But we've always done it this way!
Medicine is a conservative profession, where change is viewed with suspicion and the reason, "But we've always done it this way!" is as unquestionable as, "I'm the mommy, that's why!" was in childhood.
(Incidentally, the latter was the bumper sticker on the station wagon that served as my first car, which made meeting girls as a 16 year old uniquely challenging. A story for another time).
Owning your business means you get to make the rules.
Our ED group is a unicorn, a single-hospital democratic group in community practice. We run our own business, with commensurate risks and rewards. After a period of explicitly defined sweat equity, new members get equal equity standing with an equal vote.
Like medicine anywhere, we had certain traditions that had developed over time.
Our culture was one of givers - when someone needed to swap out of a shift, you helped if you could. When the department was getting killed, you stayed a couple of hours late to help your friends.
During a period of chronic under-staffing several years ago, this culture of giving was stressed beyond capacity, because everyone was working more than they wanted to work.
Happy moments, like a friend giving birth, turned into cause for resentment - one person's joy transformed into your pain. Tradition dictated that the extra shifts during leaves of absence were simply divided equally among all group members.
Assuming my family was like Mad Men made for a mad wife
Perhaps this model worked when every physician was part of a nuclear family, with a standard division of labor: one breadwinner who worked in medicine and a stay-at-home partner who ran the household, raised the children and absorbed any unexpected shocks to family life that the physician's career might bring.
The implicit assumption was that everyone either had (or had best rapidly develop) a system at home to absorb the impact, as everyone was expected to "step up."
This assumption was not valid for my family. My wife is a physician who works part-time, an entrepreneur who runs a consulting business, and a logistician extraordinaire who handles most child and household scheduling.
She grew understandably resentful of my job at having to pick up the slack for my group's under-staffing. She made a cogent argument that she was paying a penalty by virtue of having been born with ovaries.
Many of these things are not like the others
As I looked around at our group, I noticed that ours was not the only non-traditional medical family. There were dual-earner families, single parents, and men and women who took a more hands-on approach to parenting than prior generations of physicians. There were families who supported elderly parents.
Our docs also participated in emergency medical services, local residency programs, the county fire department, tactical medicine for the local SWAT team, urban search and rescue, the hospital foundation and regional disaster preparedness. Their time to pursue these interests was being squeezed as well.
We felt a pervasive sense of learned helplessness compounded by martyrdom in medicine. Medicine was allowed to demand your attention above all other life priorities. If your medical career did not entail suffering, you must be doing it wrong.
[Digression for purpose of illustration: During our annual residency retreat, we put on a performance meant as a good-natured ribbing for the faculty we worked with. A spoof of the quiz show Jeopardy! asked the total number of spouses, past and present, among three tenured faculty: The correct answer was 9.]Changing an institution from within
This was a difficult time in my life, but unhappiness can be a great motivator.
I'd always believed the most effective way to change a system is incrementally, by revolution from within.
My wife and I began brainstorming an alternate, ideal version of a more accommodating medical career.
Know your audience
I first assessed the voting demographic. Our group consisted of:
- One third older traditionalists, whose lives conformed well with the current system.
- One third mid-career docs closer to my age, many of whom had young families placing increasing demands on their time.
- One third young guns, who were hungry to earn and pay off debt but generally too new to the group to feel comfortable expressing strong opinions.
There were also singles in each career stage that would not be averse to new ideas as long as those ideas did not come at their expense.
Recruit powerful allies
I began by reaching out to a charismatic, mid-career superstar in our group married to another physician with a toddler.
She had built considerable good will by being the first to offer help when someone asked to swap out of a shift; was beloved by our staff for her unflappable good mood; and was well respected as a brilliant clinician.
If I could enlist her as an ally, I felt it would lend credibility to the cause - who was going to deny this rock star's reasonable request to accommodate her family life?
We met for coffee, and I confirmed that she was equally unhappy with the current situation. She also confided that she was expecting!
We decided that a combination of mid-career docs (who stood to gain time) and young guns (who stood to titrate their earning potential to achieve balance) might be sufficient to overcome expected resistance from the traditionalists. We bounced ideas back and forth, refined them, and came up with a plan.
Frame the issue properly
If I had approached the problem as one doc's unhappiness with burnout, it might not have gathered sufficient support.
For some less sympathetic colleagues, burnout means you need to step aside to make room for someone else who is willing to do the job as it exists.
Instead, I framed the issue as one of fairness to those with family commitments. I chose an expecting mother everyone loved to help me champion the change.
Our group is not a sausage party, and we are fortunate to have a large number of reproductive age female physicians choose to work with us.
Like my wife, many female physicians felt the dual tugs of a large mental load (being expected to run a household) and a large clinical load. Our message resonated with them.
Like me, there were sufficient male physicians married to working spouses who wanted to help them shoulder the mental load. Our message resonated with them as well.
Instead of one male physician's crusade against personal burnout, we hoisted a banner to make emergency medicine as practiced at our hospital compatible with a higher level of engagement in family life.
It becomes difficult to argue to preserve a sclerotic scheduling system that prevents a parent from participating more fully in family life.
On the flip side, it becomes a unique recruitment tool to offer flexibility that attracts top candidates who value flexibility in scheduling. The program promised to add to the many enticements that make our work environment desirable.
We attract and retain phenomenal physicians because we are a family friendly workplace.
One size does not fit everyone
Since joining a decade ago, our group had operated on the assumption that an equal shift load translated to equality of impact.
This benefited from simplicity: divide the number of available shifts to fill by the number of doctors, and everyone worked their share. It was time we stopped pretending that one size fit all of us in medicine.
We proposed an alternative concept, which allowed individual shift load to vary by individual need: each equity member of the group would name a target number of shifts to work each month, and must be willing to settle for their target +/-2 to account for seasonable volume fluctuations.
Ensuring financial security
This addressed financial security: each person would select a minimum range that would enable her to meet financial goals or obligations.
Ensuring balance
This allowed tailoring of a career to individual needs that varied by physician: a single young gun might work 15 shifts a month, while a hands-on parent could reduce his shift load to 10 and make it to the soccer games and piano recitals.
We decided as a group on a range of shifts that would qualify for the benefits of full equity status (full profit sharing), and a lower range of shifts that would create a new, partial equity status (half profit sharing).
Ensuring fairness
One of the features that was added to make the proposal palatable to the traditionalists was a clause that all members, whether partial or full equity, would take equal bites of the "crap pie" by assuming a proportional number of nights, weekends and holidays.
Those who worked partial equity were valuable to others because the shifts they took included the less desirable shifts (nights, weekends and holidays). Ex: I work six shifts, but half are lousy, I'm at 50% lousy shifts.
Those who worked full equity or had a greater target number added a larger proportion of desirable shifts (weekday days). You work twelve shifts, but a third are lousy, you're at 33% lousy shifts.
Hence, the partial equity track members were valuable to those who might otherwise express skepticism toward their non-traditional workload.
An unintended consequence of this clause was that it did not address an ability to reduce night shifts. This was an oversight, and I am currently gathering support for a night shift differential to address this issue.
Capping the potential for unanticipated pain
One of my biggest concerns was that I wanted a ceiling to my pain. The old way of doing business had meant that all shifts vacated by folks on a leave of absence were divided equally among the members.
Adding 2-3 shifts to my clinical load was enough to make the difference between feeling an essential part of my household vs. my being a vaguely familiar, "Don't we know you from somewhere?" phantom presence at the dinner table.
The new plan addressed this as well: during periods of prolonged leave of absence, partial equity members would be allotted one extra shift for every two extra shifts allotted to equity members.
This made the decision easy for me: I chose the partial equity track. While this meant I sacrificed significant income, the benefits were priceless. Interestingly, I was the sole member to avail himself of the partial equity track in that first year.
A significant number of people, mostly mid-career docs, opted to reduce their clinical load to the minimum needed to qualify for the full equity track, and their levels of happiness blossomed unexpectedly. Several people who were skeptical of the plan became its most enthusiastic cheerleaders.
Every year, members are surveyed for their desired number of shifts, early enough so that we can hire to address any shortfalls. Under new leadership our group has not suffered the severe under-staffing we did during those brutal two years.
If you are thinking about trying to cut back in the next few years (are your ears burning, Physician Philosopher?), consider what parts of this playbook might work for your journey.