The days when having a meaningful and rewarding career meant being available for clinical work 24/7 are over. Younger doctors are choosing to give more priority to time with family or extracurricular activities and older doctors are scaling back their hours as they move towards retirement.
Just last month, the Australian Bureau of Statistics released figures derived from the 2011 census showing that as much as 35 per cent of female general practitioners are working part-time, while the figure for males is 13 per cent. These proportions grow to 42 per cent of women and 20 per cent of men in the over-50 age group. This is up from a total 15 per cent part-time GP workforce in 1986.
As the proportion of part-timers has increased here and in other Western countries, there have been many complaints about possible damage to the profession —“Medicine shouldn’t be a part-time interest to be set aside if it becomes inconvenient; it deserves to be a life’s work”, wrote American anaesthesiologist Dr Karen Sibert, in a searing 2011 New York Times opinion piece. But there is good evidence that in fact GPs who work fewer hours practise better medicine and have greater job satisfaction than their full-time colleagues. It can benefit everybody.
Leading Australian medical recruitment agencies are finding that practices which are having difficulty recruiting full-time doctors are more easily able to fill permanent part-time positions. And some practices are now deliberately structuring themselves to be able to offer part-time positions in order to attract higher-quality applicants.
So how are practices incorporating the growing part-time workforce? What happens to continuity of care when a GP works fewer than seven sessions a week and is not always available when the clinic is open? And how does a practice share the burden of costs equitably when some work more than others?
Continuity of care
Ensuring continuity of care is a vital first step in successfully including part-time practitioners within a practice. As the chief operating officer at the new Shell Cove Family Health superclinic on the New South Wales south coast, Dr Keith McDonald, puts it, “No one wants to feel that their doctors’ waiting room is a transit lounge”.
Ideally, Dr McDonald says, they would like to have two full-time GPs but, when the Illawarra Shoalhaven Medicare Local opened the clinic in mid 2011, they found that the best way to attract the best candidates was to offer part-time positions. “There were people who were available, but not willing to totally transfer and make a full-time commitment upfront.”
They now have one full-time and five part-time GPs.
“It is ideal for continuity of care and longitudinal family-based care if you can get full-time GPs, but I prioritise quality over quantity”, Dr McDonald says.
To help with continuity of care, doctors are encouraged to fill sessions on a regular basis — the same days each week — and the practice tries to keep patients well informed about when each of the doctors is in the clinic.
On the New England Tablelands of NSW, all GPs at the award-winning Smith Street Practice work part-time (see Box). Dr Gillian Rawlings, one of the practice’s three principals, says that they have worked hard to ensure continuity of care for their patients over the 14 years the practice has operated.
“It works out that if a patient has an ongoing condition in which it is very important to have continuity, then they obviously can book to see one of the three principals.”
New patients at Smith Street are always informed that none of the practice’s GPs are in the clinic every day and that occasionally it may be necessary to see another doctor. In some instances it doesn’t work for a patient and they choose to go elsewhere but that is rare, Dr Rawlings says.
“You do have to have a little more communication and teamwork to make it work and I think that we’re quite good at that. It particularly helps that we have a similar style of practice, so that hasn’t been a difficult area.”
Modern communication technology can also help clinics maintain contact with doctors when they are not at work, particularly when it comes to pathology results.
The financial implications of including practitioners who work more or less than others can also be complicated.
The contribution towards practice overheads — insurance, capital expenditure and even stationery — is potentially going to be affected by each GP’s contribution to the clinical workload. “Setting up the financial structure so it will be fair and flexible is worth spending plenty of time to get right”, Dr Rawlings says.
“Covering costs in an equitable way was an issue we thought about from the beginning as we wanted to have flexibility in case one partner wanted to do more or less hours at any time.”
At Smith Street, the principals initially took care to allocate some costs on a pro-rata basis, including staff salaries, stationery and medical supplies. Others, such as rent and rates, were split evenly three ways.
Today, each partner is paid a percentage of their gross billings — usually 60 per cent — with regular distributions made when possible.
There is no provision for leave payments as different doctors take different amounts of leave. And each GP has his or her own disability insurance.
Alternatively, part-time roles can be offered as salaried positions with provisions for holiday pay and sick leave. This is what was offered at Shell Cove Family Health as it was a new practice in a new suburb with no established client base. The salary provided a guaranteed income.
However, a recent reassessment means that salaries will not be offered in future as the practice moves to offering percentages instead.
With the statistics suggesting that there is unlikely to be a downturn in GPs working part-time in the near future, there is little doubt that innovation in general practice models will continue in this area.
Interestingly, general practice academics suggest that beyond the practicalities of scheduling, costs and ensuring continuity of care, the most innovative new models will, like the Smith Street one, enable practice ownership to also be handled as a part-time commitment.
Dr Rawlings says that this can only be a good thing for many GPs and their patients.
“Even though we are all part-time, we have a very happy, cohesive practice which works really well for our patients — arguably better than a practice with burnt-out full-timers.
“General practice is fantastic, but if I was doing it 5 days a week, I would not be a very good GP … and I would be horrible to live with too.”
Smith Street part-time success
In 1999 in the New England Tablelands of New South Wales, Tamworth general practitioners Dr Miriam Grotowski and Dr Carmen Ast found that their work as part of a large established practice was not very compatible with raising small children. The compromises required in trying to balance the needs of their family and their professional lives left them unsatisfied.
The pair approached Dr Gillian Rawlings, then working in emergency medicine and administration with the local hospital, to see if she would be interested in setting up a new practice with them.
The result was the Marius Street Practice (later to become Smith Street Practice), comprising one receptionist-cum-practice manager and three part-time principals who, together, were raising seven children under the age of 10 years.
“We set out with the premise of running a really good general practice that would, at the same time, work for us with having young children and family”, says Dr Rawlings.
Drs Rawlings, Ast and Grotowski thought long and hard about the best practice structure to enable part-time work and to ensure they would work well together.
Fourteen years on, with close to 8000 patients, a dedicated practice manager, two registrars and a fourth GP, everyone remains employed on a part-time basis — even the practice manager. Regular practice meetings mean that, despite all the comings and goings, difficulties are quickly overcome and there is practice cohesion.
The success of their model was recognised in 2003 when they were awarded the NSW Practice of the Year.
“I think the best piece of advice for practices wanting to successfully incorporate part-time GPs is shared values”, Dr Rawlings says. “We all wanted to make a reasonable income, of course, but just as importantly we wanted to offer our patients excellent medical care and have time and flexibility to have a good family life.”
Parkerton PH, Wagner EH, Smith DG, Straley HL. Effect of part-time practice on patient outcomes. J Gen Intern Med 2003; 18: 717-724.
Mechaber HF, Levine RB, Manwell LB, et al; for the MEMO Investigators. Part-time physicians … prevalent, connected, and satisfied. J Gen Intern Med 2008; 23: 300-303.
Sibert K. Don’t quit this day job. New York Times 2011; 11 Jun.http://www.nytimes.com/2011/06/12/opinion/12sibert.html?pagewanted=all (accessed Apr 2013).
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