My second child – a daughter – was born 3 days before I was to begin year two of medical school. Already in my 30s, in the first stage of a second career, I decided to push through, and not take any time off. For a year, it worked out, as I had the support of everyone who mattered – my husband (thanks, John!), a wonderful nanny (thanks, Lilian!), friends, and even my medical school. The administration not only tolerated having me bring my infant daughter to lectures but facilitated the endeavor, setting me up in the AV room where I could nurse her while listening in on lectures.
As expected, the 3rd year was more onerous, but by the time 4th year came around, the relative flexibility still confirmed for me that pushing through had been the right move.
But then came intern year. This was before the 80-hour rule, and given all that I was trying to juggle, I just ran out of gas. Hit hard by fatigue, malaise, and feelings of detachment, I missed the telltale signs of burnout until I was, already…burned out. Totally. Four months into my family medicine residency, I quit, not knowing if I’d ever become a practicing physician.
I found work as a research associate and felt some real relief. But quitting didn’t feel right either. It didn’t help that my kids were asking whether I was a “real doctor.” I told myself that my MD and masters in public health were enough to get a satisfying job and that my career switch still made sense, and the last 4 years would not go to waste.
A chance encounter with our residency director changed all that. “So when are you coming back,” she said? I blurted out “when you have a part-time slot.” I was kidding because I knew internships like that didn’t exist. Except, a rare few did, and she offered me one. (Thanks, Pat!). Five months later, I was an intern again – a part-time intern.
Here’s how it worked: another intern and I split a single position by working alternate months. During each of our respective “off” months, we only came by on Monday afternoons for our weekly continuity clinic. Under this arrangement, the two of us took approximately 24 months to complete what is usually the first year of internship.
The reduced pace was just what I needed to bounce back – to maintain, and actually regain my sanity. I was no longer sleep deprived, irritable, detached, depressed. During my ‘off’ month I developed a prolific medical writing career, spent time with my kids and husband, and kept myself engaged with friends, reading, swimming and exercising.
At the end of that prolonged internship ‘year,’ I reverted to the conventional system and finished my last two years according to the usual schedule. But ever since I’ve wondered why it was only by accident that I had heard about this option. It seemed such an ideal way to train.
In fact, part-time medical training, which has also been called “flexible” training, is not a new idea. A 1969 article in JAMA noted that “part-time specialty training does merit a trial,” primarily as a response to the “steadily increasing numbers of women in medical school” and as a means to address the attrition of women in medicine.
The AMA house of delegates, in 1969, approved a statement saying “uncompromising adherence to the traditional residency schedule may prevent these women from ever completing residency training…appointment of qualified female physicians to part-time residencies is encouraged”.
Back then the focus was on part-time residency being a solution for women only: “the best argument for flexible post-graduate training programs is to enable the young graduate to continue her training, rather than having to drop out for childrearing and family responsibilities for long periods of time.” “This is the harbinger of the future,” stated an editorial in the Journal of Medical Women’s Association (JAMWA) in 1972 (at that time, the percentage of women admitted to medical school was 13%, compared to our current rate of nearly 51%).
However, it quickly became apparent that it should not be gender specific and could be a solution to the inflexibility of medical training and perhaps even what we now call ‘burnout.’ One woman physician was musing that this solution “should be available for election by physicians of either sex and without a demand for an explanation of reasons”. Similar sentiments were expressed in several publications. “Shared and part-time residencies offer one solution to the long hours and stresses of residency training…are not just for parents or married residents, but are important options for all residents.”
Multiple surveys of students and residents about part-time training demonstrated an interest, including having this as an option in general surgery, and pediatrics. Another survey of more than 780 students, conducted in 2015 found that >50% of students “indicated they would be interested in working part-time during some portion of their residency training.” Not only that, 52% felt that programs that offer such options would be seen as more desirable. But as pointed out elsewhere, “the demand…probably far exceeds the supply of such programs.”
So if the interest was there, if it is deemed desirable, why does this option remain so limited?
I couldn’t find any recent data on the availability of part-time residency slots offered in different specialties in the US. One 2005 study of pediatric residency programs showed during one point in time (2000-2003) 12% of programs had more than 1 part-time resident, and that nationally less than 1% of those who had taken a survey, undertook some of their training on a part-time basis.
In its Residency Training Guidelines, the American Board of Family Physicians — my board — does feature a section on part-time residency, listing the various requirements. These requirements, in fact, are some of the challenges most often cited as barriers to implementing part-time programs, regardless of specialty. Concerns about the flexible option falls into several categories: 1) effects on patient care (primarily continuity of care) 2) institutional inconvenience (effects on scheduling, hospital call, and weekend coverage), 3) program inadequacies (attitudes by fellow residents, distribution of benefits and salary), 4) certification challenges (board acceptance, exam success), and 5) resident-centered issues (prolonged training, remuneration, benefits).
There is also a perception of flexible options being “second class” and “going against a culture that equates dedication with the number of hours worked.”
Some published work has sought to challenge the prevailing notion that it is perhaps too complicated and maybe even not worth the trouble. An analysis of a ten-year experience of part-time training in Internal Medicine in Boston found that “part-time residents scored significantly higher” on clinical and humanistic skills, “while there was no difference between the groups in leadership or teaching skills.” This option, the authors concluded, “did not adversely affect clinical competence and may have fostered humanistic attributes,” and suggested that it provided “a highly useful program” for a group of residents.
An evaluation of what was called “The Flexible Option” (FO) at the UCSF pediatric residency program found that “the majority reported that the FO was critical to their success as residents and that despite some challenges nearly 90% of residents felt the program should continue to offer this option. These and other studies have shown that residents who completed flexible programs had specialty board exam pass rates that were equivalent to those who followed the traditional pathway, in addition to receiving similar or better faculty reviews.
One of the issues of studying the success of such flexible programs is that they are, in fact, flexible. There are multiple ways of implementing part-time programs. Some offer options to work continuously, but for fewer hours per week or shorter-hour days; Others (like mine) offered a shared residency option whereas two residents split the responsibilities of one intern. Some programs, like at UCSF offer a 6-months on/6 months off option.
The debate about flexible options is not just an American one. The potential merits (and challenges) of flexible training have been discussed in medical journals in Australia, Germany, Canada, Switzerland, and Israel. Similar to the situation in the US, most articles noted a mismatch between the desire of trainees to have such opportunities, and the actual availability of part-time slots.
At a time when burnout among students, residents and practicing clinicians is headlining journal theme issues and conferences, we may already have at least part of the answer in flexible training. No flexible training option could remove the structural problems that contribute to burnout in the first place, but it could offer a reprieve to some.
I know it worked for me. Chronologically speaking, it cost me an extra year to complete my training. But, without that flexibility, I wouldn’t have crossed the finish line. When I look back now, as a full-time faculty member at a medical school, I cannot imagine having done it any other way.
I also recognize that it is not for everyone. Financial considerations – such as a reduced salary – can be a big issue for many, especially those applying to enter residency with existing debt, or for those entering a primary care specialty, which traditionally pays less. Nevertheless, when I speak to students about my unusual training pathway, many are intrigued, even surprised, to learn that such an option exists, just as I was, more than 17 years ago.
As professional medical organizations and training institutions are scrambling to find and implement solutions to the serious professional issue of burnout, to the loss of joy in practice, and seeking mechanisms to ensure the ‘quadruple aim,’ they ought to consider expanding – and advertising — opportunities for flexible training.
Ranit Mishori