Flexing to Aging: A Children's Hospital Responds to a Maturing Workforce
Article Outline
- The Process
- Recommendations
- Respecting and Honoring Senior Physicians
- Challenges Not Addressed
- Other Considerations
- Next Steps
- References
- Copyright
CCSG, Connecticut Children's Specialty Group
“…As ‘our generation’ is reaching some big numbers, if one doesn't trust anyone over 30 (remember that?), what does one do with someone over 60?”
59-year-old physician
Despite the recent focus on resident work duty hours and the changing demographics of the pediatric workforce, we found scant literature directly addressing the development and implementation of specific policies regarding the aging physician.1, 2 This observation stands in stark contrast to readily accessible information on aging workers in aviation and mining.3, 4 Nationally, the changing demographics of the pediatric work force provide special challenges. Between 1991 and 2008, the percentage of women occupying PL-3 slots nationally increased from 54.4% to 73%.5 Forty percent of recently graduated residents sought part-time work and half of them accepted part-time positions. Those accepting part-time positions are more likely to work in academic medical centers than those accepting full-time work (25% vs 15%, P < .05).6 At the other end of the age spectrum, a recent American Academy of Pediatrics survey reports that even though 78% of 60- to 64-year-old pediatricians work full-time, full-time work drops off steeply thereafter. Women are less likely to work past 65 years of age and more likely to cite poor health and family responsibilities as reasons for retirement.7
Medical and surgical care at Connecticut Children's Medical Center is provided predominately by physicians employed by the hospital's Connecticut Children's Specialty Group (CCSG). Within 5 years, 16% of the female and 27% of the male CCSG workforce will be ≥60 years old, and 1 in 5 CCSG physicians will be ≥60 years old.8
Aging faculty may face challenges during their senior years in the work force, including (1) personal health challenges; (2) health challenges of family members; (3) a shift in their professional and/or personal goals; (4) decreased physical energy or capacity; or (5) decreased mental capacity, particularly during periods of sleep deprivation. These challenges may have implications for both their own and their colleagues' professional careers because others may be asked to assume additional responsibilities as the senior faculty member pursues his or her own career and life needs.
Recognizing our “maturing” workforce, a CCSG peer taskforce was assembled to develop a systematic process for considering requests for changes in clinical work load due to “senior status.” To date, such requests in our institution were handled on an ad hoc basis at a divisional level. Although the broader issues of career expectations and planning for the aging physician are critical to the mission of an academic department, they were beyond the scope of our initiative. This Commentary outlines our process, progress, and challenges.
The Process
A task force was assembled consisting of CCSG physicians from primary care and the medical and surgical specialties. We strived to achieve sex, age, and experience balance. No member is currently seeking a reduced work load. The task force believes a proactive, principle-based discussion will result in a fair, equitable, and fiscally responsible plan that achieves buy-in from current and future faculty. We sought to propose guidelines that recognize and reward the value that senior members offer without burdening other faculty and serve to retain mid-career physicians as they approach senior status.
Given the lack of published data, we sought outside information from colleagues who chair New England pediatric departments. Only one department chair reported a systematic method for addressing senior status.9 The results of these inquiries, and the consensus after a number of taskforce meetings, form the basis for current recommendations.
The task force established general principles to guide discussion and recommendations for senior status. The process is targeted toward physicians ≥55 years old. Work-life balance is critical for faculty across the “life cycle” to maintain equity and promote faculty engagement and retention. A sustainable plan will: (1) Recognize the strengths of senior faculty, such as master teaching, peer mentoring, professional development, administration, fund raising, and advocacy; (2) Institute a peer committee to oversee the implementation and promote acceptance by the faculty; (3) Preserve the creativity and flexibility of individual divisions to meet their responsibilities; and (4) Include a tiered system of clinical responsibility that ties reductions in effort to compensation, consistent with mission-based funding.
Recommendations
The task force proposed the following guidelines as a roadmap for building an equitable and structured policy to address requests for senior status.
I. Preparation for the Process
Annually, each division will review its clinical care, education, research, and administrative responsibilities. The clinical component will include daytime in- and out-patient responsibilities, nighttime, and weekend call. The portion of clinical work representing call will be calculated. This calculation may vary annually based on the number of faculty, anticipated leaves, illness, and so forth. An economic value will be assigned to clinical and call responsibilities. This value can be used to calculate requests for relief from any portion of the clinical or call load.
II. Requests for Senior Status
Faculty will become eligible the academic year after their 55th birthday. Interested faculty must notify their Division Chief and Physician-in-Chief or Surgeon-in-Chief in the prior academic year.
III. Calculations of Reduced Clinical Load and Financial/Duty Adjustments
The previously assigned monetary value for call and other clinical duties will be used to evaluate the impact on both the requesting physician and on those colleagues who will assume the extra duties. Decreased clinical responsibilities will typically result in a decrease in net compensation and/or an increase in other responsibilities critical to the divisional or institutional mission. Other nonmonetary incentives may promote satisfaction and retention of senior faculty, such as enhanced vacation, ability to take block vacations, more mid-level practitioner/fellow/postdoctoral support during clinical time and/or call, enhancements in continuing medical education, and preferred parking. Flexibility will offer divisions the opportunity to trade clinical responsibilities, or money, to meet the priorities, personal needs, and professional needs of divisional members. Given a structured approach, physicians requesting senior status and their colleagues will clearly understand the financial and work load implications.
IV. Oversight Committee
An oversight committee of CCSG peers and administrators will review all initial requests for senior status and make a recommendation to the Physician-in-Chief or Surgeon-in-Chief, as appropriate. In some cases, the oversight committee may take an active role in assisting divisions that report challenges in development of an equitable plan.
V. The Final Decision
The final decision to grant senior status rests with the Division Chief and Physician-in-Chief or Surgeon-in-Chief. Changes in clinical work load/call due to senior status will be reviewed annually by the Division Chief and authorized by the Physician-in-Chief or Surgeon-in-Chief.
Respecting and Honoring Senior Physicians
The task force had spirited discussions regarding linkage of clinical duties and salary. Participating faculty, including several mid-career clinicians and three Division Chiefs, struggled to reconcile a sense of duty and responsibility to aging peers and the realities of clinical expectations. In the end, reality trumped—someone has to do the call that senior physicians may choose to relinquish, and the cost of call will likely be covered by a decrement to the senior physician's net compensation. The senior status physician would remain a 1.0 full-time equivalent with full benefits, unless a reduced full-time equivalent is negotiated.
Challenges Not Addressed
The task force also identified challenges that were not adequately addressed by our discussions, including in-house call expectations, shift work, and small divisions that may be challenged by inadequate coverage if some members relinquish call. The task force recognized a need for financial support from the institution, especially for those small divisions that are unable to assume the full financial burden of a physician moving to senior status with a decreased clinical load.
Other Considerations
In the shadow of the Accreditation Council for Graduate Medical Education work-duty hours restrictions and further decreases recommended by the Institute of Medicine sits the elephant in the room—“the only physician allowed to continue working is (sic) the oldest one and the one with the most responsibility.”10
Next Steps
Far from being a “fait accompli,” our process is a work in progress. We believe this modest initiative is the first step in a developmentally focused perspective on the career goals and expectations of an academic physician. Just as “to everything there is a season,” to every phase of an academic physician's career, there should be “a purpose.” The challenge will be aligning the expectations, goals, and dollars.
As this commentary goes to press, we are soliciting input and considering modifications to our recommendations. We tried to develop a process that is proactive, flexible, transparent, and not prescriptive. We hope this commentary stimulates conversation in your department and at national meetings. The demographics of the pediatrics work force and regulatory influences are a speeding train coming toward us—let's address the problem and think of potential solutions while the lights are still in the distance.
References
- . To everything there is a season and a time to every purpose: retirement and the neurosurgeon. J Neurosurg. 2004;100:1123–1129
- . Neurosurgeon transition to retirement: results of the 2007 Congress of Neurological Surgeons Consensus Conference. Neurosurgery. 2009;65:231–235
- . Pilot age and expertise predict flight simulator performance: a 3-year longitudinal study. Neurology. 2007;68:648–654
- National Institute of Occupational Safety and Healthy Office of Mine Safety and Health Research. Older workers. Available at http://www.cdc.gov/niosh/mining/topics/topicpage10.htm. Accessed March 18, 2010.
- American Board of Pediatrics, Workforce Data, Available at https://www.abp.org/ABPWebStatic/. Accessed January 18, 2010.
- . Many pediatric residents seek and obtain part-time positions. Pediatrics. 2008;121:276–281
- . Patterns of work and retirement among pediatricians aged ≥50 years. Pediatrics. 2010;125:158–164
- Connecticut Children's Specialty Group data courtesy of Paula Scheiblich and Dean Rapoza, October 2009.
- Personal communication, Paul H. Dworkin, November 2009.
- . Attending physician work hours: ethical considerations and the last doctor standing. Pediatrics. 2009;124:758–762
PII: S0022-3476(10)00360-4
doi:10.1016/j.jpeds.2010.04.060
© 2010 Mosby, Inc. All rights reserved.
