-hour week means you are always available.”(3) Another perspective discounting the commitment of part-time clinicians is rooted in the idea that those who work part time are not fully committed and are letting the system down, and that a physician shortage is the result of their lack of commitment.(4) The negative perception of part-time clinical work also is evidenced by a history of some insurers excluding part-time physicians from their networks and organizations discouraging part-time work through unsupportive policies or financial penalties.(5)

Regardless of the perception, part-time physicians report higher clinician satisfaction, including lower rates of burnout and greater work control than full-time, as well as scoring at least as well as their full-time colleagues on quality measures.(5,6) Patients also have reported better satisfaction with part-time primary care physicians, despite less continuity of care and access.(7)

Part-time clinicians could be a net benefit to the healthcare system if productivity and patient satisfaction were not compromised, but there is little research that examines the impact of productivity when physicians choose to work less than an FTE. A study conducted in an academic setting suggested that productivity per clinical hour was markedly higher for part-time primary care physicians compared with full-time clinicians.(5) However it is unclear if this finding translates to the community setting.

The objective of our study was to compare differences in productivity between full-time and part-time physicians who practice in a productivity- based financial model.

Methods

Sutter Medical Group is a large multispecialty group with over 200 primary care physicians across five counties in Northern California. The compensation model in 2015 and 2016 during the period of analysis was based on percent of revenue and was essentially entirely productivity-based. Two separate standards for measuring productivity were used and adjusted for FTE: relative value units (RVUs) and Medical Group Management Association (MGMA) percentile. Every billable patient interaction is given a numerical value, and these RVUs describe all the billable work a physician produces and offers a measurement of productivity. The MGMA collects RVU information across physician specialties nationally each year and updates the productivity percentile tool for each specialty. Using MGMA percentile as a measure of productivity decreases the impact of specialty variation on productivity because the MGMA defines percentile ranks uniquely for each specialty. Each of these metrics also can be adjusted for FTE, thus offering comparable metrics of adjusted RVUs (aRVUs) and adjusted MGMA (aMGMA) percentile. A 1.0 FTE in Sutter Medical Group is defined as 36 patient contact hours per week. This time includes only scheduled face-to-face visits with patients and does not include other non–face-to-face tasks of primary care. Part-time FTEs are measured as a fraction of 36 scheduled hours.

A retrospective inquiry was conducted to obtain the productivity data for the 2015 and 2016 reporting periods of primary care physicians who were in practice for more than two years. Primary care physicians, defined as those specializing in family medicine, internal medicine, and pediatrics, were included in the study. Physicians who had a leave of absence during the period of review, those who were in medical practice for less than two years from the start of the study period, and those who were residency teaching faculty were excluded from the study. Physicians whose primary time was spent doing administrative work also were excluded.

FTEs were stratified into four groups: ≤0.50, 0.51–0.79, 0.80–0.90, and 0.91+. Differences in sex and specialty among FTE strata were analyzed using the χ2 test of independence, and analysis of variance (ANOVA) was used to compare mean differences in age. A factorial ANOVA was used to assess differences in mean aRVU and aMGMA. The main effects of FTE strata and specialty (family medicine, internal medicine, pediatrics) were included in the model in addition to the FTE strata X specialty interaction. Planned contrasts were used to test the mean differences between the ≤0.50, 0.51–0.79, and 0.80–0.90 groups with the group that worked 0.91+ FTEs, and between pediatric and internal medicine versus family medicine physicians. Analyses were conducted separately for each reporting period.

Results

The inquiry resulted in 183 physicians in the 2015 reporting period and 176 physicians in the 2016 reporting period. Of these, 161 physicians were included in both reporting years.

Table 1 shows the demographic characteristics of physicians by FTE status for both years. Over one third of physicians worked 0.91 or more clinical FTEs. Approximately 26% of physicians in 2015 and 27% in 2016 worked between 0.51 and .079 FTEs. There was no statistically significant difference in the mean age of physicians among the strata in either year but in both years, a higher percentage of men (p <.001) were in the 0.91+ FTE stratum than women. The percentage of women was twice that of men in the 0.51 to 0.79 FTE stratum for both years.

In 2015 there was no difference in the distribution of specialty by FTE strata, but in 2016, over 52% of full-time physicians were internal medicine specialists as compared with 27.5% in family medicine and 22.4% in pediatrics (p = .022).

Figure 1 shows the aRVUs for each specialty for 2015 and 2016. The figure shows that in all FTE strata, pediatricians had the highest overall aRVUs. Figure 2 shows similar results for aMGMA percentiles.

Figure 1. Mean adjusted relative value units within FTE strata, specialty, and year. Shown are adjusted relative value units (aRVUs) for each specialty for 2015 and 2016. The figure shows that in all FTE strata, pediatricians had the highest overall aRVUs.

Figure 2. Mean adjusted Medical Group Management Association (aMGMA) percentile within FTE strata, specialty, and year.

Adjusted RVUs

Results of the ANOVA of aRVUs showed that in both 2015 and 2016 there were statistically significant main effects of FTE strata and specialty, but the FTE strata X specialty interaction was not statistically significant (Table 2). In both years, clinicians who worked between 0.51 and 0.79 FTE were statistically significantly more productive than their full-time counterparts (0.91+ FTE), and pediatricians had higher aRVUs than family medicine physicians (Table 3).

Adjusted MGMA Percentile

There was no effect of FTE status or specialty on aMGMA percentile in 2015. In 2016, however, specialty was statistically significant (Table 4). Pediatricians were approximately 14 points higher on aMGMA percentile than family medicine physicians. This difference was statistically significant (p <.001; Table 3).

Discussion

This is the first study to our knowledge that compared the productivity of physicians working varying levels of FTEs. This study strongly suggests that part-time primary care physicians are at least as productive, and likely more productive, than their full-time peers when quantity of care is adjusted by FTE.

Our investigation found not only that part-time physicians may be more productive than their full-time peers, but also that primary care physicians may be subject to the findings in other fields of decreased work output beyond a certain number of hours.

The Stanford economist John Pencavel demonstrated that there was “diminishing productivity associated with an individual working long hours.” He notes that as far back as 1932, J.R. Hicks commented that “probably it has never entered the heads of most employers that it was at all conceivable that hours could be shortened and output maintained.”(8) There is little reason to expect that physicians are immune to these findings.

It must be noted that the time required to do the work of primary care is only partially described by patient contact time. FTEs reflect the number of hours physicians spend actually seeing patients; however, research demonstrates that the hours required to take care of patients in a full-time practice well exceeds a 40-hour work week, given the preparatory and follow-up work required for managing each patient. One study suggests that for every hour physicians provide in clinical care, nearly two additional hours per day of clinic time and one to two hours per day of personal time are spent on charting and other desk work.(9)

This time requirement can make the task of primary care seem insurmountable. On the basis of recommendations from national clinical care guidelines for preventive services and chronic disease management, including the time needed to address acute concerns, it would require 21.7 hours per day to sufficiently address the needs of a standard patient panel of 2500.(10)

The long hours in the practice of medicine create a cycle of burden and burnout that is difficult to sustain, and can result in physicians leaving primary care, choosing early retirement or other careers.

Research suggests that interest in pursuing alternatives to working full time is as strong in men as it is in women.

Some, including Shanafelt, a prominent expert in physician burnout, have noted that the number of hours worked per week was associated with a higher risk for burnout,(11) and that burnout led to a reduction in the amount of time physicians devote to providing clinical care to patients.(12) Others have found that part-time physicians are less likely to experience the burnout and lack of work–life balance.(6)

Because there is a projected work force shortage in primary care, the ability to recruit the next generation of PCPs may be an important driver of organization success. As the financial case mounts that the contributions of part-time physicians are as significant as those of full-time physicians, organizations may be willing to support or even encourage the hiring of physicians who want to work less than a full FTE. Offering physicians the option of part-time employment may result in higher retention.

Retention of physicians alone has been found to save over $230,000 per clinician.(13) This is a vast cost savings in recruitment costs and does not even include the costs of training a physician, which is estimated to cost close to $100,000.(14)

Our investigation furthers the research that suggests that interest in pursuing alternatives to working full time is as strong in men as it is in women. Roughly half the male physicians in this study were working less than full time in clinical practice. Although this is greater than other studies, possibly due to the diminished stigma of working less than full time in this cohort, it supports data showing that males over the age of 55 is one of the fastest growing groups to reduce their FTEs.(12)

Limitations to this study include the possible bias that is presented by a productivity model of payment that encourages production of patient visits. It is not evident that these findings would be present under systems that do not compensate for volume of work, but rather by stated FTE.

The strengths of this study include the large number of part-time physicians participating in this workforce. Future research could investigate whether encouraging part-time opportunities results in greater participation in this practice style and in improvements in recruitment and retention. In addition, it would be useful to understand whether there is a difference in overhead costs for part-time physicians compared with full-time. Electronic medical record use now allows for data mining to determine actual time spent working, and comparing time spent working with productivity could help explain whether productivity gains are due to improved efficiency or simply to working longer hours.

This study concludes that the contributions of part-time clinicians is significant and reflects an opportunity to avoid premature workforce losses to burnout, early retirement, and work–life balance considerations. As the field becomes more amenable to part-time opportunities, it may be able to draw and retain the best and brightest who previously had dropped out or sought out less demanding careers. Organizations may be able to capitalize on this opportunity and meet fiscal goals.

The authors thank the Financial Business Services department of Sutter Medical Foundation for providing blinded data for this study and the librarians at the Sutter Resource Library who were always available and helpful.

References

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