Residencies get flexible: Doctors taking personal time

The newest generation of medical students and residents is reshaping residencies. With their dual commitments to medicine and a life outside of the hospital, Generations X and Y, after eight years of college and medical school, are unwilling to defer personal goals any longer. Residents are asking for time away not only to have children, but to work internationally, do research and travel.

As a result, anecdotal evidence points to a growing number of programs factoring in leaves of absences for residents in those generations that include today's teenagers to those in their early 40s, experts said.

A fraction of the efforts are structured as part-time residencies, which can double the time required to graduate. But the bulk appear to be of shorter duration, created for individuals as needed.

In 2004-05, 302 residents were part time, according to the Accreditation Council for Graduate Medical Education.

In a study, Stephanie Pincus, MD, professor emeritus at State University of New York at Buffalo and former chief academic affiliations officer for the Dept. of Veterans Affairs, pegged the number of programs offering structured part-time options at 3.8% of the 8,000 ACGME-accredited residency programs.

From either perspective, the number of part-time residents is tiny. However, educators say anecdotal reports of full-time residents taking a leave of absence are growing.

"My sense of things is that the younger physicians, the ones currently in medical school, are going to be the ones to say, 'Hey, wait a minute, I'm not going to do this,' and will be less tolerant of what a nonphysician considers an excessive workload," Dr. Pincus said. "I don't believe the young people coming in are going to accept that, regardless of whether or not they have families."

They're going to demand less intensive residency service, she said, and will be willing to accept a longer training time to achieve that.

Pediatrician Adam Frymoyer, MD, 28, exemplifies what Dr. Pincus is seeing.

He took three months off in the fall of 2005, near the start of his second year. "I felt like things were going fast. I wanted time to explore some other avenues outside of medicine, to have the time to reflect on my experiences and where I want to go."

First, he spent time polishing his surfing skills and visiting his fiancé, also a UCSF resident, while she did an ob-gyn rotation in Hawaii. He visited his parents and friends on the East Coast, and attended his best friend's wedding in Italy.

He spent his last month translating research data from a medical school project on pain treatment into a publishable paper.

"I felt like I'd lost my research ties," Dr. Frymoyer said. "It got me back into the realm of research, and I could see that it was something I wanted in my career long term."

He said fellow residents were surprisingly supportive. "At first I thought they would be like, 'Why are you taking off?' but they said, 'Wow, that's great. I wish I had done that.' I grew a lot during that time. I feel it was influential in my career path."

How and why schools are adapting

Several resident educators said in order to attract top applicants, they've had to be accommodating. Even if residents don't end up choosing to take a leave of absence, knowing the opportunity is there can be a stress reliever in itself, they said.

"We want to be positioned to attract the best and brightest with a range of interests," said Ted Sectish, MD, pediatric residency program director at California's Lucile Packard Children's Hospital at Stanford.

Programs that are able to offer flexible options tend to be large, which makes rearranging schedules less demanding on the other residents. But even those at the big programs say it takes a supportive hospital administration, one willing to build in the manpower to keep the schedule pliable. The residents have to be supportive as well, because teamwork and careful planning and scheduling is vital, educators said.

One of the first programs to work in leave of absences, in the early '90s, was the pediatric department at University of California, San Francisco.

Robert Kamei, MD, who was the program director then, said residents were being advised to not have children because of training demands. He believed the suggestion was unreasonable, considering many of his residents were women in their childbearing years. Dr. Kamei, now vice dean of education at Duke-NUS Graduate Medical School Singapore, said eventually the flexible option expanded beyond maternity leave. Between 1992 and 2002, 24 residents out of 284 chose to take a leave of absence.

Timothy Kelly, MD, UCSF's current pediatric residency director, said that each year, about four of his 85 pediatric residents take a four- to six-month leave. He said one of the more common reasons is for international work.

While allowing time off is valued, taking care of residents still actively working is also a priority. "Nobody is expected to do more call or do an excessive number of rotations for manpower issues," Dr. Kelly said.

Gregory Kane, MD, internal medicine program director at Thomas Jefferson University Hospitals, said his residents have more than training on their agendas these days.

"They have personal aspirations," Dr. Kane said. "We recognize that, and to be a good doctor you have to be happy and need to meet your personal goals."

Making the decision to take time off

Chris Adrian, MD, was one such resident.

When he was a UCSF pediatric intern, Dr. Adrian scheduled six months of flex time, divided into chunks of two months on and two months off, so he'd have time to finish writing a novel. A grant from the National Endowment for the Arts helped him hurdle the obstacle of unpaid time off.

Flex time became especially important for Dr. Adrian during his second year when his father was diagnosed with lung cancer. Having already scheduled time off, Dr. Adrian was free to be with his parents in Florida.

His program is so flexible, Dr. Adrian said, that "even if I hadn't had that time built in, it would not have been any trouble to spend time with my parents."

UCSF went out of its way, he said, to make sure his health insurance was covered. Not all institutions provide benefits when residents are on leave, though most will offer COBRA, through which residents can extend health insurance coverage, albeit at a price.

His father died eight months after diagnosis, and Dr. Adrian finished his training. He's now working on his master's in divinity at Harvard Divinity School and working as an urgent care physician in Boston.

Though his graduation was delayed, timing wasn't an issue for Dr. Adrian, although it could be for others in similar situations. Residents must complete a certain number of clinical months before taking boards. Delays in achieving this benchmark can throw residents' graduation out of sync with their boards.

While Drs. Frymoyer and Adrian chose to take time off, others find it forced on them.

Bonnie Callahan, MD, had just started her internal medicine program at Thomas Jefferson University Hospital in Philadelphia in 2003, when she was diagnosed with dilated cardiomyopathy.

"My heart wasn't working so hot," she said. "You get all swollen and you can't breathe. It wasn't much fun."

A decade or two earlier, this might have been the end of her medical career. And indeed she didn't work for three months. But as her health improved, she rotated through electives, working 40 to 50 hours a week with no overnight call. In April 2004 she did one month on the internal medicine floor to see if she could handle it. Her doctor gave her the thumbs up, and in June she started her internship year again, with her schedule set up so she wouldn't have intense rotations back-to-back.

Her illness added a year onto her training, but it hasn't changed her professional goals. She still hopes for a career in primary care or primary care cardiology.

Throughout all the uncertainty, Dr. Callahan said she never felt pressured to quit, though she was counseled to consider less physically demanding specialties.

While more new physicians will likely seek time off during training, this isn't an indication that the quality of the physician work force is on the decline, educators say.

Dr. Kane, director of the internal medicine residency at Jefferson, stressed that regardless of the amount of time taken off, the content of residents' training remains the same.

"They don't get out of anything," he said.

Outside interests don't indicate a lack of dedication, experts said.

"These people are good, serious physicians," Dr. Pincus said. "They just have a different set of priorities."