Safety of care

Improving patient safety and reducing risks

Part-time practice, full-time safety: Reducing clinical workload while addressing risks

Originally published June 2015
P1503-3-E

According to the 2010 National Physician Survey, most physicians work about 49 hours per week. For those with on-call responsibilities the number climbs significantly.

Some doctors, however, limit their clinical work to accommodate other commitments — to conduct research, teach, pursue further learning, transition into retirement, accommodate health issues, or fulfill family responsibilities. Whatever the reason, a reduced clinical workload doesn’t diminish a physician’s obligation to provide safe patient care.

Part-time clinical work can translate into a reduced work day or work week; shift restrictions (only days or only nights); weekend hours or alternate weekend coverage; or job sharing with another physician. The permutations of practice arrangements are abundant, depending on the clinical setting and the type of medical practice.

Physicians, for instance, 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, surgeons or physicians working in a surgery subspecialty may find that the difficulties of complex operations or treatments make part-time practice less likely.1 Practices that are typically found in shift-oriented settings, such as emergency rooms, may lend themselves to working fewer hours. Settings such as group practices may be more amenable to reduced hours than solo practices because coverage from other physicians may be more easily accessible.

In 2010, 14.6% of physicians identified themselves as being in a part-time medical practice or semi-retired from the medical labour force.2

Coverage

Physicians looking to limit their clinical workload will want to assess what after-hours coverage is appropriate for their practice and their patients, and make the necessary arrangements. Some medical regulatory authorities (Colleges) also outline what coverage is expected of physicians, and the 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 the nearby emergency department or another practitioner in private practice. As the requirements will vary from province to province, physicians should check with their College.

Part-time doctors in office-based practices will have different coverage needs than physicians working limited hours or shifts in a hospital or clinic setting. Two pediatricians who are job-sharing in an office-based practice, for instance, may require intermittent coverage from an outside physician on rare occasions when both primary practitioners are away at the same time. Family doctors in solo practices with limited hours may need to find one or more colleagues in the community who are interested in providing care to patients during absences. And in a group practice, off-hour coverage arrangements may be built right into the practice model.

Finally, patients can be informed about when their physician is available for appointments and how to obtain care in the physician’s absence. For example, when patients arrive for their initial appointment, physicians could make a point of discussing their office hours and where patients should go if they need care outside those hours.

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 physicians work limited hours, the number of patient handovers may increase.

To combat risks to patient safety, part-time physicians 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 healthcare team involved in the patient’s care.

Physicians should also be aware of possible barriers to an effective handover and consider how to avoid these. Ensuring 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 if 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 there is a change to a new team or most responsible physician, allows for clarification of the history and correction of any misinformation, and provides an opportunity to address any questions and concerns.

Referrals

Doctors working reduced 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 must respond in a timely fashion when a referral is initiated and they must be vigilant when a patient needs an urgent referral.

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, part-time physicians should ensure the other healthcare 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.

Other healthcare 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 about why the referral is being made, if there is any urgency, and what they should expect to happen next. If the referral is not happening 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 test results in a timely manner. This can prove more challenging for physicians with clinical hours that are intermittent.

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 conditions and the work schedule creates important lag times, a mechanism for timely follow-up of results is important.

Would a “buddy system,” where test results are checked by a colleague in the physician’s absence, be effective? Or would it be necessary to personally check in regularly to retrieve and review test results? Could the physician providing coverage review test results?

After determining how they will handle test results in their practice, physicians should decide how they can communicate that information clearly and in a timely manner to their patients and families, and to the other doctors, health professionals, and laboratory, facility, and support staff involved in their patients’ care.

Engaging patients in their own care may also strengthen the follow-up of diagnostic tests. Physicians can consider discussing with their patients why an investigative test has been ordered. This allows patients to recognize the test’s importance to their clinical situation and the need for timely follow-up.

Clinical competence

Physicians who limit their clinical working hours may find it more challenging to maintain clinical skills in some aspects of their practice.

The Canadian Medical Association Code of Ethics states that it is a physician’s fundamental responsibility to “practise the art and science of medicine competently, with integrity, and without impairment…”3 and to engage in lifelong learning to maintain and improve skills.

Physicians with reduced clinical work have the same responsibility as full-time physicians — to practise in clinical areas where they are competent. With fewer opportunities to practise certain skills, practitioners 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.

They should also make a commitment to continuing education, and responding to the College’s norms. While physicians may have limited their clinical work, they may still have a full schedule with other responsibilities. It can be challenging to find the time for continuing education. Alternative and innovative solutions are key.

Ensuring continuity

Physicians who want to accommodate other 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 or transfers of care, referrals, and follow up on test results, physicians can minimize risks and provide effective care of patients. Physicians also have a responsibility to maintain a commitment to professional development to ensure quality and safety of care.

 
 

References

  1. NEJM CareerCentre, “Part-Time Practice on the Rise,” 2010. Accessed on December 4 2013 from: http://www.nejmcareercenter.org/article/part-time-physician-practice-on-the-rise/
  2. The College of Family Physicians of Canada, Canadian Medical Association, The Royal College of Physicians and Surgeons of Canada, National Physician Survey 2010, National Results by FP/GP or Other Specialist, Sex, Age and All Physicians. Accessed on June 1, 2015 from: http://nationalphysiciansurvey.ca/wp-content/uploads/2012/07/current_status2.pdf
  3. Canadian Medical Association, “CMA Code of Ethics,” 2004. Accessed on March 19, 2014 from: http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD04-06.pdf

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.