Physicians who accept leadership responsibilities and activities may choose to limit their clinical work. By paying close attention to how they arrange their practice to meet their responsibilities in areas such as coverage, handovers of care, referrals, and follow up on test results, physicians can minimize risks and provide effective care to patients. Physicians also have a responsibility to maintain a commitment to professional development to ensure quality and safety of care.

 

KEY WORDS:  part-time medical practice, obligations, patient coverage, referrals, handovers, transfer of care, competence, test results

 

Physicians generally work more than the typical 35–40 hour week, and many work well beyond that. However, some physicians limit their clinical work to accommodate other responsibilities, including leadership roles. Many physician leaders who blend their administrative responsibilities with their clinical practice feel that there is value in participating on both sides of the health care equation and helping to close the divide between clinicians and administration.1 Whether scaling back on clinical hours to lead an entire clinical department or service or to participate on committees or organizational projects, reduced clinical workload does not diminish the obligation to provide safe patient care.

Practice arrangements Top

 

Part-time clinical work can translate into a reduced work day or week; shift restrictions (only days or only nights); weekend hours or alternate weekend coverage; or job sharing with another physician. On one hand, physician leaders, who practise in a broad specialty but only see patients with certain specific, non-acute illnesses, may find it fairly manageable to limit their clinical work. On the other hand, physician leaders working in a surgery subspecialty may find that the difficulties of complex operations or treatments make part-time practice less likely. Shift-oriented settings, such as emergency rooms, may lend themselves to reduced hours for physicians. Large group practices may be more amenable to reduced hours than small practices because coverage by other physicians may be more easily accessible. Top

 

Coverage

 

Physician leaders seeking to limit their clinical workload will want to determine what after-hours coverage is most appropriate for their practice and patients, and make the necessary arrangements. Some medical regulatory authorities (colleges) outline what coverage is expected of physicians and physicians’ obligations to arrange after-hours, weekend, and holiday coverage for their patients. For instance, the College of Physicians and Surgeons of British Columbia expects physicians to make specific arrangements to transfer the care of a patient, whether it is to a physician working in a nearby emergency department or another practitioner in private practice.3 As the requirements will vary from province to province, physicians should check with their college.

 

Hospital-based physician leaders providing clinical care on just a day or so per week will have different coverage needs than those providing clinical care part-time in clinics or office-based practices. Some leaders may have off-hour coverage arrangements built into the practice model, while others may not. Where applicable, physician leaders with set clinical hours may inform their patients about their schedule and how to obtain care in their absence.

 

Handovers and transfers

 

Anytime the responsibility for a patient’s care is handed over or transferred from one provider to another, there is a risk that essential clinical information may be missed or will “fall between the cracks.” When physician leaders work limited hours, the number of patient handovers may increase. Top

 

To combat risks to patient safety, physicians providing clinical care on a part-time basis will want to be particularly vigilant about developing good communication and documentation habits. Relevant patient information must be available to any physicians providing coverage and to members of the health care team involved in the patient’s care.

 

Physicians should also be aware of possible barriers to an effective handover and consider how to avoid them. Ensuring that the medical record includes all relevant information is essential, particularly regarding tests, medications, and the professional responsible for follow-up care.

 

To further strengthen continuity of care, physicians may consider whether it is appropriate to involve the patient (and with the patient’s permission, the family) directly in the handover process. This approach informs the patient that there is a change to a new team or most-responsible physician, allows for clarification of the patient’s history and correction of any misinformation, and provides an opportunity to address questions or concerns. Top

 

Referrals

 

Doctors working a reduced number of clinical hours and involved in a referral, either as the referring physician or the consultant, have the same responsibilities toward a patient as a full-time practitioner. They should respond in a timely fashion when a referral is initiated, and they must be vigilant when a patient needs an urgent referral. Top

 

Physicians with a reduced clinical workload must consider how they can arrange their practice to meet their patients’ referral needs. Providing complete and clear information in the referral or consultation report is the first step. Further, physicians providing clinical care on a part-time basis should ensure that the other health care provider participating in the referral knows their working hours, who is providing coverage during any absences, and how the replacement can be contacted, particularly in an emergency. Top

 

Other health care team members should also be informed when a referral is urgent and given instructions on how to contact the physician or the doctor providing coverage.

 

Finally, giving patients information about the referral may help keep the process on track. Patients may be told why the referral is being made, whether there is any urgency, and what they should expect to happen next. If the referral is not proceeding as explained, patients should be told whom to contact for assistance.

 

Managing test results

 

Irrespective of their clinical workload, physicians who order tests or investigations are expected to follow up on the results in a timely manner. This can prove more challenging for physician leaders with clinical hours that are intermittent. Top

 

Physicians will want to determine, in advance, how they will follow up on results. They may begin by considering what a timely response to test results means for their type of practice. When the patient population is vulnerable to rapid changes in clinical condition and the work schedule creates significant lag times, a mechanism for timely follow up of results is important. Would a “buddy system” be effective, where test results are checked by a colleague in the physician’s absence? Or would it be necessary to check in regularly in person to retrieve and review test results? Could the covering physician review test results?

 

After determining how they will handle test results in their practice, physicians with part-time clinical hours should decide how they can communicate that information clearly and in a timely manner to their patients and families, as well as to the other doctors, health professionals, and support staff involved in their patients’ care. Top

 

Clinical competence

 

Depending on the number of hours worked and the extent of engagement in continuing medical education, physicians who limit their clinical working hours may find it more challenging to maintain clinical skills in some aspects of their practice. Physicians with reduced clinical work have the same responsibility as full-time physicians — to practise in clinical areas in which they are competent. With fewer opportunities to practise certain skills, physicians will want to think about the skills they want to retain or develop and the kind of clinical work that would allow them to achieve this.

 

Physicians working in both clinical and leadership capacities may need to focus on the most convenient and efficient continuing medical education delivery options, which may include online education, self-study courses, participating in communities of practice, and leveraging preferred social networks for doctors. Top

 

Medical-legal protection

 

The Canadian Medical Protective Association (CMPA) recognizes that physician involvement in leadership activities is valuable, and members remain eligible for medical-liability protection for their clinical work. In addition to CMPA protection, physicians who are employed by a hospital, clinic, or regional health authority should ensure that their employer provides adequate professional liability protection in the event of medical-liability difficulties arising from the application of organizational or business policies or procedures.4

 

Physicians who do not provide clinical care or patient advice but instead work in an administrative capacity related to health care should consider retaining their CMPA membership under the administrative medicine work category. Top

 

References

1.Stagg Elliott V. Hospitals’ new physician leaders: doctors wear multiple medical hats. Amednews.com 2011; Apr. 4. Available: http://tinyurl.com/jdb7ce9 (accessed 11 Dec. 2015).

2.Medico-legal handbook for physicians in Canada. 7th ed. Ottawa: Canadian Medical Protective Association; 2010. 50 pp.

3.Professional standards and guidelines. After-hours coverage. Vancouver: College of Physicians and Surgeons of British Columbia; 2013. 3 pp. Available: http://tinyurl.com/jzyd4r3 (accessed 11 Dec. 2015).

4.Administrative medicine. Ottawa: Canadian Medical Protective Association; 2012. Available: http://tinyurl.com/hx37un5 (accessed 11 Dec. 2015).

 

Authors

Tracy Murphy is senior policy analyst at the Canadian Medical Protective Association.

Mary MacDonald-Laprade is communications advisor at the Canadian Medical Protective Association.

Correspondence to: tmurphy@cmpa.org

 

This article has been reviewed by a panel of physician leaders.

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