Collegial Collaboration: Job sharing as an innovative approach to physician well-being and burnout prevention
Background
Burnout amongst physicians is an epidemic. Researchers define burnout as “a combination of emotional exhaustion, depersonalization, and low personal accomplishment caused by the chronic stress of medical practice.”1 In the 2018 Canadian Medical Association national physician health survey, 30% of respondents rated their overall burnout as high.2 The highest rates of burnout were seen in those physicians who were in practice for 5 or fewer years, and in women. Given that 64% of Family Physicians in Canada under the age of 35 are female3, and likely in their first 5-10 years of practice, strategies to prevent and address physician burnout are crucial to the maintenance of highly functioning primary care systems. Burnout increases the risk of medical errors and decreases productivity, thereby impacting on patient care.4 Furthermore, burnout can increase physician turnover, accelerate early retirement, and contribute to provider mental health issues.5 Although targeted mindfulness and cognitive behavioural approaches can benefit physicians with burnout6, a systematic review and meta analysis of interventions demonstrated that those programs with organization directed approaches, such as modified schedules and workloads, were most effective in ameliorating provider burnout.7
In academic medical settings, physicians have multiple competing responsibilities, including clinical care, teaching, administration and research. Academic physicians are constantly role modeling values, attitudes and professional behaviours to their learners, whether in tutorials, the clinical setting, or in the supervision of research initiatives. In a focus group study of residents, “it was not uncommon for clinician–teachers to express negative and cynical comments about the medical profession, which left learners feeling pessimistic about their chosen profession.”8 Physicians struggling with exhaustion and burnout may unintentionally be negative role models to their learners, thus impacting on career decision making processes.
Although burnout is a commonplace struggle amongst physicians, some providers may have other barriers, such as significant medical diagnoses or family obligations, which impact on their ability to maintain their full hours and scope of practice. Creative practice solutions enable physicians with illnesses and disabilities, burnout and competing life circumstances to balance their personal needs while continuing to provide patient care. Innovative practice management strategies may be even more important for Family Physicians who have unique doctor patient relationships9, and thus may be more inclined to prioritize patient care over self-care.
An Innovative Solution: Job Sharing
As defined by the Harvard Business Review, “job sharing - splitting a full-time position into two part-time jobs - is an increasingly popular flexible work arrangement.”10 Linzer and colleagues advocate for part time work and job sharing for physicians to “allow institutions to use a more flexible life cycle approach to meet the needs of an increasingly diverse workforce and prevent burnout.”11 In describing their successful job share, Sacks et al reflected that for academic Family Medicine to remain an enticing career choice, it must evolve to offer job opportunities that can provide a needed work-life balance.12 Despite the apparent advantages of this model of practice, literature on implementation and outcomes is scarce.
In an effort to maintain a healthier balance between work and other commitments, such as our family responsibilities and health care needs, we were provided with a unique trial of a job share for patient care at our academic Family Practice unit. This organization directed practice change was developed in conjunction with and supported by departmental leadership.
Aligning our philosophies of patient care, trusting the diagnostic capabilities of the collaborating partner, and ensuring an equitable workload and commensurate salary have been the foundations of success in our job share.
Academic productivity may increase in job share models as there are defined periods away from clinical care where other interests such as education, research or administration can be established. A strong relationship exists between the amount of time that academic physicians spent in the aspect of work they found most personally meaningful (patient care, research, education or administration) and burnout. Physicians who spent at least 20% of their time in the aspect of work most meaningful to them had a rate of burnout roughly half of that of those who did not.13 Intuitively, job sharing can foster academic physician well-being and sense of accomplishment as it can enable providers the opportunity to pursue scholarly pursuits in addition to patient care. Through job sharing, we have been able to cultivate academic interests that have been challenging to nurture in the past because of time constraints.
Benefits of a Job Share and Pearls to Consider
For physicians seeking to establish a clinical job share, special considerations should be taken before embarking on this practice model. From our experience, the following steps were integral to the success of our transition to a job share model:
1. Creation of a job contract with clear and well defined expectations regarding clinical hours, coverage of labs and messages, coverage for call, and supervision of learners. A collaborative agreement on duties was established and reflected in our contract and has allowed us to eliminate any potential ambiguity in defining our responsibilities.
2. Familiarity of the new partner with the existing roster of patients. Given that one of the partner physicians did her residency training at the clinic and previously covered the practice independently as a locum, she was at a unique advantage of starting the practice share with established relationships with many of the patients.
3. Division of responsibility of monitoring of messages and labs on the weekends to ensure the partner covering on Monday was not unduly burdened with results to be reviewed, thus enabling a more even workload distribution.
4. Negotiation of a non-hierarchical salary that is equitable and reflective of work done by each partner.
5. Flexibility of partners to be available to cover messages and clinical duties in the event of planned or unforeseen absences. Clerical staff benefit from this model of care as they do not have to urgently cancel clinics in these situations.
6. Coordination of regular clinic schedules and holiday schedules to ensure seamless access to care Monday through Friday, even during peak vacation periods. This model decreases the burden on our physician colleagues who would otherwise cover urgent issues in our absences.
7. Open and routine communication regarding patient care issues requiring further explanation or a second opinion.
8. Comprehensive charting which enables either provider to understand next steps required
for follow up and facilitate transfer of care when needed. Complex patients benefit from having two providers collaborating, sharing their knowledge, and developing differential diagnoses together.
9. Guidance and endorsement from departmental leadership, and full investment of partnering physicians in a trial of a new model of care, with ongoing reflections on the strengths, weaknesses and sustainability of the job share.
Drawbacks and Areas for Future Research
Although the practice share model has a multitude of advantages and our professional satisfaction levels have been extremely high, there are drawbacks, the biggest of which is a decrease in income. Regardless of the clinical setting, the improvement in work-life balance must be weighed against the financial impact of a job share. Physicians who are primary earners for their families or those with large student debts may have difficulty meeting their financial needs in a practice share. We acknowledge that we are both in a position that allows us to benefit from the practice share model without accruing a huge financial burden.
Patients have been accepting of our practice share thus far, however, we have no formal data on whether patient satisfaction scores have changed. A knowledge gap exists on how the practice share model is perceived by the allied health providers we collaborate with daily.
Abaza has advocated in the medical education literature that academic physicians must not only be understanding and supportive of our learners’ self-care needs, but also role models so that they can understand the relevance of self-care.14 Intuitively, a job share model would be an excellent example of a strategy whereby academic physicians could role model self-care to their learners, and research on this outcome should be pursued.
Conclusions
Physician burnout affects providers and their patients. It is important to recognize physician limitations and personal situations which may undermine a provider’s ability to maintain a full scope of practice. In these situations, a successful practice share model benefits all those involved. It results in high quality patient care and excellent access, while at the same time enabling those physicians to obtain a better work-life balance. Academic Family Medicine sites should consider supporting these innovative job share models as they provide a means of addressing physician wellness, thereby promoting and role modeling work-life balance.
Dr. Jennifer McCabe, Family Physician, St. Michael's Hospital; Assistant Professor, Department of Family and Community Medicine, University of Toronto.
Dr. Alina Zaltzman, Locum Family Physician, St. Michael's Hospital.
References
1. Rotenstein, L., Torre, M., Ramos, M., Rosales, R., Guille, C., Sen, S., et al. Prevalence of Burnout Among Physicians: A Systematic Review. JAMA 2018; 320(11): 1131-1150.
2. CMA National Physician Health Survey: A National Snapshot. Canadian Medical Association, October 2018. Available from: https://www.cma.ca/sites/default/files/pdf/Media-Releases/nph-survey-e.pdf. Accessed Nov 24, 2020.
3. Canadian Medical Association: Quick Facts on Canada’s Physicians, Canadian Physician Resources - 2019. Available from: https://www.cma.ca/quick-facts-canadas-physicians. Accessed Dec 1, 2020.
4. West, C., Dyrbye, L., and Shanafelt, T. Physician Burnout: Contributors, Consequences and Solutions. Journal of Internal Medicine 2018; 283(6): 516-529.
5. Patel, R., Sekhri, S., Bhimanadham, N., Imran, S., and Hossain, S. A Review on Strategies to Manage Physician Burnout. Cureus 2019; 11(6): e4805. doi:10.7759/cureus.4805
6. Clough, B., March, S., Chan, R., Casey, L, Philips, R., and Ireland, M. Psychosocial Interventions for Managing Occupational Stress and Burnout Among Medical Doctors: A Systematic Review. BMC Systematic Reviews 2017; 6: 144. https://doi.org/10.1186/s13643-017-0526-3
7. Panagioti, M., Panagopoulou, E., Bower, P., Lewith, G., Kontopantelis, E., Chew-Graham, C., et al. Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-Analysis. JAMA Internal Medicine 2017; 177(2): 195-205.
8. Kenney, N., Mann, K., and MacLeod, H. Role Modeling in Physicians’ Professional Formation: Reconsidering an Essential but Untapped Educational Strategy. Academic Medicine 2003; 78(12): 1203-1210.
9. The College of Family Physicians of Canada. Four Principles of Family Medicine. Available from: https://www.cfpc.ca/en/about-us/vision-mission-principles#four. Accessed Dec 30, 2020.
10. Gallo, A. How to Make a Job Sharing Situation Work. Harvard Business Review 2013. Available from: https://hbr.org/2013/09/how-to-make-a-job-sharing-situation-work. Accessed Dec 6, 2020.
11. Linzer, M., Levine, R., Meltzer, D., Poplau, S., Warde, C., and West, C. 10 Bold Steps to Prevent Burnout in General Internal Medicine. J Gen Intern Med 2014; 29(1): 18-20. doi:10.1007/s11606-013-2597-8
12. Sacks, J., Valin, S., Casson, I., and Wilson, C. Are 2 Heads Better than 1? Perspectives on Job Sharing in Academic Family Medicine. Can Fam Physician 2015; 61(1): 11-13.
13. Shanafelt, T., West, C., Sloan, J., Novotny, P., Poland, G., Menaker, R., et al. Career Fit and Burnout Among Academic Faculty. Arch Int Med 2009; 169(10); 990-995.
14. Abaza, M., and Nelson, K. Leading by Example: Role Modeling Resilience Helps our Learners and Ourselves. Academic Medicine 2018; 93(2): 157-158.