- Email: [email protected]
Pediatricians Working Part-Time Has Plateaued
Pediatricians Working Part-Time Has Plateaued William L. Cull, PhD, Mary Pat Frintner, MSPH, Karen G. O’Connor, BS, and Lynn M. Olson, PhD Objective To examine trends in pediatricians working part-time and residents seeking part-time work and to examine associated characteristics.
Study design The American Academy of Pediatrics (AAP) Periodic Survey of Fellows and the AAP Annual Survey of Graduating Residents were used to examine part-time employment. Fourteen periodic surveys were combined with an overall response rate of 57%. Part-time percentages were compared for surveys conducted from 20062009 and 2010-2013. The AAP Annual Surveys of Graduating Residents (combined response rate = 60%) from 2006-2009 were compared with 2010-2013 surveys for residents seeking and obtaining part-time positions following training. Multivariable logistic regression models identified characteristics associated with part-time work. Results Comparable percentages of pediatricians worked part-time in 2006-2009 (23%) and 2010-2013 (23%). There was similarly no statistically significant difference in residents seeking part-time work (30%-28%), and there was a slight decline in residents accepting part-time work (16%-13%, aOR .75, 95% CI .56-.96). Increases in working part-time were not found for any subgroups examined. Women consistently were more likely than men to work part-time (35% vs 9%), but they showed different patterns of part-time work across age. Women in their 40s (40%) were more likely than other women (33%) and men in their 60s (20%) were more likely than other men (5%) to work part-time. Conclusions There has been a levelling off in the number of pediatricians working part-time and residents seeking part-time work. Overall, women remain more likely to work part-time, although 1 in 5 men over 60 work part-time. (J Pediatr 2016;-:---).
P
ediatrics is among the specialties at the forefront of medicine concerning part-time employment and other practice characteristics related to work-life balance.1-7 Pediatrics also has the highest portion of physicians who are women at 58% compared with 31% of physicians overall.8 From 1993-2000, the percentage of pediatricians working part-time increased from 11%-15%.9 The increase in part-time during that period was commensurate with the overall shift in workforce demographic characteristics toward more female pediatricians; women were more likely than men to work part-time, 28% vs 4% in 2000. From 2000-2006, there was a period of further expansion of part-time work from 15%-23% that outpaced the corresponding increase in female pediatricians.10 The expansion of part-time work across that time was observed for a wide variety of pediatrician subgroups that included men, women, older pediatricians, younger pediatricians, generalists, and subspecialists. Changes in the number of pediatricians working part-time have important workforce implications because the total hours available for patient care is reduced when part-time work increases.5 Those working part-time are more likely to be satisfied with their relationships with colleagues, work environment, time with their own children, and time with friends.10-12 Others have found that within academics, it may be more difficult to work parttime,13,14 and work-life balance may be more difficult for some specialty areas.15 Many graduating residents entering the workforce also tend to seek and to obtain part-time work in their first positions.16,17 Residents who are female, have children, or are married to a physician are more likely to seek part-time jobs upon graduation.16 Since 2006, there have been continued changes to the pediatric workforce, including fewer pediatricians pursuing primary care18,19 that may have slowed interest in part-time work. In the current study, we examine whether part-time work has continued to increase among the full American Academy of Pediatrics (AAP) membership and among graduating residents, and we re-examine factors associated with pediatrician part-time work.
Methods We used 2 separate data sources. The prevalence of pediatrician part-time work was examined using multiple cross-sectional surveys from the AAP Periodic Survey of Fellows. Inclusion of part-time work within resident job search was assessed using multiple cross-sectional surveys from the AAP Annual Survey of
From the Department of Research, American Academy of Pediatrics, Elk Grove Village, IL Funded by the American Academy of Pediatrics. The authors declare no conflicts of interest. 0022-3476/$ - see front matter. Copyright ª 2016 Elsevier Inc. All
AAP
American Academy of Pediatrics
rights reserved. http://dx.doi.org/10.1016/j.jpeds.2015.12.062
1
THE JOURNAL OF PEDIATRICS
Graduating Residents. All surveys were reviewed and approved by the AAP Institutional Review Board. The AAP Periodic Survey of Fellows is a nationally representative survey of nonretired, US members of the AAP. The AAP estimates that 61% of board-certified pediatricians in the US between the ages of 27 and 70 years are members of the AAP. A total of 14 surveys conducted between 2006 and 2013 included a question about self-defined part-time work. Pediatricians were asked, “Do you currently work part-time? (Yes, No).” Response to this question solely was used to define pediatricians working part-time. Pediatricians also were asked to provide their average hours worked per week providing patient care, but this was used only to further describe the groups. Part-time was a point-in-time measure within each survey, and we did not ask pediatricians whether they had ever worked part-time. Each survey was sent to roughly 1600 pediatricians with up to 9 contacts per survey including 7 mail and 2 e-mail contacts. A $2.00 incentive was included in all initial mailings starting in 2007. Respondents who were currently in residency or subspecialty fellowship training were not included in the analyses. To examine changes in part-time percentages, surveys conducted from 2006-2009 were pooled and compared with surveys conducted from 2010-2013. Changes were examined for many different subgroups of pediatricians based on sex (female, male), age (<40 years, 40-49 years, 50-59 years, $60 years), practice type ($50% of time in primary care, <50% of time in primary care), and practice location (suburban, rural, urban not inner-city, urban inner-city). c2 tests were used to examine changes across time periods. A multivariable logistic regression model was built to assess which pediatricians work part-time. Time period was included as a factor along with each of the various subgroup variables. Follow-up descriptive analyses (percentages) and inferential analyses using bivariate logistic regression were conducted to better understand the relationship of age and sex on part-time work. Mean total work hours were also compared for part-time and full-time work and for 20062009 and 2010-2013 using t tests. The AAP Annual Survey of Graduating Residents is fielded annually to a sample of graduating pediatric residents as they complete their training. Each year, 1000 residents were randomly selected from an AAP database that included all residents from US residency programs. Residents were contacted up to 4 times by mail, and up to 4 times by e-mail. Starting in 2011, a $2.00 incentive was included in all initial mailings. The survey included core questions that are repeated each year and thematic questions that vary each year. One of the core domains of the survey focused on resident job search experiences. Within the job search question bank, residents were asked whether they included part-time or reducedhour jobs within their job search and whether their new position was a part-time or reduced-hours job. Only residents who were actively seeking nontraining positions were included in the analyses. 2
Volume -
www.jpeds.com
The results from the AAP Annual Survey of Graduating Residents conducted in 2006-2009 were compared with the surveys conducted from 2010-2013 for both seeking and accepting part-time positions. These comparisons were also examined for a variety of subgroups: sex (female, male), age (mean split: <31 years, $31 years), have children (yes, no), marital status (spouse/partner is physician, spouse/partner is not a physician, single), medical school location (US/ Canada, other), US underrepresented minority (Black/Hispanic/Native American, White/Asian/Other), educational debt (mean split, including some residents without any debt: #$143 000, >$143 000), job search difficulty (moderate/considerable, some/none), program size (small: <10 residents per class, medium: 10-19 residents per class, large: 20 or more residents per class), and having mentor (yes, no). Comparisons were made using c2 tests. A multivariable logistic regression model examined factors associated with residents seeking part-time work and another examined factors associated with accepting part-time jobs. The time variable (2006-2009, 2010-2013) and the various subgroup variables were examined as possible factors. Because of the large number of candidate factors available in the resident survey analyses, variables showing no association in bivariate analyses (P > .15) were excluded from the final multivariable models. For both the AAP Periodic Survey and the Annual Survey of Graduating Residents, analyses of nonresponse bias were conducted for all surveys combined. Sex and age of the respondents were compared with the sex and age of the full target samples. A P value of #.05 was used for all statistical analyses, and the number of cases in each analysis varied slightly based on missing responses.
Results A total of 22 650 pediatricians were surveyed within the 14 Periodic Surveys examined, and 12 873 pediatricians (57%) responded. Response rates for individual surveys ranged from 48%-69%. Across surveys, respondents were not more likely than the target sample to be female (56% vs 55%, P = .074). Respondents were slightly older, and this difference was statistically significant (49 vs 48 years, P < .001). Analyses were based on the 10 268 pediatricians who answered the part-time question. From 2006-2009 to 2010-2013, the percentage of part-time employment among pediatricians has remained unchanged at 23% (Table I). All of the subgroups examined based on sex, age, practice type, and practice location similarly showed no significant change in part-time work. Approximately one-third of female pediatricians in both 2006-2009 (36%) and in 2010-2013 (34%) reported parttime work, and this decrease approached significance (P = .063). Pediatricians reporting that they worked parttime worked an average of 24.7 (SD = 11.9) hours per week in direct patient care in 2006-2009 and 24.6 (SD = 12.7) hours per week in 2010-2013 (P = .767). Full-time Cull et al
- 2016
ORIGINAL ARTICLES
Table I. The percentage of pediatricians working part-time from 2006-2013 by subgroups (n = 10 268)
Total Sex Female (n = 5675) Male (n = 4593) Age Less than 40 y (n = 2771) 40-49 y (n = 3003) 50-59 y (n = 2870) 60 y and older (n = 1562) Specialty Pediatric primary care (n = 7290) Pediatric subspecialist (n = 2872) Primary practice location Suburban (n = 4257) Rural (n = 1126) Urban, not inner city (n = 2761) Urban, inner city (n = 1962)
2010-2013 % Part-time
D (time 2-time 1)*
23
23
0
36 8
34 9
2 1
27 26 18 22
24 26 18 24
3 0 0 2
27
26
1
15
15
0
27 22 21
27 23 21
0 1 0
19
18
1
*None of the differences were significant at P # .05.
pediatricians worked an average of 38.4 (SD = 16.5) hours per week in direct patient care in 2006-2009 and 38.7 (SD = 17.7) hours per week in 2010-2013 (P = .366). This is a difference of 13.7 fewer direct patient care hours worked for pediatricians working part-time in 2006-2009 (P < .001), and 14.1 fewer hours in 2010-2013 (P < .001). The percentages of pediatricians working part-time still are higher for some groups compared with others (Table I). Women (35%) were more likely than men (9%) (aOR 6.74, 95% CI 5.92-7.67), primary care pediatricians (27%) were more likely than specialists (15%) (aOR 1.67, 95% CI 1.461.91), and pediatricians working in suburban areas (27%) were more likely than those working in rural areas (22%) (aOR 1.42, 95% CI 1.20-1.67) to work part-time. For age, the patterns in the bivariate and multivariable results differed. When the other factors were controlled in the multivariable model, 40- to 49-year-old pediatricians and pediatricians 60 years and older were more likely than younger pediatricians to work part-time (40-49 years: aOR 1.25, 95% CI 1.10-1.41; 60 years and older: aOR 2.19, 95% CI 1.85-2.60). Follow-up analyses were conducted to probe the interrelationship of sex and age on part-time work. When broken out separately for men and women, the relationships of age to part-time work have different patterns. For women (Figure), there is a peak in the 40- to 49-year-old group with 40% working part-time, which is higher than the other age groups where one-third report working part-time (33%). The 40- to 49-year-old year group was the only group to be significantly different than the under 40-yearold group (OR 1.23, 95% CI 1.12-1.46). For the men (Figure), on the other hand, it is the oldest group, 60 years and older, where the greatest proportion report part-time work (20% vs 5% other age groups). The 60-year-old Pediatricians Working Part-Time Has Plateaued
40 % Working Part-Time
2006-2009 % Part-time
45 40
35 30
34
32
32
25 20
20
15 10 5 4
0
5
5
Under 40-49 50-59 60 and 40 Over
Under 40-49 50-59 60 and 40 Over
Women*
Men
Figure. Pediatrician part-time employment by age and sex (all years combined, 2006-2013).*For all age groups, women were statistically significantly more likely than men to work part-time.
group was the only group to have a higher part-time percentage than the under 40-year-old group (OR 6.00, 95% CI 4.05-8.89). Women were more likely to work parttime than men for all age groups, but the sex difference was much smaller for the age 60 and over pediatricians. Of the 8000 residents who were surveyed in 2006-2013, a total of 4824 (60%) responded. The response rates across years ranged from 57% (2010) to 64% (2012). Respondents were more likely than the full target pool to be women (75% vs 72%, P < .001), and the age of respondents and the full target pool was similar (31.4 vs 31.3 years, P = .73). A total of 64% of residents applied for a nontraining position (n = 2437). Graduating residents on the job market showed no change from 2006-2009 to 2010-2013 in the percentage seeking part-time positions when coming out of residency (30% vs 28%, respectively; Table II). There was a small statistically significant decline in the percent of residents on the job market who accepted a part-time position (16% in 2006-2009 vs 13% in 2010-2013, P < .05). There were several subgroups, such as residents with children and those whose spouse/partner was not a physician, for whom declines were observed both in the percentage seeking and the percentage accepting part-time positions, P < .05 (Table II). Of the residents who had children, 40% of those graduating in 2006-2009 and 32% of residents graduating in 2010-2013 sought part-time positions, P < .05. For residents from US or Canadian medical schools, nonminority residents, residents with larger educational debt, and residents from large programs, declines were only found for the percentage accepting part-time positions, P < .05. In the multivariable models (Table III), several predictors of pursuing and accepting part-time work were found. Residents who were female, had children, were married, were US medical graduates, had less debt, and had more job search difficulty were more likely to pursue part-time work. Those married to a physician were even more likely than those married to a nonphysician to pursue part-time 3
THE JOURNAL OF PEDIATRICS
Volume -
www.jpeds.com
Table II. Graduating residents seeking and accepting part-time positions 2006-2013 by subgroups (n = 2437) % Seeking part-time
Total Sex Female (n = 1914) Male (n = 509) Age <31 y (n = 1507) $31 y (n = 907) Have children Yes (n = 870) No (n = 1536) Marital status Spouse/partner is a physician (n = 552) Spouse/partner is not a physician (n = 1222) Single (n = 652) Medical school location US or Canada (n = 1953) Foreign (n = 475) US Underrepresented minority Yes (n = 267) No (n = 2161) Educational debt <$143 000 (n = 1202) $$143 000 (n = 1186) Job search difficulty Moderate-considerable difficulty (n = 503) No-some difficulty (n = 1931) Program size Small (n = 395) Medium (n = 1015) Large (n = 1001) Have a mentor Yes (n = 2124) No (n = 299)
% Accepting part-time
2006-2009
2010-2013
2006-2009
2010-2013
30
28
16*
13
33 18
30 17
19 8
15 6
29 31
26 30
16 17
12 15
40* 24
32 25
24* 12
17 12
40 31* 19
42 25 20
24 18* 7
22 11 10
30 28
27 29
18* 10
13 14
28 30
27 28
13 17*
14 13
31 29
30 26
16 17*
14 13
48 26
41 24
19 16
16 13
27 31 31
32 26 28
16 16 18*
16 13 13
30 31
27 31
16 16
14 13
*P < .05 for changes across time from 2006-2009 to 2010-2013.
work. The same characteristics with the exception of debt were also statistically significant predictors of actually accepting a part-time job.
Discussion The rise in the percentage of pediatricians working parktime has plateaued. The AAP Periodic Survey of Fellows
reveals that just under one-quarter of pediatricians work part-time, and that percentage has remained stable from 2006-2013. Pursuit of part-time employment among graduating residents, as collected from the AAP Survey of Graduating Residents, has similarly leveled off at just under 30%. Results may reflect shifts in the preferences of pediatricians or might suggest an upper limit on the number of pediatricians within the healthcare system that can work part-time at any time.
Table III. Resident characteristics associated with seeking and accepting part-time work: Multivariable logistic regressions % Seeking part-time
% Accepting part-time
Predictor variables
aOR
95% CI
aOR
95% CI
2010-2013 time period Female Age $31 y Have children Marital status (Spouse/partner is a physician is reference) Spouse/partner is not a physician Single Foreign medical school location Educational debt $$143 000 Moderate-considerable job search difficulty
.84 2.75* 1.19 1.81*
.70-1.02 2.10-3.60 .96-1.48 1.46-2.26
.75* 3.34* 1.29 1.99*
.59-.96 2.25-4.96 .98-1.69 1.52-2.61
.55* .40* .63* .76* 2.83*
.44-.69 .30-.53 .47-.83 .62-.93 2.26-3.54
.50* .33* .46* .81 1.42*
.38-.66 .23-.49 .31-.67 .62-1.05 1.05-1.92
*P < .05.
4
Cull et al
- 2016 Pediatrics has a higher percentage of female physicians than the other medical specialties and provides a leading example for the rest of medicine concerning the impact of sex shifts on the workforce. During the period from 20062012, the percentage of women in pediatrics continued to increase slightly from 54%-58%,8,20 but there was no associated increase in part-time work. There does not appear to be a simple linear relationship where part-time work rises with the percentage of women in pediatrics as was found in earlier periods.9 This in part may be due to counterbalancing workforce shifts such as the increase in the number of pediatricians, both women and men, who are pursuing subspecialty positions18 where part-time work has been less common. There are many other changes that happened over the study time period that also may have contributed to the part-time plateau. The educational debt level of graduating residents continued to rise and may have made it more difficult financially to work part-time.19 Changes in residency duty hours may have led graduating residents to be less well prepared,21 and may have lead employers or graduates initially to prefer full-time work. Finally, the economic downturn of 2007-200822 may have shifted the balance from employees being able to bargain for increasing benefits to companies needing to reduce staff in order to remain viable. The hiring environment and possible shifting benefits may have led some pediatricians to conclude that part-time work was not a realistic option. Many of the factors previously associated with part-time employment10 also emerged as independent significant predictors within our study. Female sex, being married, and living in a suburban area were all repeat predictors of parttime employment within AAP Periodic Survey models. Being a primary care pediatrician and age were also found to be related to working part-time in the current study, but they were not significant in previous multivariable models.10 Demand for subspecialists in many geographical areas5,23 and greater likelihood of working in academic medicine13,14 may make part-time work more difficult to arrange for subspecialists. The difference in direct patient care hours worked between part-time and full-time pediatricians, roughly 14 hours, was also consistent with prior research10 and did not vary from 2006-2009 to 2010-2013. Different patterns of part-time work were apparent across the age groups for men and women. One out of every 5 men age 60 years and older works part-time, which is at least 4 times higher than the part-time prevalence for the other male age groups. Part-time work seems to provide a good late-career option for many men.24 For women, on the other hand, there was no higher prevalence of part-time work when they reached 60 years and older. The prevalence was equally high for all age groups with a slight increase for the 40- to 49year-old group where 4 in 10 work part-time. This age coincides with years with younger children for many women pediatricians. Although part-time percentages are no longer increasing, there remain a sizeable number of pediatricians working Pediatricians Working Part-Time Has Plateaued
ORIGINAL ARTICLES part-time, and the flexibility in work hours within pediatrics will continue to be a draw for many medical students.1 Studies have shown that physicians working part-time report less stress and burnout.11,12 Patients of part-time primary care physicians reported greater satisfaction with their doctor despite experiencing some decrease in access and continuity of care.25 The number of pediatricians working part-time is an important consideration for pediatric workforce discussions,5,26,27 and future projections should not assume continually rising part-time percentages. In the resident part-time job-seeking model, female sex, having children, and being married to a physician were the strongest predictors, which is consistent with previous research.16 Several new predictors were identified in the current study which may be related to the statistical power resulting from the combination of 8 years of AAP Annual Survey of Graduating Residents data. The new predictors of seeking part-time work included US Medical Graduates, educational debt <$143 000, and job search difficulty. The association of pursuing part-time work and greater job search difficulty suggests that some employers remain less receptive to part-time work. There are limitations to the current study. First, within all surveys, part-time was self-reported, and it is possible that perceptions of what is part-time work shifts over time, though the average patient care hours worked among those who identify as part-time remained the same. Second, some nonresponse bias was found in the surveys, with older physicians being more likely to respond, however, this difference was very small. Third, given space constraints on the surveys, greater detail about part-time work, such as the use of job-sharing and the positives and negatives of working part-time, was not examined. We also cannot determine if a pediatrician ever worked part-time as a physician, and work characteristics not collected in the survey, such as working in a managed care organization, may be associated with parttime work. Finally, the percentages of part-time work from the AAP Periodic Survey of Fellows are representative of pediatricians who are currently practicing medicine and are AAP members and are not representative of all pediatricians. n Submitted for publication Sep 11, 2015; last revision received Nov 11, 2015; accepted Dec 22, 2015. Reprint requests: William L. Cull, PhD, Department of Research, American Academy of Pediatrics, 141 Northwest Point Blvd, Elk Grove Village, IL, 60007. E-mail: [email protected]
References 1. Spector ND, Cull W, Daniels SR, Gilhooly J, Hall J, Horn I, et al. Gender and generational influences on the pediatric workforce and practice. Pediatrics 2014;133:1112-21. 2. Freed GL, Dunham KM, Switalski KE, Jones MD Jr, McGuinness GA. Recently trained general pediatricians: perspectives on residency training and scope of practice. Pediatrics 2009;123(Suppl 1):S38-43. 3. Freed GL, Dunham KM, Switalski KE, Jones MD Jr, McGuinness GA. Pediatric fellows: perspectives on training and future scope of practice. Pediatrics 2009;123(Suppl 1):S31-7. 5
THE JOURNAL OF PEDIATRICS
www.jpeds.com
4. Freed GL, Dunham KM, Switalski KE, Jones MD Jr, McGuinness GA. Recently trained pediatric subspecialists: perspectives on training and scope of practice. Pediatrics 2009;123(Suppl 1):S44-9. 5. Committee on Pediatric Workforce, American Academy of Pediatrics. Pediatrician workforce policy statement. Pediatrics 2013;132:390-7. 6. Shrier DK, Shrier LA, Rich M, Greenberg L. Pediatricians leading the way: integrating a career and a family/personal life over the life cycle. Pediatrics 2006;117:519-22. 7. Berkowitz CD, Frintner MP, Cull WL. Pediatric resident perceptions of family-friendly benefits. Acad Pediatr 2010;10:360-6. 8. American Medical Association. Physician characteristics and distribution in the US, 2014 edition. Chicago: American Medical Association; 2014. 9. Cull WL, Mulvey HJ, O’Connor KG, Sowell DR, Berkowitz CD, Britton CV. Pediatricians working part-time: past, present, and future. Pediatrics 2002;109:1015-20. 10. Cull WL, O’Connor KG, Olson LM. Part-time work among pediatricians expands. Pediatrics 2010;125:152-7. 11. Mechaber HF, Levine RB, Manwell LB, Mundt MP, Linzer M, Schwartz M, et al. Part-time physicians.prevalent, connected, and satisfied. J Gen Intern Med 2008;23:300-3. 12. Shugerman R, Linzer M, Nelson K, Douglas J, Williams R, Konrad R, et al. Pediatric generalists and subspecialists: determinants of career satisfaction. Pediatrics 2001;108:E40. 13. Alexander D, Boat T, Britto M, Burke A, Homes A, Sectish T, et al. Federation of Pediatric Organizations Task Force on Women in Pediatrics: considerations for part-time training and employment for researchintensive fellows and faculty. J Pediatr 2009;154:1-3.e2. 14. Women Chairs of the Association of Medical School Pediatric Department Chairs. Women in pediatrics: recommendations for the future. Pediatrics 2007;119:1000-5. 15. Schwingshackl A. The fallacy of chasing after work-life balance. Front Pediatr 2014;2:26.
6
Volume 16. Cull WL, Caspary GL, Olson LM. Many pediatric residents seek and obtain part-time positions. Pediatrics 2008;121:276-81. 17. Fix AL, Kaelber DC, Melgar TA, Chamberlain J, Cull W, Robbins BW. Graduating med-peds residents’ interest in part-time employment. Acad Pediatr 2011;11:369-74. 18. Frintner MP, Cull WL. Pediatric training and career intentions, 20032009. Pediatrics 2012;129:522-8. 19. Frintner MP, Mulvey HJ, Pletcher BA, Olson LM. Pediatric resident debt and career intentions. Pediatrics 2013;131:312-8. 20. American Medical Association. Physician characteristics and distribution in the US, 2008 edition. Chicago: American Medical Association; 2008. 21. Drolet BC, Whittle SB, Khokhar MT, Fischer SA, Pallant A. Approval and perceived impact of duty hour regulations: survey of pediatric program directors. Pediatrics 2013;132:819-24. 22. Goodman CJ, Mance SM. Employment loss and the 2007-09 recession: an overview. Mon Labor Rev 2011;3-12. 23. Pletcher BA, Rimsza ME, Cull WL, Shipman SA, Shugerman RP, O’Connor KG. Primary care pediatricians’ satisfaction with subspecialty care, perceived supply, and barriers to care. J Pediatr 2010;156: 1011-5.e1. 24. Merline AC, Cull WL, Mulvey HJ, Katcher AL. Patterns of work and retirement among pediatricians aged >50 years. Pediatrics 2009;125: 158-64. 25. Panattoni L, Stone A, Chung S, Tai-Seale M. Patients report better satisfaction with part-time primary care physicians, despite less continuity of care and access. J Gen Intern Med 2015;30:327-33. 26. Goodman DC , Committee on Pediatric Workforce, American Academy of Pediatrics. The pediatrician workforce: current status and future prospects. Pediatrics 2005;116:e156-73. 27. Shipman SA, Lan J, Chang C, Goodman DC. Geographic maldistribution of primary care for children. Pediatrics 2011;127:19-27.
Cull et al
Study design The American Academy of Pediatrics (AAP) Periodic Survey of Fellows and the AAP Annual Survey of Graduating Residents were used to examine part-time employment. Fourteen periodic surveys were combined with an overall response rate of 57%. Part-time percentages were compared for surveys conducted from 20062009 and 2010-2013. The AAP Annual Surveys of Graduating Residents (combined response rate = 60%) from 2006-2009 were compared with 2010-2013 surveys for residents seeking and obtaining part-time positions following training. Multivariable logistic regression models identified characteristics associated with part-time work. Results Comparable percentages of pediatricians worked part-time in 2006-2009 (23%) and 2010-2013 (23%). There was similarly no statistically significant difference in residents seeking part-time work (30%-28%), and there was a slight decline in residents accepting part-time work (16%-13%, aOR .75, 95% CI .56-.96). Increases in working part-time were not found for any subgroups examined. Women consistently were more likely than men to work part-time (35% vs 9%), but they showed different patterns of part-time work across age. Women in their 40s (40%) were more likely than other women (33%) and men in their 60s (20%) were more likely than other men (5%) to work part-time. Conclusions There has been a levelling off in the number of pediatricians working part-time and residents seeking part-time work. Overall, women remain more likely to work part-time, although 1 in 5 men over 60 work part-time. (J Pediatr 2016;-:---).
P
ediatrics is among the specialties at the forefront of medicine concerning part-time employment and other practice characteristics related to work-life balance.1-7 Pediatrics also has the highest portion of physicians who are women at 58% compared with 31% of physicians overall.8 From 1993-2000, the percentage of pediatricians working part-time increased from 11%-15%.9 The increase in part-time during that period was commensurate with the overall shift in workforce demographic characteristics toward more female pediatricians; women were more likely than men to work part-time, 28% vs 4% in 2000. From 2000-2006, there was a period of further expansion of part-time work from 15%-23% that outpaced the corresponding increase in female pediatricians.10 The expansion of part-time work across that time was observed for a wide variety of pediatrician subgroups that included men, women, older pediatricians, younger pediatricians, generalists, and subspecialists. Changes in the number of pediatricians working part-time have important workforce implications because the total hours available for patient care is reduced when part-time work increases.5 Those working part-time are more likely to be satisfied with their relationships with colleagues, work environment, time with their own children, and time with friends.10-12 Others have found that within academics, it may be more difficult to work parttime,13,14 and work-life balance may be more difficult for some specialty areas.15 Many graduating residents entering the workforce also tend to seek and to obtain part-time work in their first positions.16,17 Residents who are female, have children, or are married to a physician are more likely to seek part-time jobs upon graduation.16 Since 2006, there have been continued changes to the pediatric workforce, including fewer pediatricians pursuing primary care18,19 that may have slowed interest in part-time work. In the current study, we examine whether part-time work has continued to increase among the full American Academy of Pediatrics (AAP) membership and among graduating residents, and we re-examine factors associated with pediatrician part-time work.
Methods We used 2 separate data sources. The prevalence of pediatrician part-time work was examined using multiple cross-sectional surveys from the AAP Periodic Survey of Fellows. Inclusion of part-time work within resident job search was assessed using multiple cross-sectional surveys from the AAP Annual Survey of
From the Department of Research, American Academy of Pediatrics, Elk Grove Village, IL Funded by the American Academy of Pediatrics. The authors declare no conflicts of interest. 0022-3476/$ - see front matter. Copyright ª 2016 Elsevier Inc. All
AAP
American Academy of Pediatrics
rights reserved. http://dx.doi.org/10.1016/j.jpeds.2015.12.062
1
THE JOURNAL OF PEDIATRICS
Graduating Residents. All surveys were reviewed and approved by the AAP Institutional Review Board. The AAP Periodic Survey of Fellows is a nationally representative survey of nonretired, US members of the AAP. The AAP estimates that 61% of board-certified pediatricians in the US between the ages of 27 and 70 years are members of the AAP. A total of 14 surveys conducted between 2006 and 2013 included a question about self-defined part-time work. Pediatricians were asked, “Do you currently work part-time? (Yes, No).” Response to this question solely was used to define pediatricians working part-time. Pediatricians also were asked to provide their average hours worked per week providing patient care, but this was used only to further describe the groups. Part-time was a point-in-time measure within each survey, and we did not ask pediatricians whether they had ever worked part-time. Each survey was sent to roughly 1600 pediatricians with up to 9 contacts per survey including 7 mail and 2 e-mail contacts. A $2.00 incentive was included in all initial mailings starting in 2007. Respondents who were currently in residency or subspecialty fellowship training were not included in the analyses. To examine changes in part-time percentages, surveys conducted from 2006-2009 were pooled and compared with surveys conducted from 2010-2013. Changes were examined for many different subgroups of pediatricians based on sex (female, male), age (<40 years, 40-49 years, 50-59 years, $60 years), practice type ($50% of time in primary care, <50% of time in primary care), and practice location (suburban, rural, urban not inner-city, urban inner-city). c2 tests were used to examine changes across time periods. A multivariable logistic regression model was built to assess which pediatricians work part-time. Time period was included as a factor along with each of the various subgroup variables. Follow-up descriptive analyses (percentages) and inferential analyses using bivariate logistic regression were conducted to better understand the relationship of age and sex on part-time work. Mean total work hours were also compared for part-time and full-time work and for 20062009 and 2010-2013 using t tests. The AAP Annual Survey of Graduating Residents is fielded annually to a sample of graduating pediatric residents as they complete their training. Each year, 1000 residents were randomly selected from an AAP database that included all residents from US residency programs. Residents were contacted up to 4 times by mail, and up to 4 times by e-mail. Starting in 2011, a $2.00 incentive was included in all initial mailings. The survey included core questions that are repeated each year and thematic questions that vary each year. One of the core domains of the survey focused on resident job search experiences. Within the job search question bank, residents were asked whether they included part-time or reducedhour jobs within their job search and whether their new position was a part-time or reduced-hours job. Only residents who were actively seeking nontraining positions were included in the analyses. 2
Volume -
www.jpeds.com
The results from the AAP Annual Survey of Graduating Residents conducted in 2006-2009 were compared with the surveys conducted from 2010-2013 for both seeking and accepting part-time positions. These comparisons were also examined for a variety of subgroups: sex (female, male), age (mean split: <31 years, $31 years), have children (yes, no), marital status (spouse/partner is physician, spouse/partner is not a physician, single), medical school location (US/ Canada, other), US underrepresented minority (Black/Hispanic/Native American, White/Asian/Other), educational debt (mean split, including some residents without any debt: #$143 000, >$143 000), job search difficulty (moderate/considerable, some/none), program size (small: <10 residents per class, medium: 10-19 residents per class, large: 20 or more residents per class), and having mentor (yes, no). Comparisons were made using c2 tests. A multivariable logistic regression model examined factors associated with residents seeking part-time work and another examined factors associated with accepting part-time jobs. The time variable (2006-2009, 2010-2013) and the various subgroup variables were examined as possible factors. Because of the large number of candidate factors available in the resident survey analyses, variables showing no association in bivariate analyses (P > .15) were excluded from the final multivariable models. For both the AAP Periodic Survey and the Annual Survey of Graduating Residents, analyses of nonresponse bias were conducted for all surveys combined. Sex and age of the respondents were compared with the sex and age of the full target samples. A P value of #.05 was used for all statistical analyses, and the number of cases in each analysis varied slightly based on missing responses.
Results A total of 22 650 pediatricians were surveyed within the 14 Periodic Surveys examined, and 12 873 pediatricians (57%) responded. Response rates for individual surveys ranged from 48%-69%. Across surveys, respondents were not more likely than the target sample to be female (56% vs 55%, P = .074). Respondents were slightly older, and this difference was statistically significant (49 vs 48 years, P < .001). Analyses were based on the 10 268 pediatricians who answered the part-time question. From 2006-2009 to 2010-2013, the percentage of part-time employment among pediatricians has remained unchanged at 23% (Table I). All of the subgroups examined based on sex, age, practice type, and practice location similarly showed no significant change in part-time work. Approximately one-third of female pediatricians in both 2006-2009 (36%) and in 2010-2013 (34%) reported parttime work, and this decrease approached significance (P = .063). Pediatricians reporting that they worked parttime worked an average of 24.7 (SD = 11.9) hours per week in direct patient care in 2006-2009 and 24.6 (SD = 12.7) hours per week in 2010-2013 (P = .767). Full-time Cull et al
- 2016
ORIGINAL ARTICLES
Table I. The percentage of pediatricians working part-time from 2006-2013 by subgroups (n = 10 268)
Total Sex Female (n = 5675) Male (n = 4593) Age Less than 40 y (n = 2771) 40-49 y (n = 3003) 50-59 y (n = 2870) 60 y and older (n = 1562) Specialty Pediatric primary care (n = 7290) Pediatric subspecialist (n = 2872) Primary practice location Suburban (n = 4257) Rural (n = 1126) Urban, not inner city (n = 2761) Urban, inner city (n = 1962)
2010-2013 % Part-time
D (time 2-time 1)*
23
23
0
36 8
34 9
2 1
27 26 18 22
24 26 18 24
3 0 0 2
27
26
1
15
15
0
27 22 21
27 23 21
0 1 0
19
18
1
*None of the differences were significant at P # .05.
pediatricians worked an average of 38.4 (SD = 16.5) hours per week in direct patient care in 2006-2009 and 38.7 (SD = 17.7) hours per week in 2010-2013 (P = .366). This is a difference of 13.7 fewer direct patient care hours worked for pediatricians working part-time in 2006-2009 (P < .001), and 14.1 fewer hours in 2010-2013 (P < .001). The percentages of pediatricians working part-time still are higher for some groups compared with others (Table I). Women (35%) were more likely than men (9%) (aOR 6.74, 95% CI 5.92-7.67), primary care pediatricians (27%) were more likely than specialists (15%) (aOR 1.67, 95% CI 1.461.91), and pediatricians working in suburban areas (27%) were more likely than those working in rural areas (22%) (aOR 1.42, 95% CI 1.20-1.67) to work part-time. For age, the patterns in the bivariate and multivariable results differed. When the other factors were controlled in the multivariable model, 40- to 49-year-old pediatricians and pediatricians 60 years and older were more likely than younger pediatricians to work part-time (40-49 years: aOR 1.25, 95% CI 1.10-1.41; 60 years and older: aOR 2.19, 95% CI 1.85-2.60). Follow-up analyses were conducted to probe the interrelationship of sex and age on part-time work. When broken out separately for men and women, the relationships of age to part-time work have different patterns. For women (Figure), there is a peak in the 40- to 49-year-old group with 40% working part-time, which is higher than the other age groups where one-third report working part-time (33%). The 40- to 49-year-old year group was the only group to be significantly different than the under 40-yearold group (OR 1.23, 95% CI 1.12-1.46). For the men (Figure), on the other hand, it is the oldest group, 60 years and older, where the greatest proportion report part-time work (20% vs 5% other age groups). The 60-year-old Pediatricians Working Part-Time Has Plateaued
40 % Working Part-Time
2006-2009 % Part-time
45 40
35 30
34
32
32
25 20
20
15 10 5 4
0
5
5
Under 40-49 50-59 60 and 40 Over
Under 40-49 50-59 60 and 40 Over
Women*
Men
Figure. Pediatrician part-time employment by age and sex (all years combined, 2006-2013).*For all age groups, women were statistically significantly more likely than men to work part-time.
group was the only group to have a higher part-time percentage than the under 40-year-old group (OR 6.00, 95% CI 4.05-8.89). Women were more likely to work parttime than men for all age groups, but the sex difference was much smaller for the age 60 and over pediatricians. Of the 8000 residents who were surveyed in 2006-2013, a total of 4824 (60%) responded. The response rates across years ranged from 57% (2010) to 64% (2012). Respondents were more likely than the full target pool to be women (75% vs 72%, P < .001), and the age of respondents and the full target pool was similar (31.4 vs 31.3 years, P = .73). A total of 64% of residents applied for a nontraining position (n = 2437). Graduating residents on the job market showed no change from 2006-2009 to 2010-2013 in the percentage seeking part-time positions when coming out of residency (30% vs 28%, respectively; Table II). There was a small statistically significant decline in the percent of residents on the job market who accepted a part-time position (16% in 2006-2009 vs 13% in 2010-2013, P < .05). There were several subgroups, such as residents with children and those whose spouse/partner was not a physician, for whom declines were observed both in the percentage seeking and the percentage accepting part-time positions, P < .05 (Table II). Of the residents who had children, 40% of those graduating in 2006-2009 and 32% of residents graduating in 2010-2013 sought part-time positions, P < .05. For residents from US or Canadian medical schools, nonminority residents, residents with larger educational debt, and residents from large programs, declines were only found for the percentage accepting part-time positions, P < .05. In the multivariable models (Table III), several predictors of pursuing and accepting part-time work were found. Residents who were female, had children, were married, were US medical graduates, had less debt, and had more job search difficulty were more likely to pursue part-time work. Those married to a physician were even more likely than those married to a nonphysician to pursue part-time 3
THE JOURNAL OF PEDIATRICS
Volume -
www.jpeds.com
Table II. Graduating residents seeking and accepting part-time positions 2006-2013 by subgroups (n = 2437) % Seeking part-time
Total Sex Female (n = 1914) Male (n = 509) Age <31 y (n = 1507) $31 y (n = 907) Have children Yes (n = 870) No (n = 1536) Marital status Spouse/partner is a physician (n = 552) Spouse/partner is not a physician (n = 1222) Single (n = 652) Medical school location US or Canada (n = 1953) Foreign (n = 475) US Underrepresented minority Yes (n = 267) No (n = 2161) Educational debt <$143 000 (n = 1202) $$143 000 (n = 1186) Job search difficulty Moderate-considerable difficulty (n = 503) No-some difficulty (n = 1931) Program size Small (n = 395) Medium (n = 1015) Large (n = 1001) Have a mentor Yes (n = 2124) No (n = 299)
% Accepting part-time
2006-2009
2010-2013
2006-2009
2010-2013
30
28
16*
13
33 18
30 17
19 8
15 6
29 31
26 30
16 17
12 15
40* 24
32 25
24* 12
17 12
40 31* 19
42 25 20
24 18* 7
22 11 10
30 28
27 29
18* 10
13 14
28 30
27 28
13 17*
14 13
31 29
30 26
16 17*
14 13
48 26
41 24
19 16
16 13
27 31 31
32 26 28
16 16 18*
16 13 13
30 31
27 31
16 16
14 13
*P < .05 for changes across time from 2006-2009 to 2010-2013.
work. The same characteristics with the exception of debt were also statistically significant predictors of actually accepting a part-time job.
Discussion The rise in the percentage of pediatricians working parktime has plateaued. The AAP Periodic Survey of Fellows
reveals that just under one-quarter of pediatricians work part-time, and that percentage has remained stable from 2006-2013. Pursuit of part-time employment among graduating residents, as collected from the AAP Survey of Graduating Residents, has similarly leveled off at just under 30%. Results may reflect shifts in the preferences of pediatricians or might suggest an upper limit on the number of pediatricians within the healthcare system that can work part-time at any time.
Table III. Resident characteristics associated with seeking and accepting part-time work: Multivariable logistic regressions % Seeking part-time
% Accepting part-time
Predictor variables
aOR
95% CI
aOR
95% CI
2010-2013 time period Female Age $31 y Have children Marital status (Spouse/partner is a physician is reference) Spouse/partner is not a physician Single Foreign medical school location Educational debt $$143 000 Moderate-considerable job search difficulty
.84 2.75* 1.19 1.81*
.70-1.02 2.10-3.60 .96-1.48 1.46-2.26
.75* 3.34* 1.29 1.99*
.59-.96 2.25-4.96 .98-1.69 1.52-2.61
.55* .40* .63* .76* 2.83*
.44-.69 .30-.53 .47-.83 .62-.93 2.26-3.54
.50* .33* .46* .81 1.42*
.38-.66 .23-.49 .31-.67 .62-1.05 1.05-1.92
*P < .05.
4
Cull et al
- 2016 Pediatrics has a higher percentage of female physicians than the other medical specialties and provides a leading example for the rest of medicine concerning the impact of sex shifts on the workforce. During the period from 20062012, the percentage of women in pediatrics continued to increase slightly from 54%-58%,8,20 but there was no associated increase in part-time work. There does not appear to be a simple linear relationship where part-time work rises with the percentage of women in pediatrics as was found in earlier periods.9 This in part may be due to counterbalancing workforce shifts such as the increase in the number of pediatricians, both women and men, who are pursuing subspecialty positions18 where part-time work has been less common. There are many other changes that happened over the study time period that also may have contributed to the part-time plateau. The educational debt level of graduating residents continued to rise and may have made it more difficult financially to work part-time.19 Changes in residency duty hours may have led graduating residents to be less well prepared,21 and may have lead employers or graduates initially to prefer full-time work. Finally, the economic downturn of 2007-200822 may have shifted the balance from employees being able to bargain for increasing benefits to companies needing to reduce staff in order to remain viable. The hiring environment and possible shifting benefits may have led some pediatricians to conclude that part-time work was not a realistic option. Many of the factors previously associated with part-time employment10 also emerged as independent significant predictors within our study. Female sex, being married, and living in a suburban area were all repeat predictors of parttime employment within AAP Periodic Survey models. Being a primary care pediatrician and age were also found to be related to working part-time in the current study, but they were not significant in previous multivariable models.10 Demand for subspecialists in many geographical areas5,23 and greater likelihood of working in academic medicine13,14 may make part-time work more difficult to arrange for subspecialists. The difference in direct patient care hours worked between part-time and full-time pediatricians, roughly 14 hours, was also consistent with prior research10 and did not vary from 2006-2009 to 2010-2013. Different patterns of part-time work were apparent across the age groups for men and women. One out of every 5 men age 60 years and older works part-time, which is at least 4 times higher than the part-time prevalence for the other male age groups. Part-time work seems to provide a good late-career option for many men.24 For women, on the other hand, there was no higher prevalence of part-time work when they reached 60 years and older. The prevalence was equally high for all age groups with a slight increase for the 40- to 49year-old group where 4 in 10 work part-time. This age coincides with years with younger children for many women pediatricians. Although part-time percentages are no longer increasing, there remain a sizeable number of pediatricians working Pediatricians Working Part-Time Has Plateaued
ORIGINAL ARTICLES part-time, and the flexibility in work hours within pediatrics will continue to be a draw for many medical students.1 Studies have shown that physicians working part-time report less stress and burnout.11,12 Patients of part-time primary care physicians reported greater satisfaction with their doctor despite experiencing some decrease in access and continuity of care.25 The number of pediatricians working part-time is an important consideration for pediatric workforce discussions,5,26,27 and future projections should not assume continually rising part-time percentages. In the resident part-time job-seeking model, female sex, having children, and being married to a physician were the strongest predictors, which is consistent with previous research.16 Several new predictors were identified in the current study which may be related to the statistical power resulting from the combination of 8 years of AAP Annual Survey of Graduating Residents data. The new predictors of seeking part-time work included US Medical Graduates, educational debt <$143 000, and job search difficulty. The association of pursuing part-time work and greater job search difficulty suggests that some employers remain less receptive to part-time work. There are limitations to the current study. First, within all surveys, part-time was self-reported, and it is possible that perceptions of what is part-time work shifts over time, though the average patient care hours worked among those who identify as part-time remained the same. Second, some nonresponse bias was found in the surveys, with older physicians being more likely to respond, however, this difference was very small. Third, given space constraints on the surveys, greater detail about part-time work, such as the use of job-sharing and the positives and negatives of working part-time, was not examined. We also cannot determine if a pediatrician ever worked part-time as a physician, and work characteristics not collected in the survey, such as working in a managed care organization, may be associated with parttime work. Finally, the percentages of part-time work from the AAP Periodic Survey of Fellows are representative of pediatricians who are currently practicing medicine and are AAP members and are not representative of all pediatricians. n Submitted for publication Sep 11, 2015; last revision received Nov 11, 2015; accepted Dec 22, 2015. Reprint requests: William L. Cull, PhD, Department of Research, American Academy of Pediatrics, 141 Northwest Point Blvd, Elk Grove Village, IL, 60007. E-mail: [email protected]
References 1. Spector ND, Cull W, Daniels SR, Gilhooly J, Hall J, Horn I, et al. Gender and generational influences on the pediatric workforce and practice. Pediatrics 2014;133:1112-21. 2. Freed GL, Dunham KM, Switalski KE, Jones MD Jr, McGuinness GA. Recently trained general pediatricians: perspectives on residency training and scope of practice. Pediatrics 2009;123(Suppl 1):S38-43. 3. Freed GL, Dunham KM, Switalski KE, Jones MD Jr, McGuinness GA. Pediatric fellows: perspectives on training and future scope of practice. Pediatrics 2009;123(Suppl 1):S31-7. 5
THE JOURNAL OF PEDIATRICS
www.jpeds.com
4. Freed GL, Dunham KM, Switalski KE, Jones MD Jr, McGuinness GA. Recently trained pediatric subspecialists: perspectives on training and scope of practice. Pediatrics 2009;123(Suppl 1):S44-9. 5. Committee on Pediatric Workforce, American Academy of Pediatrics. Pediatrician workforce policy statement. Pediatrics 2013;132:390-7. 6. Shrier DK, Shrier LA, Rich M, Greenberg L. Pediatricians leading the way: integrating a career and a family/personal life over the life cycle. Pediatrics 2006;117:519-22. 7. Berkowitz CD, Frintner MP, Cull WL. Pediatric resident perceptions of family-friendly benefits. Acad Pediatr 2010;10:360-6. 8. American Medical Association. Physician characteristics and distribution in the US, 2014 edition. Chicago: American Medical Association; 2014. 9. Cull WL, Mulvey HJ, O’Connor KG, Sowell DR, Berkowitz CD, Britton CV. Pediatricians working part-time: past, present, and future. Pediatrics 2002;109:1015-20. 10. Cull WL, O’Connor KG, Olson LM. Part-time work among pediatricians expands. Pediatrics 2010;125:152-7. 11. Mechaber HF, Levine RB, Manwell LB, Mundt MP, Linzer M, Schwartz M, et al. Part-time physicians.prevalent, connected, and satisfied. J Gen Intern Med 2008;23:300-3. 12. Shugerman R, Linzer M, Nelson K, Douglas J, Williams R, Konrad R, et al. Pediatric generalists and subspecialists: determinants of career satisfaction. Pediatrics 2001;108:E40. 13. Alexander D, Boat T, Britto M, Burke A, Homes A, Sectish T, et al. Federation of Pediatric Organizations Task Force on Women in Pediatrics: considerations for part-time training and employment for researchintensive fellows and faculty. J Pediatr 2009;154:1-3.e2. 14. Women Chairs of the Association of Medical School Pediatric Department Chairs. Women in pediatrics: recommendations for the future. Pediatrics 2007;119:1000-5. 15. Schwingshackl A. The fallacy of chasing after work-life balance. Front Pediatr 2014;2:26.
6
Volume 16. Cull WL, Caspary GL, Olson LM. Many pediatric residents seek and obtain part-time positions. Pediatrics 2008;121:276-81. 17. Fix AL, Kaelber DC, Melgar TA, Chamberlain J, Cull W, Robbins BW. Graduating med-peds residents’ interest in part-time employment. Acad Pediatr 2011;11:369-74. 18. Frintner MP, Cull WL. Pediatric training and career intentions, 20032009. Pediatrics 2012;129:522-8. 19. Frintner MP, Mulvey HJ, Pletcher BA, Olson LM. Pediatric resident debt and career intentions. Pediatrics 2013;131:312-8. 20. American Medical Association. Physician characteristics and distribution in the US, 2008 edition. Chicago: American Medical Association; 2008. 21. Drolet BC, Whittle SB, Khokhar MT, Fischer SA, Pallant A. Approval and perceived impact of duty hour regulations: survey of pediatric program directors. Pediatrics 2013;132:819-24. 22. Goodman CJ, Mance SM. Employment loss and the 2007-09 recession: an overview. Mon Labor Rev 2011;3-12. 23. Pletcher BA, Rimsza ME, Cull WL, Shipman SA, Shugerman RP, O’Connor KG. Primary care pediatricians’ satisfaction with subspecialty care, perceived supply, and barriers to care. J Pediatr 2010;156: 1011-5.e1. 24. Merline AC, Cull WL, Mulvey HJ, Katcher AL. Patterns of work and retirement among pediatricians aged >50 years. Pediatrics 2009;125: 158-64. 25. Panattoni L, Stone A, Chung S, Tai-Seale M. Patients report better satisfaction with part-time primary care physicians, despite less continuity of care and access. J Gen Intern Med 2015;30:327-33. 26. Goodman DC , Committee on Pediatric Workforce, American Academy of Pediatrics. The pediatrician workforce: current status and future prospects. Pediatrics 2005;116:e156-73. 27. Shipman SA, Lan J, Chang C, Goodman DC. Geographic maldistribution of primary care for children. Pediatrics 2011;127:19-27.
Cull et al