Association of part-time clinical work with well-being and mental health in General Internal Medicine: A survey among Swiss hospitalists

Lisa Bretagne; Stefanie Mosimann; Christine Roten; Martin Perrig; Daniel Genné; Manfred Essig; Marco Mancinetti; Marie Méan; Pauline Darbellay Farhoumand; Lars C Huber; Elisabeth Weber; Christoph Knoblauch; Andreas W Schoenenberger; Sonia Frick; Eliane Wenemoser; Daniel Ernst; Michael Bodmer; Drahomir Aujesky; Christine Baumgartner

doi:10.1371/journal.pone.0290407

. 2023 Sep 28;18(9):e0290407. doi: 10.1371/journal.pone.0290407

Association of part-time clinical work with well-being and mental health in General Internal Medicine: A survey among Swiss hospitalists

Lisa Bretagne ^1,^*, Stefanie Mosimann ^1,², Christine Roten ¹, Martin Perrig ¹, Daniel Genné ³, Manfred Essig ⁴, Marco Mancinetti ⁵, Marie Méan ⁶, Pauline Darbellay Farhoumand ⁷, Lars C Huber ⁸, Elisabeth Weber ⁹, Christoph Knoblauch ¹⁰, Andreas W Schoenenberger ¹¹, Sonia Frick ¹², Eliane Wenemoser ¹³, Daniel Ernst ¹⁴, Michael Bodmer ¹⁵, Drahomir Aujesky ¹, Christine Baumgartner ¹

Editor: Lorenzo Righi¹⁶

¹Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

²School of Health Professions Education, Maastricht University, Maastricht, The Netherlands

³Department of Internal Medicine, Hospital of Biel-Bienne, Bienne, Switzerland

⁴Department of General Internal Medicine, Tiefenau Hospital, Bern, Switzerland

⁵Department of Medicine, University and Hospital of Fribourg, Fribourg, Switzerland

⁶Department of Internal Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland

⁷Department of Medicine, Geneva University Hospitals (HUG), Geneva, Switzerland

⁸Department of General Internal Medicine, Stadtspital Zürich Triemli, Zürich, Switzerland

⁹Department of General Internal Medicine, Stadtspital Zürich Waid, Zürich, Switzerland

¹⁰Department of General Internal Medicine, Hospital of Nidwalden, Stans, Switzerland

¹¹Department of General Internal Medicine, Cantonal Hospital of Münsterlingen, Münsterlingen, Switzerland

¹²Department of General Internal Medicine, Hospital of Limmattal, Schlieren, Switzerland

¹³Department of General Internal Medicine, Hospital Region of Oberaargau, Langenthal, Switzerland

¹⁴Department of General Internal Medicine, Hospital of Thun, Thun, Switzerland

¹⁵Department of General Internal Medicine, Cantonal Hospital of Zug, Baar, Switzerland

¹⁶Center for Primary Care and Public Health: Unisante, SWITZERLAND

Competing Interests: The authors have declared that no competing interests exist.

^✉

* E-mail: lisa.bretagne@gmail.com

Roles

Lisa Bretagne: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Project administration, Writing – original draft

Stefanie Mosimann: Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Christine Roten: Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Martin Perrig: Conceptualization, Methodology, Writing – review & editing

Daniel Genné: Conceptualization, Investigation, Writing – review & editing

Manfred Essig: Conceptualization, Investigation, Writing – review & editing

Marco Mancinetti: Conceptualization, Investigation, Writing – review & editing

Marie Méan: Conceptualization, Investigation, Writing – review & editing

Pauline Darbellay Farhoumand: Conceptualization, Investigation, Writing – review & editing

Lars C Huber: Conceptualization, Investigation, Writing – review & editing

Elisabeth Weber: Conceptualization, Investigation, Writing – review & editing

Christoph Knoblauch: Conceptualization, Investigation, Writing – review & editing

Andreas W Schoenenberger: Conceptualization, Investigation, Writing – review & editing

Sonia Frick: Conceptualization, Investigation, Writing – review & editing

Eliane Wenemoser: Conceptualization, Investigation, Writing – review & editing

Daniel Ernst: Conceptualization, Investigation, Writing – review & editing

Michael Bodmer: Conceptualization, Investigation, Writing – review & editing

Drahomir Aujesky: Conceptualization, Investigation, Writing – review & editing

Christine Baumgartner: Conceptualization, Formal analysis, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft

Lorenzo Righi: Editor

PMCID: PMC10538797 PMID: 37768911

Abstract

Introduction

Burnout and low job satisfaction are increasing among the General Internal Medicine (GIM) workforce. Whether part-time compared to full-time clinical employment is associated with better wellbeing, job satisfaction and health among hospitalists remains unclear.

Materials and methods

We conducted an anonymized cross-sectional survey among board-certified general internists (i.e. hospitalists) from GIM departments in 14 Swiss hospitals. Part-time clinical work was defined as employment of <100% as a clinician. The primary outcome was well-being, as measured by the extended Physician Well-Being Index (ePWBI), an ePWBI ≥3 indicating poor wellbeing. Secondary outcomes included depressive symptoms, mental and physical health, and job satisfaction. We compared outcomes in part-time and full time workers using propensity score-adjusted multivariate regression models.

Results

Of 199 hospitalists invited, 137 (69%) responded to the survey, and 124 were eligible for analysis (57 full-time and 67 part-time clinicians). Full-time clinicians were more likely to have poor wellbeing compared to part-time clinicians (ePWBI ≥3 54% vs. 31%, p = 0.012). Part-time compared to full-time clinical work was associated with a lower risk of poor well-being in adjusted analyses (odds ratio 0.20, 95% confidence interval 0.07–0.59, p = 0.004). Compared to full-time clinicians, there were fewer depressive symptoms (3% vs. 18%, p = 0.006), and mental health was better (mean SF-8 Mental Component Summary score 47.2 vs. 43.2, p = 0.028) in part-time clinicians, without significant differences in physical health and job satisfaction.

Conclusions

Full-time clinical hospitalists in GIM have a high risk of poor well-being. Part-time compared to full-time clinical work is associated with better well-being and mental health, and fewer depressive symptoms.

Introduction

Physicians’ well-being has been shown to positively contribute to patient satisfaction and quality of care [1]. In recent years, studies have shown a decrease in physician well-being and career satisfaction, as well as an increase in burnout [2, 3]. General internal medicine (GIM) is particularly affected by this trend [4, 5]. A recent study among GIM residents in Switzerland showed that 19% had a low well-being and 60% felt burnt-out [6]. More than a fifth of the residents in this study regretted their career choice [6]. Combined with an expected increase in the need for GIM physicians both in the ambulatory and hospital setting due to the ageing population and the growing number of complex and multimorbid patients, changes are needed in career models for GIM to maintain enough board-certified general internists caring for hospitalized patients (hereinafter referred to as hospitalists) in the years to come [7].

Several studies have investigated causes of burnout and factors that influence well-being [3]. Having control over one’s schedule and the number of hours worked weekly have been identified as important predictors of both a better work-life balance and better career satisfaction [8]. The Swiss Medical Association (FMH) has suggested that promotion of part-time work may increase retention of physicians in clinical functions [9]. Another study has shown that the opportunity to engage in other activities than clinical work that were deemed meaningful by participants, such as research or teaching, was associated with lower rates of burnout [10]. In order to prevent migration of general internists from the hospital setting to ambulatory care, experts have called for increasing opportunities for part-time work in the GIM hospital setting [7]. However, the impact of working part-time as a clinician in a hospital setting on physician well-being, job satisfaction, and health has not been sufficiently investigated. Previous studies in the USA, the Netherlands, or Germany suggested an increase in job satisfaction and decrease in stress and burnout with part-time compared to full-time work among physicians, but results on work-life balance were conflicting [11–16]. Those studies were conducted either in specialties such as pediatrics, radiology, or gynecology, or did not take into account their specialty. One study conducted in a hospital setting in GIM found no difference in overall job satisfaction between part-time and full-time physicians, however, well-being and health were not assessed [17]. In addition, these studies did not discriminate between part-time work overall and part-time clinical work with protected time for non-clinical tasks, which may contribute to improved wellbeing without reducing overall working hours.

The aim of this study was to assess the association between part-time compared to full-time clinical work and aspects of well-being, job satisfaction, and health among hospitalists of GIM departments in Switzerland.

Materials and methods

Study design and population

We conducted an anonymized cross-sectional electronic survey among hospitalists in Switzerland. The Swiss health care system is characterized by universal access that is ensured through mandatory health care insurance [18]. Among practicing physicians, 22% are specialized in GIM, making it the most frequent specialization in Switzerland [19]. Board certification for GIM in Switzerland requires a 5-year training; [20] GIM residents can then transition to a position either as a hospitalist or an outpatient general practitioner, or may still decide to pursue a training in another medical specialty, as many subspecialties (e.g., cardiology, infectious diseases, etc.) require at least 2 years of training in GIM. Patients hospitalized on a GIM ward of a Swiss teaching hospital are cared for by a GIM resident and a supervising (board-certified) hospitalist, and other specialists are involved depending on the patient’s disease and on request of the hospitalist. The hospitalists themselves are supervised regularly (e.g., once a week) or upon request by a chief physician, who is also responsible for running the department and for other administrative tasks, teaching, and research. Overall, the hospitalists have the overview and bear the ultimate responsibility for optimal patient care.

The survey was sent to hospitalists from GIM departments of 14 Swiss hospitals, including small regional hospitals and large tertiary care centres from various Swiss regions. We deliberately excluded resident physicians from the survey as a considerable part of the residents working in GIM departments will switch to speciality training [21]. Furthermore, few hospitals in Switzerland allow part-time employment of residents in GIM, thus only few residents work part-time in GIM, [6] and it would have been difficult to get a big enough sample size of participants for meaningful results. By focusing on hospitalists, we intended for the study population to be more homogeneous and representative of the “general internist”. We excluded chief-physicians in hospital medicine, hospitalists without direct patient care on a ward, those who had newly transitioned to a position as hospitalist within the last month or those who intended to leave GIM within the next month, as their answers may not be representative of the GIM hospitalist workforce. The aim of our study and use of data for publication was stated at the beginning of our survey, and we indicated that participation in the survey would be taken as consent. Because the survey was anonymized, we were unable to collect individual informed consent forms. The authors had no access to information that could identify individual participants. This study has been granted an exemption from requiring ethical approval due to its nature.

Data collection

The survey was conducted using the public survey function of REDCap (Research Electronic Data Capture), which allows collection of anonymized responses. Study data were collected and managed using REDCap electronic data capture tools hosted at the CTU, Bern [22, 23]. The survey consisted of questions to assess the physicians’ demographic data, work percentage and schedule, and measures of well-being, job satisfaction and health. The survey link was sent to the hospitalists by the project collaborators of each participating hospital via e-mail in December 2021. A reminder was sent per email after 1 week, 2 weeks and 4 weeks.

For this study, full-time clinical work was defined as a full time (i.e. 100%) employment as a clinical hospitalist, which corresponds to 46–50 clinical hours per week in Switzerland. Part-time clinical work was defined as level of employment <100% for clinical work (i.e. less than 46 clinical hours per week). Physicians employed full time, but with a predefined percentage of their work specifically dedicated to non-clinical tasks (i.e. research, teaching, or administration), were considered as part-time clinicians, because we hypothesized that diversification of one’s work and engaging in meaningful non-clinical tasks may affect well-being similar to engaging in meaningful tasks outside of the hospital during time off [10]. The percentage of clinical employment was based on self-report of the number of hours specified in hospitalists’ contracts, and did not include overtime.

Outcomes

The primary outcome of this study was well-being as assessed using the expanded Physician Well-being Index (ePWBI) [24]. The ePWBI consists of 7 questions that are answered by yes or no (with one point assigned for each “yes”), and 2 questions that are answered using a 7-point Likert scale (with a score of -1 to +1 assigned to each of these questions). The score was validated in a sample of 6880 US physicians, and a score of ≥3 points was associated with a higher risk of adverse outcomes, including medical error, burnout, severe fatigue, suicidal ideation and poor quality of life [24, 25]. Thus, we defined an ePWBI score of ≥3 points as poor wellbeing.

Secondary outcomes included job satisfaction, burnout, quality of life, work-life balance, mental and physical health, fatigue, depressive symptoms, and physical activity. Job satisfaction was assessed using a single-item measure rated on a 5-point Likert scale [26, 27]. Burnout was assessed using the single-item measures of depersonalisation and emotional exhaustion from the PWBI score as a measure for burnout, as done in a previous study evaluating the well-being of Swiss residents [6]. These single-item measures representing depersonalisation and emotional exhaustion are adapted from the Maslach Burnout Inventory (MBI), which is considered the gold standard for measuring burnout, but is limited by its length (i.e. 22 items) [28]. The usability of these two items as an abbreviated tool to assess burnout has been demonstrated previously [29]. Quality of life was measured by a linear analogue scale with a response range from 0 (as bad as it can be) to 10 (as good as it can be) [30, 31]. Work-life balance was assessed using the additional question of the ePWBI “My work schedule leaves me enough time for my personal/family life”, rated on a 5-point Likert scale. Mental and physical health were assessed using the Medical Outcomes Study Short-Form Health Survey (SF-8). The questionnaire entails 8 items with 5- and 6-point Likert-type scales and generates norm-based T-scores ranging from 0 to 100, with higher scores indicating better health, calibrated to the general U.S. population (mean = 50, SD = 10). The sub-scale scores can be computed to two summary scores, the Physical Component Summary (PCS) and the Mental Component Summary (MCS), calculated as the weighted sum of the 8 sub-scale scores and normalized to the U.S. general population [32, 33]. Fatigue was assessed by the Stanford Sleepiness Scale, a 7-item self-assessment of one’s current level of sleepiness [34]. Depressive symptoms were assessed by the 2 first items of the 9-item Patient Health Questionnaire (PHQ-2), which has been validated as a screening tool for depression [35]. The score asks the frequency of depressed mood and anhedonia, scoring each as 0 (not at all) to 3 (nearly every day). A combined score of ≥3 has been recognised as a threshold for depression [35]. Physical activity, was assessed by the daily step count, a readily available measure inversely related to health outcomes such as all-cause mortality, type 2 diabetes, and cardiovascular events [36]. Participating physicians were asked to indicate the average number of steps taken per day for the current month, the previous month, and two months prior, according to the default health app on their smart-phone.

Statistical analysis

We calculated that a sample size of 92 participants would provide 80% power to detect a moderate 0.5–0.6-standard deviation effect size in the primary outcome, a level that has been previously used to describe a clinically significant difference in outcomes [37, 38]. According to our knowledge, the minimally clinically important difference in the ePWBI (as well as the original PWBI) has not been described in the literature, although an ePWBI of ≥3 points was previously associated with a higher risk of adverse outcomes [24]. We estimated that a survey sample of at least 184 participants would be sufficient to meet the target sample size, assuming a response rate of at least 50% (based on a previous study in GIM in Switzerland) [6].

Characteristics of part-time and full-time clinical hospitalists were compared using chi-squared tests for categorical variables and t-tests or Wilcoxon rank sum tests for continuous variables, as appropriate. To assess the association between part-time vs. full-time clinical work and outcomes, we used propensity score methods to model the probability of the exposure (i.e. working full-time or part-time as a clinician) while accounting for potential confounders and minimizing bias [39]. Potential confounders were identified using a directed acyclic graph, and covariates were included based on review of the literature [40]. To derive the propensity scores (and thus to assess the conditional probability of working part-time given an individual participant’s covariate values), [39] we developed a logistic regression model using part-time vs. full-time clinical work as the dependent variable, and age, sex, parenthood, relationship status, academic ambition, reduced work capacity due to health reasons, time since transition to a hospitalist (i.e. years of experience as a hospitalist), and number of patients to care for as the independent variables. The reference group consisted of full-time clinical hospitalists. Propensity scores were derived from the logistic regression model, and quintiles of the propensity scores were computed. The association between part-time vs. full-time clinical work and the ePWBI (as a continuous variable) was assessed using a linear regression model adjusted for quintiles of the propensity score. To analyze the ePWBI as a binary outcome with a cut-off of ≥3 to define low well-being, [41] a logistic regression model adjusted for quintiles of the propensity score was used [42]. The association between part-time vs. full-time work and secondary outcomes including job satisfaction, quality of life, fatigue, work-life balance, and mobility was similarly assessed using linear regression models, adjusting for quintiles of the propensity scores. The association between part-time vs. full time work and depressive symptoms and burnout was analyzed using a logistic regression model, adjusting for quintiles of the propensity score.

In a sensitivity analysis, we categorized hospitalists working part-time clinically, but in blocks of entire weeks, in the full-time instead of part-time group, to assess whether working in blocks may mitigate potential effects of part-time clinical work on well-being or job satisfaction. In a second sensitivity analysis, we compared hospitalists working full-time and part-time overall (instead of clinically) to assess the association between well-being and part-time overall. This sensitivity analysis was performed to further investigate whether diversification of one’s work or mere reduction in working hours were driving potential differences in well-being.

Two-sided p-values of 0.05 were considered statistically significant. All statistical analyses were conducted with Stata statistical software, release 16 (Stata Corporation, College Station, TX, USA).

Results

Of the 199 hospitalists who received the survey, 137 answered for a response rate of 69% (Fig 1). Thirteen participants were excluded because they met the predefined exclusion criteria, resulting in a final study sample of 124 hospitalists, of whom 57 (46%) had a full-time and 67 (54%) a part-time clinical employment (median clinical employment percentage 70%, interquartile range [IQR] 50–80%). Compared to full-time clinical hospitalists, those with a part-time clinical employment were older (age ≥40 years in 24% vs. 5%, p = 0.004), more likely to be female (76% vs. 54%, p = 0.011) and to have children (64% vs. 41%, p = 0.014), had a longer duration since graduation from medical school (median 8.5 years, IQR 7–11 years vs. 7 years, IQR 6–9 years, p<0.001), and more experience as a hospitalist (median 4 years, IQR 2–7 years vs. 2 years, IQR 1–5 years, p = 0.010; Table 1). There was no significant difference in long-term goals overall, although part-time clinicians more often wished to become general practitioners (25% in part-time vs. 11% in full-time clinicians), whereas full-time clinicians more often aimed to become specialists in another discipline (10% in part-time vs. 19% in full-time clinicians). The absolute amount of weekly overtime did not differ significantly between the two groups, however the proportion of overtime according to employment percentage was significantly higher for part-time than full-time clinicians (12%, IQR 8–18% vs. 8%, IQR 8–13%, p = 0.002; Table 1).

Table 1. Characteristics of participating hospitalists.

	Full-time clinical employment (n = 57)	Part-time clinical employment (n = 67)^*	p-value
Clinical employment level in %, median (IQR)	100 (100–100)	70 (50–80)	< 0.001
Overall employment level in %, median (IQR) ^†	100 (100–100)	80 (60–90)	< 0.001
Full-time employment overall, n (%)	57 (100%)	14 (21%)	< 0.001
Gender, n (%)
Male	26 (46%)	16 (24%)	0.011
Female	31 (54%)	51 (76%)	0.011
Age in years, n (%)
< 40	54 (95%)	51 (76%)	0.004
≥ 40	3 (5%)	16 (24%)	0.004
Parenthood, n (%)	20 (41%)	38 (64%)	0.014
Relationship status, n (%)			0.08
Single	10 (18%)	4 (6%)
Partnership	22 (39%)	20 (31%)
Married	25 (44%)	37 (57%)
Divorced	0 (0%)	2 (3%)
Other	0 (0%)	2 (3%)
Time since graduation in years, median (IQR)	7 (6–9)	8.5 (7–11)	< 0.001
Experience as attending hospitalist in years, median (IQR)	2 (1–5)	4 (2–7)	0.010
Long-term goal, n (%)
Clinical hospitalist	30 (53%)	31 (46%)	0.23
Academic position	2 (4%)	2 (3%)
General practitioner	6 (11%)	17 (25%)
Specialist in other discipline	11 (19%)	7 (10%)
Undecided	8 (14%)	10 (15%)
Average clinical hours per week, median (IQR)	50 (50–55)	38 (28–45)	< 0.001
Overtime per week in hours, median (IQR)	8 (8–13)	7.8 (4.8–12.2)	0.45
Overtime in relation to planned working time, median (IQR)	0.08 (0.08–0.13)	0.12 (0.08–0.18)	0.002
Average number of night shifts per month, median (IQR)	3 (0–4)	1 (0–3)	0.015
Average adjusted number of night shifts per month, (median, IQR) ^‡	3 (0–4)	2.5 (0–5)	0.53
Average number of patients to care for per day, mean (95% CI)	20.2 (18.7–21.8)	18.3 (17–19.5)	0.05

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Abbreviations: CI: confidence interval; IQR, interquartile range. Values were missing for: number of children (n = 16); relationship status (n = 2); time since graduation (n = 1); experience as a hospitalist (n = 2); average clinical hours per week (n = 15); average number of night shifts per month (n = 4); average number of patients (n = 3).

P-values were calculated using chi-squared tests for categorical variables and t-tests or Wilcoxon rank sum tests for continuous variables.

* part-time clinical work was defined as an employment of <100% for clinical work

† refers to employment for clinical work plus any additional employment for non-clinical tasks (e.g. research)

‡ adjusted to 100% clinical employment

§ calculated by weekly overtime (in hours) divided by planned weekly working hours

The most frequently reported reason for part-time clinical work among hospitalists working part-time was family duties (63%), while it was more personal time (90%) followed by family duties (63%) in the 41 (72%) full time hospitalists who wished to reduce to part-time (S1 Table). Only 3 hospitalists (4%) in the clinical part-time group were employed in another clinical activity outside of the hospital, and 2 hospitalists who wished to work part-time (5%) wanted to work clinically outside of the hospital (S1 Table).

The mean ePWBI was lower, i.e. indicating better well-being, in part-time clinicians (mean 1.6, 95% confidence interval [CI] 0.9–2.2) compared to full-time clinicians (mean 2.2, 95% CI 1.6–2.8), although the difference was not statistically significant. Part-time clinicians were significantly less likely to have poor wellbeing (defined by an ePWBI ≥3) than full-time clinical hospitalists (31% vs. 54%, p = 0.012, Table 2). Among the items of the ePWBI, the largest difference between the two groups was observed for work-life balance: 72% of full-time hospitalists felt that their work schedule did not leave enough time for their personal or family life, while this was less frequently reported by part-time hospitalists (56%). In propensity-score adjusted analyses, part-time compared to full-time clinical hospitalists tended to have a lower ePWBI score (mean difference 1.00, 95% CI -2.11–0.11, p = 0.08), and they had a statistically significantly lower risk of poor well-being, with an odds ratio (OR) of 0.20 (95% CI 0.07–0.59) for an ePWBI ≥3 points (p = 0.004; Table 3).

Table 2. Well-being and job satisfaction among full-time and part-time hospitalists.

	Full-time clinical employment (n = 57)	Part-time clinical employment (n = 67)	p-value
ePWBI score^*, mean (SD)	2.2 (2.2)	1.6 (2.4)	0.15
Poor well-being (ePWBI ≥3)^*, n (%)	30 (54%)	19 (31%)	0.012
Symptoms of burnout in the last month ^§	36 (63%)	34 (51%)	0.17
Job satisfaction ^♦
Extremely dissatisfied	0 (0%)	1 (2%)	0.55
Dissatisfied	4 (7%)	3 (5%)
Neutral	12 (22%)	8 (13%)
Satisfied	31 (57%)	40 (65%)
Extremely satisfied	7 (13%)	10 (16%)
Quality of life, mean (SD) ^†	6.1 (1.7)	6.6 (2.0)	0.14
Work-life balance ^‡
Satisfactory	8 (14%)	20 (30%)	0.09
Unclear	8 (14%)	9 (14%)
Not satisfactory	41 (72%)	37 (56%)
Mental and physical health (SF-8) ⁺
Physical Component Summary, mean (SD)	50.7 (7.0)	51.6 (7.4)	0.52
Mental Component Summary, mean (SD)	43.2 (10.3)	47.2 (9.5)	0.028
Fatigue, median (IQR) ^¶	2 (1–3)	1 (0–2)	0.07
Depressive symptoms ^#	10 (18%)	2 (3%)	0.006
Mean daily step count over 3 months, mean (95% CI)	7505 (6837–8173)	7122 (6224–8019)	0.48

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Abbreviations: ePWBI, extended Physician Well-Being Index; IQR, interquartile range; SD, standard deviation; SF-8: Short-form Health Survey.

All values are in n (%) unless otherwise specified. Values were missing for: ePWBI score (n = 6); job satisfaction (n = 8); quality of life (n = 5); work-life balance (n = 1); Physical Component Summary (n = 1); Mental Component Summary (n = 3); mean daily step count (n = 62).

P-values were calculated using chi-squared tests for categorical variables and t-tests or Wilcoxon rank sum tests for continuous variables.

* the ePWBI consists of 9 questions and ranges from -2 to 9, with lower scores denoting better well-being. A score of ≥3 points was defined as poor wellbeing.

§ measured by a positive answer to at least one of the two first questions of the ePWBI

♦ rated on a 5-point Likert scale

† measured by a linear analogue scale with a response range from 0 (as bad as can be) to 10 (as good as it can be).

‡ measured by question 9 of the ePWBI

⁺ The SF-8 consists of 8 items with 5- and 6-point Likert-type scales. Each item generates a norm-based T-score ranging from 0 to 100 with higher scores indicating better health, calibrated to a mean score of 50 in the general U.S. population. The Physical and Mental Component Summary is calculated as the weighted sum of the 8 sub-scale scores and normalised to the U.S. general population.

¶ assessed using the 7-item Stanford Sleepiness Scale, 1 being fully alert and 7 imminent sleep onset

# measured using the 2 first items of the 9-item Patient Health Questionnaire (PHQ-2).

Table 3. Adjusted association between part-time vs. full-time work and outcomes based on propensity score models.

	Full-time clinical employment (n = 57)	Part-time clinical employment (n = 67)	p-value
ePWBI score, mean (95% CI)*	1.95 (0.92–2.98)	0.95 (-0.16–2.06)	0.08
Poor well-being (ePWBI ≥3), OR (95% CI)*	Ref.	0.20 (0.07–0.59)	0.004
Symptoms of burnout in the last month, OR (95% CI) §	Ref.	0.47 (0.18–1.22)	0.12
Job satisfaction, mean (95% CI) ♦	3.75 (3.38–4.11)	3.79 (3.41–4.16)	0.85
Quality of life, mean (95% CI) †	6.27 (5.41–7.13)	6.73 (5.82–7.64)	0.32
Work-life balance, mean (95% CI) ‡	0.61 (0.24–0.98)	0.31 (-0.07–0.71)	0.15
Physical Component Summary, mean (95% CI) ⁺	50.3 (47.0–53.6)	51.0 (47.5–54.5)	0.71
Mental Component Summary, mean (95% CI) ⁺	44.0 (39.6–48.5)	48.9 (44.2–53.5)	0.044
Fatigue, mean (95% CI) ¶	1.45 (0.86–2.04)	0.99 (0.36–1.61)	0.14
Depressive symptoms, OR (95% CI) #	Ref.	0.14 (0.02–0.85)	0.033
Mean daily step count, mean (95% CI)	7962 (6883–9041)	8710 (7400–10019)	0.26

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Abbreviations: CI: confidence interval; ePWBI, extended Physician Well-Being Index; IQR, interquartile range; OR, odds ratio; SF-8: Short-form Health Survey

Results were adjusted for the propensity of working part-time, as well as age, sex, parenthood, relationship status, academic ambition, reduced work capacity due to health reasons, time since transition to hospitalist, and number of patients to care for

*§♦†‡⁺¶# see Table 2

There was a statistically significantly lower prevalence of depressive symptoms in part-time compared to full-time clinicians based on the PHQ-2 (3% vs. 18%; p = 0.006, Table 2). In the propensity-score adjusted analyses, part-time clinicians had a statistically significantly lower risk for depressive symptoms than full-time hospitalists (OR 0.14, 95% CI 0.02–0.85, p = 0.033, Table 3). The Mental Component Summary (MCS) score of the SF-8 indicated better mental health for part-time (mean 47.22, SD 9.54) compared to full-time physicians (mean 43.19, SD 10.30, p = 0.028), while the Physical Component Summary (PCS) did not significantly differ (Table 2). In the propensity-score adjusted analyses, the results were similar, with a higher mean MCS score for part-time clinicians than their full-time colleagues (mean difference 4.82, 95% CI 0.13–9.5, p = 0.044, Table 3) and no statistically significant difference in the PCS score. Among the individual items of the SF-8, the largest difference between the two groups was observed for the item evaluating the impact of emotional problems on daily functioning (“during the past 4 weeks, how much did personal or emotional problems keep you from doing your usual work, school or other daily activities?”). Symptoms of burnout, job satisfaction, overall quality of life, work-life balance, and fatigue tended to be better rated by part-time compared to full-time clinical hospitalists, although without any statistically significant differences (Table 2). Physical activity, as measured by the mean number of daily steps over the last 3 months did not differ between groups (7122 compared to 7505, p = 0.478), although the result was only available for 62/124 hospitalists. Similarly, the propensity-score adjusted analyses showed no statistically significant difference in the rest of the secondary outcomes (Table 3).

In a sensitivity analysis considering hospitalists working clinically part-time in blocks of whole weeks as full-time, results remained similar, although the beneficial association of part-time work with depressive symptoms and the MCS of the SF-8 score did not reach statistical significance (S2 Table). In a second sensitivity analysis comparing hospitalists working full-time and part-time overall, the association between part-time overall and better well-being, as well as a lower risk for depressive symptoms, remained statistically significant. Additionally, the positive trend towards fewer symptoms of burnout, better work-life balance and less fatigue reached a statistically significant difference in this analysis (S3 Table).

Discussion

In our survey among hospitalists in GIM, half of all full-time clinicians reported poor well-being. Our results showed that part-time compared to full-time clinical work was associated with a lower risk of poor well-being. Hospitalists working part-time clinically were significantly less likely to have symptoms of depression and had a better mental health compared to their full-time colleagues. Job satisfaction, quality of life, work-life balance, and symptoms of burnout were not statistically significant between both groups.

The fact that more than half of all full-time and almost a third of part-time clinical hospitalists who completed our survey reported poor wellbeing is alarming, given that poor physician well-being is not only associated with burnout, depression, suicidal ideation, substance abuse, and poor quality of life, [41, 43] but also negatively affects patient satisfaction and quality of care [1]. Additionally, physicians tend to underrecognize their mental and physical health issues and not seek help [43]. Overall, 40% of the physicians who answered our survey had low well-being. In other studies, low well-being ranged from 53% in resident physicians in Calgary, Canada, [44] to 18.6% in GPs in Denmark [45]. Low well-being seemed to be more frequent in board-certified hospitalists than residents (19%) in GIM in Switzerland [6]. To our knowledge, the relationship between part-time employment, both clinical and overall part-time, and well-being has not been investigated in physicians previously. Our results suggest that part-time clinical work is associated with better well-being compared to working as a full-time clinician. Potential explanations may be reduced stress and burden from work, but also increased diversification of one’s tasks. We chose to study part-time clinical employment on the premise that non-clinical tasks may diversify the work of clinicians and allow them to spend time on work that is meaningful to them, increasing well-being similar to any other activity part-time physicians may choose besides their clinical work [10]. The sensitivity analysis comparing full-time and part-time employment overall also showed an association between part-time work overall and higher well-being, with a similar odds ratio to our main analysis. Overall, our analysis showed a positive association between part-time clinical work and well-being, whether the remaining time is spent on non-clinical professional tasks or tasks outside of the hospital.

The association of overall part-time work with job satisfaction was investigated in several studies. Only one, dating from 1995 and including only radiologists, found a higher job satisfaction for full-time physicians than part-time physicians, [46] while several more recent studies indicate that full-time physicians are less satisfied with their job compared to their part-time colleagues [11, 14, 15, 47]. Of two studies including specifically physicians in GIM, a higher job satisfaction in part-time workers was confirmed in a survey among internists and GPs in an ambulatory setting [47]. The other study included academic members of the Society of General Internal Medicine in the US and showed a similar job satisfaction in part-time and full-time clinicians and clinician-educators, [17] in line with our results. Overall, part-time work does not seem to have a consistent effect on job satisfaction, which may be explained by the fact that several predictors of job satisfaction are organizational variables specific to each hospital or health center environment, such as communication within the team, remuneration, feedback, or social standing of the institution the physicians work in [48].

Several previous studies showed a better work-life balance, fewer work-privacy conflicts, [11, 13, 15, 49] and a lower rate of burnout in physicians working part-time overall or their preferred number of hours compared to full-time physicians, [12, 47, 50, 51] a trend that was also observed in our study. The fact that we did not observe a statistically significant association similar to other studies may be due to our study comparing part-time clinical employment instead of part-time overall. In the sensitivity analysis using part-time overall, the association with work-life balance and burnout was statistically significant. Another reason may be insufficient power for these outcomes or the use of other questionnaires. For example, we only gathered data on symptoms of burnout rather than using the full MBI, because this test would have been too time-consuming for our survey among busy hospitalists. Alternatively, there may be a true lack of association between part-time work and work-life balance or burnout, because part-time workers are often taking care of family duties, as reported by two-thirds of part-time clinical hospitalists in our study–and are often part of dual-earner couples. Thus, they may be expected to take on a disproportionally high load of family duties during their time off clinical work, causing family role overload [52]. It is also possible that the addition of non-clinical tasks or the proportionally higher overtime of part-time physicians lead to burnout as much as in the full-time clinical employment group. While part-time work may be one potential solution to promote work-life balance, [11, 13, 15, 49] implementation of other measures improving work-life balance of GIM physicians in a hospital setting, such as providing protected time for non-clinical tasks, prioritization of tasks and measures to improve the productivity, increasing the autonomy of physicians over their working schedule, and the development of institutional support systems such as employee assistance programs, remain important, as this may increase the attractiveness of GIM for future physicians [53]. In fact, an international systematic review of medical students’ choice of specialty showed that work-life balance was significantly associated with the choice of specialty in 60% of articles, compared to 38.2% for gender, 45% for interest and 30% for prestige and income [54].

We found very few studies investigating physician’s physical and mental health as a whole. One study assessing physical health did not find any association between the number of working hours and somatic complaints, which also matches our findings [55]. Concerning mental health, most studies concentrated on burnout, probably because this outcome is the most closely related to work-related outcomes, such as efficiency and medical error [5]. One study in Australia showed that junior doctors working more than 55 hours per week were more than twice as likely to report mental health issues than those working 40–44 hours per week [56]. Another study among resident physicians in Saudi Arabia showed that longer working hours were associated with higher rates of anxiety and depression, with odds of depression that were twice as high for physicians working more than 40 hours per week [57]. In a Norwegian prospective survey, the number of working hours did not influence the probability of mental health problems in first-year residents undergoing a compulsory internship year in surgery and internal medicine [58]. However, it is unclear in the article if part-time employment was a possibility during this study. Furthermore, the evaluation was based on self-assessment of overall health status rather than validated scores, which has been shown to be poor in physicians, [43] and mental health issues reported as minor were not taken into consideration.

Supporting and increasing opportunities for part-time (clinical) work may not only contribute to physician well-being and health, but could also be important to ensure retention of a healthy GIM workforce in hospitals. Of all Swiss physicians, 22% work in GIM, making it the most frequently chosen medical speciality in Switzerland [19]. However, in a hospital setting, the number of GIM specialists drops to 13% [59]. In order to prevent migration of general internist hospitalists to ambulatory care and promote their retention in the hospital setting, experts have called for increasing opportunities for part-time work in the GIM hospital setting, [7] a call that is supported by the results of our study. In addition, part-time work has been suggested to increase the attractiveness of GIM, allowing physicians to facilitate their personal development during different phases of their career [60]. A recent survey found that 68% of physicians working full-time would like to reduce to part-time employment [61]. This preference is not only the result of an increasing proportion of women (who may still choose to be mothers and have a family life) in medicine overall and in GIM, [9] but also reflects the priorities of the next generation of general internists, such as a growing equality of men and women in sharing of family duties and a better balance between work, family and spare time [62]. Our findings support the hypothesis that part-time employment or replacement of some clinical work with non-clinical professional tasks is associated with higher well-being, although it is unclear from the results of this cross-sectional survey if the association is causal. More research is needed to investigate whether part-time clinical activity of hospitalists has an impact on quality of patient care. In fact, a recent cross-sectional study among Medicare beneficiaries from the US found a higher mortality in patients treated by physicians with reduced clinical time [63].

To our knowledge, this is the first study to investigate the association between part-time work and physician well-being in physicians specialized in GIM. We found no study assessing all aspects of well-being consecutively. The response rate of 69% was high for a physician survey, and the percentage of part-time hospitalists in our results (43% overall part-time and 54% clinical part-time hospitalists) is close to the percentage of part-time hospitalists declared by the participating GIM wards (51%). Thus, we expect the answers to the survey to be representative of our study population, although the results may not apply to each individual hospital, especially those employing only few part-time hospitalists. We could not compare characteristics of hospitalists who answered the questionnaire and those who did not, because the answers were anonymous. One limitation of our study is that our sample size is relatively small, so although it was sufficiently powered to detect significant differences in our primary outcome, it may have been underpowered concerning the secondary outcomes. The sample size was also too small for a meaningful subgroup analysis of our data (e.g. by sex). Second, although we adjusted our analysis for known confounders that influence the association between part-time work and well-being, we cannot exclude the potential for residual confounding. To ensure that participants could not be identified, we did not gather any information on the site participants were employed at, as some sites had as few as 4 potential participants. Thus, we were not able to adjust our analysis for hospital site to reflect the size of the hospital they were employed at. We did not gather data on the age of participant’s children, which could further influence the workload at home and therefore affect the decision of working part-time work as well as a participants’ wellbeing. We adjusted for parenthood as a potential confounder but not the number of children, because we hypothesized that having children per se rather than the number of children would causally affect whether a physician was working part-time of full-time. Third, we only looked at the situation in GIM in Switzerland, thus our result may not be generalizable to other health care systems or settings. Fourth, as this is a cross-sectional study, the association between part-time clinical employment and higher well-being shown in our results does not guarantee causation. Finally, we did not use a validated score for burnout. We included questions assessing symptoms of burnout; however, they did not include the frequency component. We decided not to include the MBI, as it would have made the survey too long and may have lowered the response rate. In this study, we did not assess patient safety or other patient outcomes.

Conclusions

In conclusion, full-time clinical hospitalists in GIM have a high risk for poor well-being. Part-time compared to full-time clinical work is associated with better well-being and better mental health. Supporting and enabling part-time clinical work may contribute to an improvement in well-being and mental health among GIM hospitalists and their retention in hospital settings.

Supporting information

S1 Table. Reasons for part-time clinical work among hospitalists working part-time and among those working full-time but wishing to reduce to part-time clinical work.

Participants were able to select multiple reasons. *Other reasons listed for part-time clinical employment: administrative work, university duties.

(DOCX)

Click here for additional data file.^{(12.3KB, docx)}

S2 Table. Sensitivity analysis considering part-time clinicians working whole weeks (n = 22) as full-time, adjusted for quintiles of the propensity scores.

Abbreviations: CI: confidence interval; ePWBI, extended Physician Well-Being Index; IQR, interquartile range; OR, odds ratio; SF-8: Short-form Health Survey. Results were adjusted for the propensity of working part-time, as well as age, sex, parenthood, relationship status, academic ambition, reduced work capacity due to health reasons, time since transition to hospitalist, and number of patients to care for * the ePWBI consists of 9 questions and ranges from -2 to 9, with lower scores denoting better well-being. A score of ≥3 points was defined as poor wellbeing.§ measured by a positive answer to at least one of the two first questions of the ePWBI. ♦ rated on a 5-point Likert scale. † measured by a linear analogue scale with a response range from 0 (as bad as can be) to 10 (as good as it can be). ‡ measured by question 9 of the Epwbi. ⁺ 8 items with 5- and 6-point Likert-type scales. Each item generates a norm-based T-score ranging from 0 to 100 with higher scores indicating better health, calibrated to a mean score of 50 in the general U.S. population. The Physical and Mental Component Summary is calculated as the weighted sum of the 8 sub-scale scores and normalised to the U.S. general population. ¶ assessed using the 7-item Stanford Sleepiness Scale, 1 being fully alert and 7 imminent sleep onset. # measured using the 2 first items of the 9-item Patient Health Questionnaire (PHQ-2).

(DOCX)

Click here for additional data file.^{(13.9KB, docx)}

S3 Table. Sensitivity analysis considering full-time and part-time employment overall, adjusted for quintiles of the propensity scores.

Abbreviations: CI: confidence interval; ePWBI, extended Physician Well-Being Index; IQR, interquartile range; OR, odds ratio; SF-8: Short-form Health Survey. Results were adjusted for the propensity of working part-time, as well as age, sex, parenthood, relationship status, academic ambition, reduced work capacity due to health reasons, time since transition to hospitalist, and number of patients to care for * the ePWBI consists of 9 questions and ranges from -2 to 9, with lower scores denoting better well-being. A score of ≥3 points was defined as poor wellbeing. § measured by a positive answer to at least one of the two first questions of the Epwbi. ♦ rated on a 5-point Likert scale. † measured by a linear analogue scale with a response range from 0 (as bad as can be) to 10 (as good as it can be). ‡ measured by question 9 of the ePWBI. ⁺ 8 items with 5- and 6-point Likert-type scales. Each item generates a norm-based T-score ranging from 0 to 100 with higher scores indicating better health, calibrated to a mean score of 50 in the general U.S. population. The Physical and Mental Component Summary is calculated as the weighted sum of the 8 sub-scale scores and normalised to the U.S. general population. ¶ assessed using the 7-item Stanford Sleepiness Scale, 1 being fully alert and 7 imminent sleep onset. # measured using the 2 first items of the 9-item Patient Health Questionnaire (PHQ-2).

(DOCX)

Click here for additional data file.^{(13.9KB, docx)}

Data Availability

Data cannot be shared publicly to preserve the anonymity of participants. As the sample size is relatively small, some participants may be recognized due to the gathered personal information. The data is available upon request from the first or last authors (Lisa Bretagne and Christine Baumgartner), or from the Department of General Internal Medicine at the Inselspital, Bern (forschung.kaim@insel.ch).

Funding Statement

This work was supported by a grant from the Swiss Society of General Internal Medicine (SGAIM) Foundation (https://www.sgaim.ch/de/themen/forschung/portraet-sgaim-foundation) awarded to L.B. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0290407.r001

Decision Letter 0

Lorenzo Righi

4 Jul 2023

PONE-D-23-11884Association of part-time clinical work with well-being and mental health in General Internal Medicine: A survey among Swiss hospitalistsPLOS ONE

Dear Dr. Bretagne,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Many thanks for this interesting article dealing with a relevant and pressing issue.

I also thank the reviewers very much for their valuable input. I am sure that by following the reviewer's suggestions, the quality of the article will further increase.

Please respond to the comments of Reviewer 1. I ask you to focus mainly on points 1 (this point was also indicated by Reviewer 2), 2, 3, 4, 7. If possible also respond to points 5, 6, and 8.

Please add a short paragraph about the Swiss Health Care System in the introduction so as to help readers understand the similarities and differences with their Health Care System. Also comment on the possibility of part-time physicians then working outside the hospital, as suggested by Reviewer 4.

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Lorenzo Righi

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Reviewer #1: Yes

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Reviewer #4: Yes

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Reviewer #1: Yes

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5. Review Comments to the Author

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Reviewer #1: The authors conducted a cross-sectional online study collecting information on working hours and mental health and well-being among Swiss hospitalits. In my opinion, the topic under investigation is of great relevance for health care systems and in order to maintain sufficient patient care – not only in Switzerland and specifically in the light of physican shortage. The analysis was very detailed, including a range of important factors of well-being and health.

I have some comments and suggestions to enhance the clarity of the manuscript.

1. In your method section, you describe that physicians came from small regional hospitals or large tertiary care centres. Did you think of adding this as a confounding variable in your regression models? There is evidence that this could be important in terms of well-being, job satisfaction and mental health of physicians (DOI: 10.1055/s-0042-121596, 10.1055/a-1173-9188).

2. Sample: In my opinion, the reason why some participants were excluded is questionable. For instance, if you assume that residents are generally working full-time (by giving one reference only), you could also exclude female or older physicians, because they are more likely to work part-time as well. Besides, why did you exclude physicians planning to leave GIM in the next month (Figure 1)?

3. On page 6, line 120-123, the authors describe how they define full-time and part-time, which is very helpful (many other studies simply refer to these categories without explaining them, and it may differ between countries), however, was this based on number of hours determined by contract or does it include total hours in addition to overtime hours? It would be helpful to clarify this by one sentences.

4. On page 6, line 123-125 you mention that physicians employed full-time but with predefined percentage of work dedicated to non-clinical tasks such as research, was considered as part-time. On the other hand, in your introduction, you say that the possibility to be engaged in these non-clinical tasks – such as research - was associated with lower rates of burnout. Even if your results do not show that these activities may be linked to lower burnout rates, it may still bias your results. Even if physicians do not spend all of their time in direct patient contact, they may still be working 50hrs a week and therefore be affected by burnout. At the same time, categorizing them into the part-time group makes it sound as if “doing” research is not as valuable as working in direct patient care. Maybe the authors want to reconsider their categorization scheme or explain this categorization more comprehensively.

5. On page 8, line 8 you mention that “parenthood” was added as a covariate. Did you ask for the age or number of children? The impact of child care or the “double burden” may be different for someone with a child aged 2 or aged 17, or whether someone has oen child or four to look after. If not, this could be added to the limitation section.

6. Discussion section: It would be interesting, if the authors share their ideas regarding the causation or reason for their findings based on previous literature and give some implications. What can hospitals do with these findings? Would could be changed (in terms of working hours) in order to maintain or improve well-being?

7. In this context, it is interesting that they did not find any differences regaridng burnout. By looking at Table 1, I was wondering whether working part-time creates equal amount of stress/burnout, because neither the overtime hours nor the average number of patients to care is significantly different between the two groups. Maybe part-time physicians are stressed because they have the same amount of work but less time for it.

8. I find the amount of information ( indictaed by §,*, ♦, ‡, etc.)) below each table rather confusing – maybe the authors can find a way to avoid this accumulation, as most information is given repeatedly under each table.

Reviewer #2: The authors present a study with the aim of assessing the association between part-time compared to full-time clinical work and aspects of well-being, job satisfaction, and health among hospitalists of GIM departments in Switzerland.

The manuscript has serious limitations that prevent me from recommending publication.

Reviewer #3: The paper addresses an important issue, whether part-time compared to full-time clinical work is associated with better well-being and mental health and fewer depressive symptoms.

The paper is well written with an appropriate analytical approach and deserves publication. However, I have a comment related to selectivity bias and suggesting to address.

Out of 199 hospitalists who received the survey, 137 answered and the response rate is 69%. Thirteen participants were also excluded. I would suggest comparing 137 and 62 cases/hospitalists in terms of background characteristics and whether they differ. I hope this comparison is possible as samples were taken from hospitals.

Reviewer #4: Thanks for sending over this paper for my review, which looks at part-time and full time physicians wellbeing.

While there are some strengths and interesting features, I believe the paper can be strengthened by some further developments in terms of theoretical background and discussion.

Introduction:

Is there any theories related to having multiple jobs for physicians/ employees may contribute to wellbeing?

And under what context (eg government support, economic environment, life trajectory) this might be beneficial?

Methods:

Have the analysis separated part-time physicians with other jobs (so may potentially work full time hours)and those who only work is as a part-time physicians? If not, then I believe the interpretation of the results and thus in the discussion will need to be clear about the complex composition of the part-time group.

Data analysis:

Can you explain a bit more on the reliability or evidence that the one item measures and shorten measurements are appropriate?

Discussion:

With some part-time physicians have other job commitments but some don’t, and attributing diversified work for their higher satisfaction doesn’t sound very strong.

Line 376 -388: When quoting studies conducted in other countries, mentioning the potentially similar or different context that led to inconsistencies in results will improve the clarity and depth of discussion.

Line 389 - 401: Any other factors push and pull factors for the “trend” to go part-time and take up multiple positions and related discussions? Reflecting the interest of the “next generation” sound like an over simplification of the phenomenon.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

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PLoS One. 2023 Sep 28;18(9):e0290407. doi: 10.1371/journal.pone.0290407.r002

Author response to Decision Letter 0

6 Aug 2023

Dear Dr. Righi,

Thank you for the opportunity to revise and resubmit our manuscript entitled “Association of part-time clinical work with well-being and mental health in General Internal Medicine: A survey among Swiss hospitalists”.

We have provided a point-by-point response to each comment below, and highlighted the changes made in the manuscript. Each author has approved the revised version, and we hope that these changes meet with your approval.

The data analyzed for the current study are not publicly available, because this specific study was exempted from ethical approval. Additionally, the gathered data contains sensitive and personal information on hospitalists who, although anonymized, may still be identifiable. Data may be shared with researchers for reasonable scientific purposes on request if the use has been approved by an ethical committee. For data access and requests for the analytical code, researchers may contact the corresponding author.

Please do not hesitate to contact us with any remaining questions or for additional clarification.

Thank you again for your valuable review and the opportunity to revise our manuscript. We look forward to your response.

On behalf of the investigators,

Lisa Bretagne

Comments from the academic editor:

1. Many thanks for this interesting article dealing with a relevant and pressing issue. I also thank the reviewers very much for their valuable input. I am sure that by following the reviewer's suggestions, the quality of the article will further increase. Please respond to the comments of Reviewer 1. I ask you to focus mainly on points 1 (this point was also indicated by Reviewer 2), 2, 3, 4, 7. If possible also respond to points 5, 6, and 8.

Response: Thank you for your comment. We have now responded to all comments from Reviewer 1; see responses below. We have also addressed the comments from the other reviewers in the letter below.

2. Please add a short paragraph about the Swiss Health Care System in the introduction so as to help readers understand the similarities and differences with their Health Care System.

Response: We have added a paragraph on the Swiss Health Care System and General Internal Medicine in Switzerland to the methods section (page 6, lines 92-105):

“We conducted an anonymized cross-sectional electronic survey among hospitalists in Switzerland. The Swiss health care system is characterized by universal access that is ensured through mandatory health care insurance.[18] Among practicing physicians, 22% are specialized in GIM, making it the most frequent specialization in Switzerland.[19] Board certification for GIM in Switzerland requires a 5-year training;[20] GIM residents can then transition to a position either as a hospitalist or an outpatient general practitioner, or may still decide to pursue a training in another medical specialty, as many subspecialties (e.g., cardiology, infectious diseases, etc.) require at least 2 years of training in GIM. Patients hospitalized on a GIM ward of a Swiss teaching hospital are cared for by a GIM resident and a supervising (board-certified) hospitalist, and other specialists are involved depending on the patient’s disease and on request of the hospitalist. The hospitalists themselves are supervised regularly (e.g., once a week) or upon request by a chief physician, who is also responsible for running the department and for other administrative tasks, teaching, and research. Overall, the hospitalists have the overview and bear the ultimate responsibility for optimal patient care.

The survey was sent to hospitalists from GIM departments of 14 Swiss hospitals, […]”

We had the impression that the description of the Swiss Health Care System fits best in the first paragraph of the methods section. If you think that this should be moved to the introduction section, please let us know.

3. Also comment on the possibility of part-time physicians then working outside the hospital, as suggested by Reviewer 4.

Response: Only 3 hospitalists (4% of all part-time hospitalists) had another clinical activity outside of the hospital (S1 Table). We do not think that this number is high enough to have any major influence on our results. Additionally, we did not find any previous literature on having multiple part-time jobs outside the hospital and well-being. We have now commented on this in the results section (page 13, lines 248-251):

“Only 3 hospitalists (4%) in the clinical part-time group were employed in another clinical activity outside of the hospital, and 2 hospitalists who wished to work part-time (5%) wanted to work clinically outside of the hospital (S1 Table).”

Reviewer 1:

The authors conducted a cross-sectional online study collecting information on working hours and mental health and well-being among Swiss hospitalists. In my opinion, the topic under investigation is of great relevance for health care systems and in order to maintain sufficient patient care – not only in Switzerland and specifically in the light of physician shortage. The analysis was very detailed, including a range of important factors of well-being and health.

Response: Thank you for your comment.

I have some comments and suggestions to enhance the clarity of the manuscript.

Response: Thank you for raising this important point. Unfortunately, we had to remove the variable “site” from our questionnaire to participants because of confidentiality concerns, as some centres only had few possible participants and they would have been immediately identifiable. Thus, we could not adjust our analysis for the site the participants worked at. We agree that this could be a confounding factor and we have added this to the limitations (page 20, lines 449-452):

“To ensure that participants could not be identified, we did not gather any information on the site participants were employed at, as some sites had as few as 4 potential participants. Thus, we were not able adjust our analysis for hospital site to reflect the size of the hospital they were employed at.”

Response: We tried to get a sample that would be representative of the typical (Swiss) physician in GIM working in a hospital setting (i.e., hospitalist). First, we did not include resident physicians because in Switzerland, several years of residency in GIM is mandatory for many other specialties (e.g., cardiology, infectious diseases, endocrinology, etc.). Because of this, many residents in GIM do not envision a career in GIM. In addition, residents who want to become family doctors also need to complete at least 2 years in GIM in a hospital setting. In our opinion, residents in GIM do not reflect the future in-hospital GIM workforce, which is why we did not include them in our study. Additionally, very few hospitals in Switzerland allow part-time work for residents, which would have made the sampling difficult.

Second, we excluded hospitalists who did not have any patient contact because the aim of the study was to assess the association between the amount of clinical work and well-being. Third, we also excluded hospitalists who had transitioned in the last month as the transition is usually perceived as stressful and they may not have had enough time to adapt to their new position, so their responses concerning well-being may not be representative of hospitalist workforce. Lastly, we excluded physicians who were leaving GIM in the next month, as they were transitioning to another specialty and thus, in our opinion, they were similarly not representative of the hospitalist workforce. We now extended the rationale for excluding these participants in our methods section (page 7, lines 106-116):

“We deliberately excluded resident physicians from the survey as a considerable part of the residents working in GIM departments will switch to speciality training.[21] Furthermore, few hospitals in Switzerland allow part-time employment of residents in GIM, thus only few residents work part-time in GIM,[6] and it would have been difficult to get a big enough sample size of participants for meaningful results. By focusing on hospitalists, we intended for the study population to be more homogeneous and representative of the “general internist”. We excluded chief-physicians in hospital medicine, hospitalists without direct patient care on a ward, those who had newly transitioned to a position as hospitalist within the last month or those who intended to leave GIM within the next month, as their answers may not be representative of the GIM hospitalist workforce.”

Response: The categories for full-time and part-time were based on the number of hours defined in the hospitalists’ contract. Overtime was presented for each group in the baseline characteristics (Table 1).

We now clarified this in the methods section (page 8, line 137-138):

“The percentage of clinical employment was based on self-report of the number of hours specified in hospitalists’ contracts, and did not include overtime.”

Response: Our hypothesis was that non-clinical activities, such as research and teaching, combined with clinical work contribute to a better well-being compared to a full-time clinical activity (see our reference 10), given that this results in a diversification of one’s work/everyday life, similar to working part-time and thus spending time for e.g. childcare. This is why we decided to compare part-time and full-time clinical employment rather than overall employment in our main analysis. We now explained this categorization more comprehensively (page 8, lines 133-137):

“Physicians employed full time, but with a predefined percentage of their work specifically dedicated to non-clinical tasks (i.e. research, teaching, or administration), were considered as part-time clinicians, because we hypothesized that diversification of one’s work and engaging in meaningful non-clinical tasks may affect well-being similar to engaging in meaningful tasks outside of the hospital during time off.[10]”

However, we agree with the reviewer that this may be debatable, and that overall working hours rather than diversification of one’s work may contribute to reduced well-being. Therefore, we performed a sensitivity analysis comparing part-time and full-time employment overall (i.e., with inclusion of employment for non-clinical tasks). We now further clarified this in the methods section (page 11, lines 208-212):

“In a second sensitivity analysis, we compared hospitalists working full-time and part-time overall (instead of clinically) to assess the association between well-being and part-time overall. This sensitivity analysis was performed to further investigate whether diversification of one’s work or mere reduction in working hours were driving potential differences in well-being.”

The results of this sensitivity analysis similarly showed a statistically significant difference for well-being, similar to the main results, as well as reduced symptoms of burnout, improved work-life balance, reduced fatigue and symptoms of depression (see S3 Table). In our main analysis, well-being, depressive symptoms and mental health showed a statistical difference between the groups.

It is possible and even probable that research may lead to more overtime; however, we wanted to show that even if hospitalists do not want to or cannot reduce overall working time, replacing some clinical time with other non-clinical activities may be way of improving well-being, as explained in the discussion section (page 17, lines 354-364):

“We chose to study part-time clinical employment on the premise that non-clinical tasks may diversify the work of clinicians and allow them to spend time on work that is meaningful to them, increasing well-being similar to any other activity part-time physicians may choose besides their clinical work. [10] The sensitivity analysis comparing full-time and part-time employment overall also showed an association between part-time work overall and higher well-being, with a similar odds ratio to our main analysis. Overall, our analysis showed a positive association between part-time clinical work and well-being, whether the remaining time is spent on non-clinical professional tasks or tasks outside of the hospital.

5. On page 8, line 8 you mention that “parenthood” was added as a covariate. Did you ask for the age or number of children? The impact of child care or the “double burden” may be different for someone with a child aged 2 or aged 17, or whether someone has one child or four to look after. If not, this could be added to the limitation section.

Response: We asked for the number of children but not their age. We decided to adjust for parenthood as a potential confounder for the relationship between level of employment and wellbeing and not the number of children, because we hypothesized that having children per se rather than the number of children would causally affect whether someone was working full-time of part-time. We have added this in the limitations (pages 20-21, lines 452-457):

“We did not gather data on the age of participant’s children, which could further influence the workload at home and therefore affect the decision of working part-time work as well as a participants’ wellbeing. We adjusted for parenthood as a potential confounder but not the number of children, because we hypothesized that having children per se rather than the number of children would causally affect whether a physician was working part-time of full-time.”

Response: As mentioned in the discussion (page 17, lines 350-351), we have found no previous studies investigating employment level of physicians and well-being overall, although previous literature on single components of well-being showed a better work-life balance, fewer work-privacy conflicts, and a lower rate of burnout and depression in physicians working part-time overall or their preferred number of hours compared to full-time physicians (pages 17-19, lines 365-415). Our results suggest that reducing work hours or replacing some clinical time with non-clinical time may lead to better well-being in GIM hospitalists. Potential reasons for improved well-being may be reduced stress and burden from work, but also a diversification on one’s tasks in everyday life. We have now added this to the discussion (page 17, lines 353-354).

“Potential explanations may be reduced stress and burden from work, but also increased diversification of one’s tasks.”

However, the causality this association between well-being and part-time work cannot be shown in this study using cross-sectional survey data.

A recent cross-sectional study among a random sample of Medicare beneficiaries in the USA (Kato et al., JAMA Intern Med 2021, see our new reference 63) has shown a higher mortality in patients cared for by hospitalists with reduced clinical time. We think additional studies are necessary before any recommendation can be made for institutions to promote part-time work. We have now extended the discussion section accordingly (page 20, lines 429-435):

“Our findings support the hypothesis that part-time employment or replacement of some clinical work with non-clinical professional tasks is associated with higher well-being, although it is unclear from the results of this cross-sectional survey if the association is causal. More research is needed to investigate whether part-time clinical activity of hospitalists has an impact on quality of patient care. In fact, a recent cross-sectional study among Medicare beneficiaries from the US found a higher mortality in patients treated by physicians with reduced clinical time.[63]”

7. In this context, it is interesting that they did not find any differences regarding burnout. By looking at Table 1, I was wondering whether working part-time creates equal amount of stress/burnout, because neither the overtime hours nor the average number of patients to care is significantly different between the two groups. Maybe part-time physicians are stressed because they have the same amount of work but less time for it.

Response: That is a valid hypothesis and has been added to the discussion (page 18, lines 390-392):

“It is also possible that the addition of non-clinical tasks or the proportionally higher overtime of part-time physicians lead to burnout as much as in the full-time clinical employment group.”

8. I find the amount of information ( indicated by §,*, ♦, ‡, etc.)) below each table rather confusing – maybe the authors can find a way to avoid this accumulation, as most information is given repeatedly under each table.

Response: we have removed the footnotes that were repeatedly given and only left it under Table 2 (see footnotes of Table 3).

Reviewer 2:

The authors present a study with the aim of assessing the association between part-time compared to full-time clinical work and aspects of well-being, job satisfaction, and health among hospitalists of GIM departments in Switzerland.

The manuscript has serious limitations that prevent me from recommending publication.

Response: We thank the reviewer for his review and would be happy to receive more detailed information on how he came to this decision, so that we can give our best to improve the manuscript.

Reviewer 3:

The paper addresses an important issue, whether part-time compared to full-time clinical work is associated with better well-being and mental health and fewer depressive symptoms.

The paper is well written with an appropriate analytical approach and deserves publication. However, I have a comment related to selectivity bias and suggesting to address.

Response: thank you for your comment.

1. Out of 199 hospitalists who received the survey, 137 answered and the response rate is 69%. Thirteen participants were also excluded. I would suggest comparing 137 and 62 cases/hospitalists in terms of background characteristics and whether they differ. I hope this comparison is possible as samples were taken from hospitals.

Response: Unfortunately, we do not have any information on the hospitalists who received the survey but did not fill out the questionnaire as the answers are anonymous. Therefore, we do not know who answered and who did not and thus we cannot compare their characteristics. We have added this to the limitations (page 20, lines 443-444):

“We could not compare characteristics of hospitalists who answered the questionnaire and those who did not, because the answers were anonymous.”

Reviewer 4:

Thanks for sending over this paper for my review, which looks at part-time and full time physicians wellbeing.

While there are some strengths and interesting features, I believe the paper can be strengthened by some further developments in terms of theoretical background and discussion.

Response: thank you for your comment and your review.

1. Introduction: Is there any theories related to having multiple jobs for physicians/ employees may contribute to wellbeing? And under what context (e.g. government support, economic environment, life trajectory) this might be beneficial?

Response: We found no literature on the impact of working in multiple part-time jobs on well-being in literature, neither for physicians nor other employees. While working in several clinical jobs is frequent among certain specialists in Switzerland (e.g., working 3 days in hospital and 2 days in a private practice), it is not as frequent in GIM and is more frequently done by chief physicians than hospitalists included in our survey. In our study, only 3 hospitalists worked another clinical job outside of the hospital (4% of part-time hospitalists, see S1 Table). We have added this information in the results section (page 13, lines 248-251):

2. Methods: Have the analysis separated part-time physicians with other jobs (so may potentially work full time hours) and those who only work is as a part-time physicians? If not, then I believe the interpretation of the results and thus in the discussion will need to be clear about the complex composition of the part-time group.

Response: Yes, we separated physicians working part-time with another professional activity next to clinical work and those without. In the main analysis, we only looked at part-time clinical work, independently on whether they had another professional activity or not. In a sensitivity analysis, we separated the sample in a group of participants working part-time overall or full-time overall, taking into account any other professional activity physicians may have. We now clarified this in the methods section (please also see our answer to comment 4 from reviewer 1). We now also made this clearer in the discussion on page 17, lines 354-358:

and on page 20, lines 429-431:

Our findings support the hypothesis that part-time employment or replacement of some clinical work with non-clinical professional tasks is associated with higher well-being, […]

3. Data analysis: Can you explain a bit more on the reliability or evidence that the one item measures and shorten measurements are appropriate?

Response: We have cited several studies in the manuscript on the validity of our outcome measures including the one-item measures and the shortened measurements used (see our references 26-36 in the manuscript). We decided to use one-item measures and shortened measurements to keep the questionnaire length to a minimum, thus encouraging participation.

4. Discussion: With some part-time physicians have other job commitments but some don’t, and attributing diversified work for their higher satisfaction doesn’t sound very strong.

Response: Our premise was that working part-time as a clinician with other professional activities may be beneficial on well-being, similar to working part-time without any other professional activity (but potentially other commitment such as childcare), as this enables physicians to spend time on work that is most meaningful to them (see our reference 10: Career fit and burnout among academic faculty, Shanafelt et al., 2009). That is why we decided to separate participants to groups with part-time clinical work or full-time clinical work. The higher well-being in the part-time clinical group could be due to any activity physicians chose to do besides their clinical work, be it a non-clinical professional activity, physical activity, family or social time. We have clarified this is the discussion (see our response to your comment 2).

5. Line 376 -388: When quoting studies conducted in other countries, mentioning the potentially similar or different context that led to inconsistencies in results will improve the clarity and depth of discussion.

Response: We have added more context to the study showing inconsistent results with our study (page 19, lines 410-415)

“In a Norwegian prospective survey, the number of working hours did not influence the probability of mental health problems in first-year residents undergoing a compulsory internship year in surgery and internal medicine.[58] However, it is unclear in the article if part-time employment was a possibility during this study. Furthermore, the evaluation was based on self-assessment of overall health status rather than validated scores, which has been shown to be poor in physicians,[43] and mental health issues reported as minor were not taken into consideration.”

6. Line 389 - 401: Any other factors push and pull factors for the “trend” to go part-time and take up multiple positions and related discussions? Reflecting the interest of the “next generation” sound like an over simplification of the phenomenon.

Response: The high rates of burnout, combined with a high number of female physicians and a trend towards equal sharing of family duties between men and women seem to be the main reason cited in articles. Physicians, general internists included, are not ready to sacrifice their hobbies and family life to their job anymore (see our reference 62: Promising Future in General Internal Medicine for the Next Generation of Physicians. Allenbach et al. 2018). We now specified this in the discussion section (pages 19-20, lines 425-429):

“This preference is not only the result of an increasing proportion of women (who may still choose to be mothers and have a family life) in medicine overall and in GIM,[9] but also reflects the priorities of the next generation of general internists, such as a growing equality of men and women in sharing of family duties and a better balance between work, family and spare time.[62] ”

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PLoS One. doi: 10.1371/journal.pone.0290407.r003

Decision Letter 1

Lorenzo Righi

8 Aug 2023

Association of part-time clinical work with well-being and mental health in General Internal Medicine: A survey among Swiss hospitalists

PONE-D-23-11884R1

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PLoS One. doi: 10.1371/journal.pone.0290407.r004

Acceptance letter

Lorenzo Righi

19 Sep 2023

PONE-D-23-11884R1

Association of part-time clinical work with well-being and mental health in General Internal Medicine: a survey among Swiss hospitalists

Dear Dr. Bretagne:

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Table. Reasons for part-time clinical work among hospitalists working part-time and among those working full-time but wishing to reduce to part-time clinical work.

Participants were able to select multiple reasons. *Other reasons listed for part-time clinical employment: administrative work, university duties.

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S2 Table. Sensitivity analysis considering part-time clinicians working whole weeks (n = 22) as full-time, adjusted for quintiles of the propensity scores.

(DOCX)

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S3 Table. Sensitivity analysis considering full-time and part-time employment overall, adjusted for quintiles of the propensity scores.

Abbreviations: CI: confidence interval; ePWBI, extended Physician Well-Being Index; IQR, interquartile range; OR, odds ratio; SF-8: Short-form Health Survey. Results were adjusted for the propensity of working part-time, as well as age, sex, parenthood, relationship status, academic ambition, reduced work capacity due to health reasons, time since transition to hospitalist, and number of patients to care for * the ePWBI consists of 9 questions and ranges from -2 to 9, with lower scores denoting better well-being. A score of ≥3 points was defined as poor wellbeing. § measured by a positive answer to at least one of the two first questions of the Epwbi. ♦ rated on a 5-point Likert scale. † measured by a linear analogue scale with a response range from 0 (as bad as can be) to 10 (as good as it can be). ‡ measured by question 9 of the ePWBI. ⁺ 8 items with 5- and 6-point Likert-type scales. Each item generates a norm-based T-score ranging from 0 to 100 with higher scores indicating better health, calibrated to a mean score of 50 in the general U.S. population. The Physical and Mental Component Summary is calculated as the weighted sum of the 8 sub-scale scores and normalised to the U.S. general population. ¶ assessed using the 7-item Stanford Sleepiness Scale, 1 being fully alert and 7 imminent sleep onset. # measured using the 2 first items of the 9-item Patient Health Questionnaire (PHQ-2).

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Data Availability Statement

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PERMALINK

Association of part-time clinical work with well-being and mental health in General Internal Medicine: A survey among Swiss hospitalists

Lisa Bretagne

Stefanie Mosimann

Christine Roten

Martin Perrig

Daniel Genné

Manfred Essig

Marco Mancinetti

Marie Méan

Pauline Darbellay Farhoumand

Lars C Huber

Elisabeth Weber

Christoph Knoblauch

Andreas W Schoenenberger

Sonia Frick

Eliane Wenemoser

Daniel Ernst

Michael Bodmer

Drahomir Aujesky

Christine Baumgartner

Roles

Abstract

Introduction

Materials and methods

Results

Conclusions

Introduction

Materials and methods

Study design and population

Data collection

Outcomes

Statistical analysis

Results

Fig 1. Flowchart: Hospitalists of General Internal Medicine departments included in this study.

Table 1. Characteristics of participating hospitalists.

Table 2. Well-being and job satisfaction among full-time and part-time hospitalists.

Table 3. Adjusted association between part-time vs. full-time work and outcomes based on propensity score models.

Discussion

Conclusions

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Lorenzo Righi

Roles

Author response to Decision Letter 0

Decision Letter 1

Lorenzo Righi

Roles

Acceptance letter

Lorenzo Righi

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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