Many anesthesiology groups have evolved in a culture of “equal work for equal pay,” which can make it difficult to accept some physicians working more or less than others. In today’s market, however, a number of factors are converging that may force groups to reassess these founding principles. This was the topic presented by Genie G. Blough, M.B.A., F.A.C.M.P.E., and Shena J. Scott, M.B.A., C.M.P.E., at the ASA Practice Management Conference in San Antonio, Texas, on January 31-February 2, 2003. Highlights from the presentation of their survey findings appear below. In a subsequent “Practice Management” column, we will summarize their conclusions on designing part-time work systems. The full monograph and survey results are included in the conference compendium, available through <publications@ asahq.org>.

Background
In the current environment of an anesthesia provider shortage, aging population, changing demographic mix of medical school graduates and the younger generation’s different approach to life balance, anesthesiology groups today need to find a way to create flexible schedules if they wish to retain necessary workers in a tight market.

In July 2001, Gifford Eckhout, M.D., and Armin Schubert, M.D., assessed the shortfall of anesthesiologists as approaching 4,000 nationwide. With continuing hospital demand, they predicted shortages of up to 7,900 anesthesiologists by 2005.¹ At the same time, the population is aging. Between 1990 and 1998, the number of people over 65 in the United States increased 11 percent, while the number over age 85 increased 34 percent. Like it or not, anesthesiologists also are getting older. Based upon the assumption that anesthesiologists will generally retire at age 65 — and many retire earlier — the age distribution of current ASA membership implies retirement attrition in the year 2011 that is nearly three times greater than in 2001.² If groups insist that physicians must work in an “all or nothing” capacity, they will force the retirement of older workers who might otherwise be willing to continue working in a reduced capacity.

A third factor is the changing mix of medical school graduates. Women now make up 45 percent of the medical school population. While the number of women applicants to medical school continues to increase yearly, the number of women choosing anesthesiology is declining.³ A recent New York Times survey cited childrearing as the primary reason that 25 percent of female doctors work less than 40 hours per week, while only 12 percent of male doctors do.⁴

Another pressure in the current market is the different approach to life balance of the younger generation. Generations X and Y tend to value flexibility and time off significantly more than the prominent “baby boomer” values of income, status and longevity. Tending to have married later, many are two income families. Finances are less of an issue than achieving a satisfactory balance of personal and family responsibilities. Blough and Scott conclude that anesthesiology groups who do not find ways to create flexibility in their practices will lose the best and brightest workers, young and old, male and female.

Survey Results
In September 2002, Blough and Scott conducted a survey⁵ to find out where groups were in this process. The survey was designed to identify trends and was not based on statistical sampling methods. The responses came from 138 practices encompassing approximately 4,000 physicians, or roughly 15 percent of ASA’s actively practicing members. Most were from medium-sized private practices working in a care-team setting and covering call at one or two hospitals. More than 95 percent of the academic respondents reported part-time structures already in place through their universities.

Blough and Scott asked several questions to assess call frequency and intensity since they felt that these factors would determine anesthesiologists’ desire to cut back. The average number of weeknights reported by the 78 percent of physicians who indicated they stay in-house for call⁶ was 2.61, and the average frequency of back-up call was 2.99 weeknights per month [Figure 1]. Respondents reported being involved in cases an average of 7.18 hours during a typical weeknight call. They also reported working an average of 11.34 weekends per year and being involved in cases an average of 12.71 hours per weekend call. The average number of weeks off per year was reported to be 7.85 with a range between four and 12.

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Most (56 percent) reported being compensated on an equal share basis with 23 percent reporting a time- or points-based system, roughly 4 percent indicating straight productivity and 5 percent a hybrid formula. With regard to ease of buying and selling call, more than two-thirds of groups on a time or point system indicated that this was an easy process while only one-third of those on an equal share system did.

More than three-quarters of the responding groups published their call schedules no more than three months in advance. A striking 30 percent scheduled call on a month-to-month basis. The data clearly indicated that groups publishing their schedule for six months or more in advance found it easier to buy and sell call. Anesthesia practices contemplating an offer of a part-time option should be able to distribute the schedule further ahead without much difficulty if the ability to plan is an issue for their members.

The survey form asked whether groups perceived an excess of either buyers or sellers. Twice as many groups reported an excess of sellers as opposed to an excess of buyers. Clearly, reducing call is already an important issue and will become more so as the provider population ages and the shortage continues.

Blough and Scott also asked about the types of part-time arrangements currently in use and about restrictions and limitations, if any. The most common types of part-time work schedules were: 1) proportional reduction in weekday hours and call (sometimes restricted to “job-shares,” which add up to a round number of FTEs); 2) set-hours, noncall positions; and 3) “floating” noncall positions in which the anesthesiologist floats through the schedule in noncall positions only. They asked respondents to identify direct compensation methods for these most popular part-time structures.

As shown in Figure 2, for the set-hours, noncall part-timers, most received a fixed salary or a proportional reduction of shareholder income. Most floating noncall positions were paid hourly or through a proportional reduction (averaging 25 percent less than a full-call shareholder). For the proportionally reduced position, most practices reduced pay by an equal percentage to the work reduction when compared with a full-time shareholder. Blough and Scott were surprised that only 11 percent took an extra percentage (average 7 percent) to help offset fixed costs (e.g., malpractice, credentialing) that do not fluctuate when someone reduces his or her work hours. An important take-home message for groups considering part-time work is that fixed costs need to be a consideration when setting part-time compensation.

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More than half the survey respondents indicated that they prorate benefits for part-timers (for example, if someone is working 75 percent of a full schedule, the group may pay 75 percent of the benefit cost, and the individual pays the balance). Blough and Scott estimate that this further reduces total compensation by 15 percent to 20 percent on top of the salary reductions reported above. More than 60 percent of the groups in the sample decreased vacation, which effectively reduces hourly compensation.⁷ In summary, they estimate that the reduction in total compensation for a noncall set-schedule position is in the neighborhood of 45 percent-50 percent with the reduction for a floating noncall position approximately 35 percent-40 percent.

The majority of groups do not place a time limit on how long someone may occupy a part-time position (those who do averaged two years). Nor do they limit the number that may be occupied concurrently (those who do set it at 11.5 percent of group size). They do not limit voting rights or require a certain number of years of service to be eligible for a part-time position. Blough and Scott attribute this to the fact that most groups with a “plan” have not planned at all but instead have reacted to individual requests. Interestingly, one of the obstacles respondents cited to developing a plan was that “nobody was interested.” Blough and Scott say this is in fact the best time for planning — before a group is dealing with an individual who has a face, a history and a preconceived notion of what is fair.

References:

1. See monograph for calculation.

2. Eckhout G, Schubert A. Where have all the anesthesiologists gone? Analysis of the national anesthesia worker shortage. ASA Newsl. 2001; 65(4):16-19.

3. Grogano AW. National residency matching program results for 2002: Excellent results for anesthesiology,” ASA Newsl. 2002; 66(5):13-18,26.

4. Calmes SH. Anesthesiology demographics: Women’s changing specialty choices and implications for the anesthesiology workforce shortage. ASA Newsl. 2001; 65(8):22-23.

5. Steinhauer J. For women in medicine, a road to compromise, no perks. New York Times. March 1, 1999; sect A:1.

6. Full survey information available in the ASA Practice Management monograph available at <www.ASAhq.org>.

7. Based upon previous surveys Blough and Scott conducted for ASA, they deduced that many of these physicians were staying in house by choice. They noted a trend away from in-house coverage requirements in their 2001 hospital contracting survey as compared with the same survey conducted four years earlier. In 2001, fewer than 50 percent of anesthesiologists reported an in-house coverage requirement.

8. See monograph for calculation.