FI/RE=>part time work

[q-school]

I assume virtually all physicians here think they are outstanding clinically.  That is a function of intelligence, work ethic, training, and maybe some luck thrown on top of it.  Most here are relatively early in their careers I think and so the hours of training plus close supervision plus testing more or less make this very likely to be the case.  For procedurists, there are plenty of data that suggest higher volumes, or at least thresholds, are associated with better outcomes.

Yet I hazard that we all know some physicians still working who may be capable but not at the top of their game.  Or, you know, ... some who are ROAD  Retired, but on active duty.

What strategies do we have to ensure that we stay at the top of the game?

To a degree, working full time for me ensures that I stay current.  I have mandatory CME, I attend group meetings with lots of clinical discussions, i do a high volume of procedures, I have to answer tough questions from patients.  I ask other smart people tough questions all the time.

If we have plans to cut back at 40 or 45, but still want to work part time for a considerable length of time, how do we ensure that at 55 or 60 we can be good to great?  even if we want to volunteer, how do we maintain skills?

Thanks!

 

 

 

[Zaphod]

My field is so broad, and as a proceduralist any field is too broad really, but point was I am shocked retrospectively that academic guys try to be a jack of all trades at all. Its not possible to actually be very good by doing a little bit of this and that all the time.

After residency I did a fellowship that was of course subspecialized, and then have been practicing 100% in this area since. I really only do about 4 procedures only and maybe some variations thereof. Its crazy. A study came out last year showing among respondents I was above 99% for one of those procedures, with a ginormous percentage of docs doing a smattering only. I wouldnt feel comfortable doing other procedures I havent done in years, but I've always been that way, not seeing how its ethically right to be doing stuff you dont do regularly, as its impossible to be good as the person who does it daily, etc...

I do believe in thresholds that need to be done, and actually have thought of expanding on my threshold philosophy more in general as it really pertains to a lot of aspects in life. Its hard to say where that is for procedures, I mean I feel rusty after a week without operating. It may be more to do with consistent level than absolute. For example the owner of our practice operates about once a month, I dont think that cuts it at all, too far and few. However if one did procedures a half day a week its just the volume thats changed and dont think it would have the same negative impacts.

Its a tough and difficult discussion, where those that really work mostly with their brains have the upper hand.

[SValleyMD]

IMO the old timers that are incompetent are so because they're either arrogant or they just dont care anymore - two issues that can make for crappy docs at any age mind you.

I don't think it's hard to work part time and "keep your clinical skill" if you're a clinic/hospital based physician if you keep an open mind and keep somewhat of a pulse on what's going on.. (emails, journals, etc).

Now surgical/procedural skills are a different animal and yes that becomes infinity more difficult and varied- probably no right answer on that one but keeping an open mind and not letting your ego get in the way (I.e., you can learn from your juniors) helps there too IMO.. I also see some limit their procedures to a certain few to consolidate their volume

[VagabondMD]

I am going to speak from the perspective of one of the elder members of this forum, beginning my 22nd year in practice this month. A general theme in practice (and moreover in life) is not to extrapolate the present too far into the future. Things are always changing, and you are always adapting, sometimes gradually, sometimes more suddenly. Put bluntly, 90% of the procedures that I performed last month were not procedures that I practiced in my fellowship.

IMO, your effectiveness in practice draws on your knowledge, judgment, and experience. Your knowledge may be at a peak when you finish training, your judgment is relatively time-independent, and your experience grows over time. I have found that I no longer know or remember relatively obscure stuff that filled my head 20 years ago, but I do know what I need to know on a daily basis, and I know how to find the answer to questions when they arise. In fact, that part has never been easier.

To some extent, your increasing experience will compensate for your gradually decaying knowledge. The latter can be bolstered by reading journals and books and going to courses and meetings. For me, the latter has been more effective that the former, but everyone learns differently.

As to the actual question at hand, I have found two types of part timers in my career. The first type we will call the "Glider". This is the partner who has had a full career, wants to slow down, and then glide into retirement. (I hope that this is me soon!) Don't expect him/her to set the world on fire by learning new procedures, burning the midnight oil reading journals, or doing anything but what he or she is expected to do. Give this person, at most, two or three years to glide and then fade away.

The second type I will call the "Avocationist". This person considers the medical practice to be his/her greatest interest in life and will go part time later in the career but will continue to learn, build new service lines, spend days off in the medical library (or the online equivalent) and at meetings, etc. You get the idea. This person loves the field, you know he/she loves the field and has an indefinite time horizon. One of my now-deceased former partners worked for our group into his late 70's (working weekends, taking call, etc.), and later got a job at the VA so that he could teach residents, well into his 80's. He died at age 88, and I am not sure he ever separated from his profession until last breath. Find a way to keep this person around as long as you can.

 

[Miss Bonnie MD]

This might be specialty specific, but for me (derm), I find attending conferences key. I am also in academics right now so hear about stuff as they come out generally.

I am still very early in my career (2 yrs out). Most of the diseases we treat are off-label uses and treatments change rapidly. At least for the medical derm part. I do basic excisions only and can't imagine that really changing except for choice / technique of top suturing.

I do plan on working less in the next 5-10 yrs but don't think dropping to 2-3 days a week (vs the 4 now) will make me "rusty."

[wideopenspaces]

I love what Vagabond says. I will always work part time and honestly I feel like this allows me to be more on top of things. I have more time to think about patient situations, to read journals, do cme, reach out to other members of the treatment team, etc. If I was full time I probably wouldn't want to do this after seeing patients from 8-5 every day. But maybe that's just me? I also really like having the more experienced docs around, esp when I run into rare side effects or random situations as they have typically seen these same things before and can weigh in on the situation.

[Hatton]

As probably the oldest poster who will comment on this I will take a shot.  I just turned 60. I still operate.  Sometimes it is my case, sometimes I assist. Lots of surgeons in my hospital are older.  My good friend is operating at 81 and training new docs in his practice in vaginal surgery.  It is hard to know about this issue. I am no longer in a hurry to get back to the office or to go deliver a baby so I think my complication rate is lower than when I was also doing ob.  I think there is some value in experience and listening to patients.  Some docs are in trouble their entire careers with excessive complications.  I find a bigger problem is excessive overconfidence that some have right out of residency. It takes a few years to really learn to do anything.  When will I stop operating?  The neck and back pain that I am starting to have will probably answer that question in the near future.

 

 

[RogueDadMD]

In my field (peds EM) some of the procedures were expected to be good at performing are ones that NO peds EM doc in any situation gets to do on a daily or maybe even weekly basis.  Intubation is a great example.

In peds EM in a children's hospital that's affiliated with a university -- which are the high volume high acuity ones -- there just aren't many performed compared to a general/adult ED.  I'm not only expected to be proficient when I may be rarely doing them, I have to supervise and allow trainees to take some of them from me occasionally.  So I have to keep up my skills through sim and other ways (work w/anesthesia).

Or another great example for me is ultrasound -- when I did my training we had a non existent peds US program for our group (though I learned some working in the big house adult ED next door where they have a great program).  The evidence and practice just hadn't filtered from general/adult EM to peds and there are/were not many highly skilled people in peds EM who could teach US.

We're building an US program now and the trainees coming out just a few years behind me are way ahead and so I'm going out of my way to build an US skill set.  I went to a 3 day intensive course recently to brush up my skills and am just doing more of them now to build back up a comfort and skill level.

I'm also on the "academic" track and do less shifts than my colleagues, so going out of my way to keep my clinical skills on par with what's required is something I consider a necessity.

[childay]

It is an interesting question.  I expect it depends on both whether you are doing complex procedures and how fast the medicine side changes in your field.  Some specialties I am sure are more appropriate for very part-time work than others.

[Arkad]

A lot of this discussion often turns to the technical and mechanical aspects of practice.  As someone who is going to be stopping practice soon in my mid to late 50s, I think I still have the technical skills needed to do my job very well.  I continue to teach residents, fellows and some attendings.  However, as I slow down, I have realized that the biggest difference between me now and 20 years ago is not what I do and how I do it but the ability to see the practice of medicine differently.  Some of that has come from taking care of patients for many years, seeing families get older, seeing the benefit of some of the surgeries I do as well as how some do not always do what we think they should be doing for our patients.  This can only come with time and experience.  During training I did not always have that appreciation when working with older attendings and I have no idea if the residents I train now understand that either when they work with me.  My point is that "older" attendings have some very valuable skills that are not tangible.  Unfortunately we tend to only appreciate that when we ourselves get older.

[q-school]

Certainly agree arkad.
A related question is will physicians who cut back significantly in their 40s still accrue the same wisdom in their 50s and 60s or will early retirement and presumably focus on other areas of life mean they may not develop the same way? Or whether there is some way to have both?

[The White Coat Investor]

q-school wrote:

I assume virtually all physicians here think they are outstanding clinically.  That is a function of intelligence, work ethic, training, and maybe some luck thrown on top of it.  Most here are relatively early in their careers I think and so the hours of training plus close supervision plus testing more or less make this very likely to be the case.  For procedurists, there are plenty of data that suggest higher volumes, or at least thresholds, are associated with better outcomes.

Yet I hazard that we all know some physicians still working who may be capable but not at the top of their game.  Or, you know, … some who are ROAD  Retired, but on active duty.

What strategies do we have to ensure that we stay at the top of the game?

To a degree, working full time for me ensures that I stay current.  I have mandatory CME, I attend group meetings with lots of clinical discussions, i do a high volume of procedures, I have to answer tough questions from patients.  I ask other smart people tough questions all the time.

If we have plans to cut back at 40 or 45, but still want to work part time for a considerable length of time, how do we ensure that at 55 or 60 we can be good to great?  even if we want to volunteer, how do we maintain skills?

Thanks!

 

 

 

Click to expand...

This is something I've spent a lot of time thinking about and talking to my partners about as I went to 3/4 time a year ago and am considering going to half time in another year.

I've made a few conclusions:

1) Identify the thresholds. Is 6 shifts a month enough? 8? 10? Two of a particular procedure a month enough? Figure out what the threshholds are, and if you are doing a procedure that falls below one, refer it elsewhere.

2) If being a doc is a major part of your life/identity, you need to treat it like that. That means passing on vacation or hobby time to do CME. If you're going to punch out in 2 years, it's not as big a deal. But if you plan to be doing medical mission work in 20 years, you can't stop learning.

3) The less I work, the more compassionate I am and the more I enjoy the work. The more I work, the more skilled I am. Balancing yourself on that continuum is critical.

4) Some things you'll never forget, and that probably accounts for 80% of your work. One shift a month is plenty for me to still be good at working up undifferentiated abdominal pain. I'm not going to forget how to suture up a simple laceration or reduce a nursemaid's fracture. So concentrate your efforts on stuff that changes most often.

[hightower]

Interesting discussion. In my line of work (hospital IM), I don't see any negative effect to cutting back to a part time status for the work I do.  It's not difficult to stay current with reading, attending cme events, etc.  I can't really comment on surgical skills, since I have none, but I will say that since procedures are very rare in my field (central lines, intubations, various fluid taps, etc), I do not feel comfortable doing them at all.  If I were to do procedures I would want them to be a regular part of every single day I work.  Since they are not, I'd rather stay away from doing them altogether.  So, I can understand the fear of a surgeon wanting to cut back to a part time status.  But, I can't imagine that your experience would be that drastically different if you went from a 1 FTE to a 0.5 FTE (enough to retain health insurance).  Is it possible to work 2.5 days a week?  I don't see how you could lose skill or experience if you're still working that much each week.  Now, if you're talking about working only a few days per month, ok, that might be a problem.

[CM]

wideopenspaces wrote:

I have more time to think about patient situations, to read journals, do cme, reach out to other members of the treatment team, etc. If I was full time I probably wouldn’t want to do this after seeing patients from 8-5 every day. But maybe that’s just me?

Click to expand...

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[RetiredERdoc]

I guess I must be the exception here as I never considered myself to be an outstanding clinician. I had a poor bedside manner (burnout, my old friend!), but I knew how to work up a patient, could "move the meat", could perform the expected procedures ok,and knew when to get help (second opinion from a colleague on duty, consult, etc). As I became burned out I strongly considered going part time, but worried about a decrease in my average skills so elected to retire instead. Definitely a hard decision to make as to how much keeps you up to par with your skills. I guess that is why they usually make the er director do 6-8 shifts a month. That just seemed like too many.