What is the meaning of continuing medical education for physicians who have taken a prolonged leave of absence, or who have been out of practice for a period of time and then return? With no current regulations, Dr. Pauline Chen explores the boundaries between professional standards and personal needs, and what this may mean for the future of medical practice.
[Well Blogs, NY Times] Several years ago, a highly respected medical expert I had just met shared a little-known detail of his illustrious career: as a young doctor, he had stopped practicing medicine for a few years to homeschool his son.
His revelation took me completely by surprise. Doctors rarely talked about taking time off for fear that colleagues would assume them incompetent or in possession of some serious personal flaw.
I understood my colleagues’ hesitation because I always avoided bringing up my own decision to take a professional hiatus.
I had had a harrowing pregnancy, marked by bleeding that worsened anytime I operated. I stopped seeing patients soon after my first trimester and made the decision to extend that break after the birth of healthy twin daughters. But I did so without realizing just how difficult it would be to return.
In all the articles, essays and books on the growing trend among professionals to “opt out” of their careers, doctors, I would discover, remained strangely absent. While the lawyers, accountants, business executives and teachers seemed to ease back into their careers after a few years raising children, attending to their own or loved ones’ health issues or even pursuing entirely new careers, I couldn’t find answers to even my most basic questions. Did I need to be tested, proctored or re-trained? Would I work as an assistant, a doctor-in-training equivalent or a fully trained physician? Were there rules and “industry standards” I needed to pass in order to assure patients I was safe? And in the world of practicing doctors, would the time I spent away from medicine always remain “That-Period-Which-Shall-Not-Be-Named?”
Now, nearly a decade later, studies have shown that more doctors than ever are choosing to take time off, at least twice as many as in previous generations. But while these physicians have more company and support than their predecessors, returning to practice remains daunting in large part because of the persistent stigma. (Interestingly, most of the re-entry doctors I spoke to hesitated or declined to be quoted for this article.)
Although concerns about the competency of returning doctors are justified, the profession’s aversion to discussing the issue and reluctance even to recognize it has had perverse results. There are no national standards for doctors who want to return to clinical practice, only a helter-skelter set of hurdles, hoops and headaches.
“The safety net has big holes in it,” said Dr. Claudette Dalton, the former chair of the American Medical Association’s task force on re-entry who has interrupted her own medical career and re-entered clinical practice twice. For example, roughly half of all the state medical boards, including New York’s, have no policy for doctors attempting to return to clinical practice after an extended period of time away. But even in those states with requirements that range from mandatory completion of an official re-entry training program to passing a written exam, it’s unclear that such policies really do ensure competence. Research on physician re-entry is scarce; and no one really knows when time away begins to affect a doctor’s clinical skills and what might best remediate any deficiencies. Indeed, aside from a few surveys, little is even known about who the re-entering doctors are.
“Our profession needs to be able to reassure patients that the doctor they are seeing knows what he or she is doing and isn’t rusty and creaky like some unoiled door hinge,” Dr. Dalton said.
One particularly promising initiative is a mentored clinical program that slowly re-introduces doctors to practice. At the physician re-entry program at Cedars-Sinai Medical Center in Los Angeles, one of fewer than a dozen such programs throughout the country, re-entering doctors work with three different experienced senior physicians in their field, attend lectures, participate in teaching and work rounds, take call and progressively shoulder more responsibility. At the end of two or three months, the doctors submit to a rigorous exit interview, where they can be drilled on any of the cases they have seen.
Of the 14 doctors who have gone through the Cedars-Sinai program, 13 have successfully returned to practice. But with the costs for such programs ranging from $5,000 to $10,000 a month or more, many doctors cannot even consider enrolling in one even if their state licensing boards mandates them.
“We’ve had a blind spot when it comes to physician re-entry,” said Dr. Leo G. Gordon, who heads the Cedars-Sinai program, “even though it really should be part of the profession’s obligation, especially with the upcoming physician shortage.”
That doctor deficit is expected to surpass 100,000 physicians within the next 15 years. But according to the American Medical Association, at least10,000 doctors each year are currently looking to return to clinical practice. Re-entry experts believe that these doctors, if successfully returned to practice, could not only help to alleviate the doctor shortage but would do so quickly.
“This is not a seven-year pipeline,” said Dr. Dalton, referring to the usual time required to educate and train a new doctor. “This is a 6-month to a year pipeline at most because a lot of those doctors when assessed could be perfectly fine.”
Although the A.M.A. and a few professional organizations like the American Academy of Pediatrics have increased their efforts to support returning physicians and create national standards, those initiatives will only falterwithout a major shift in the attitude of the profession itself.
“We have to realize that it’s not about abdicating your profession,” Dr. Dalton said. “It’s about having some sensibility about the priority in your life at a certain moment, then returning to your clinical roots and coming back to serve your profession.”
I have been back in clinical practice for several years now. My path of return was neither obvious nor straightforward, but I have always remained grateful to the doctor who oversaw my re-entry process. He and his colleagues willingly took me on, persisted in putting me through the paces and displayed an unfailing and contagious devotion to the highest standards of care.
Through it all, they understood that stopping working as a doctor temporarily to be a mother never meant I had stopped loving patient care.