Painful Choices: The Price of Reentering Medicine
Everybody likes to take a break, but what happens when it's time to get back to work and you've lost your key to re-entry?
It turns out that getting back in the game is expensive, time consuming, and sometimes nearly impossible. So before you take a hiatus from medicine, ask yourself -- can you afford it?
What Path to Re-entry?
Christine Stone, MD, hasn’t practiced internal medicine in 14 years. She now lives in a medically underserved urban area of Colorado, where she would like to start providing care. "Everyone is screaming for primary care docs right now, [but] people don’t know what to do with me," she told MedPage Today in an interview.
Stone approached administrators at the University of Colorado School of Medicine for help, to no avail. "There's no category for a doctor like you. We would have to change the bylaws to help you," she recounted.
"I couldn't get good advice," said Stone, who has been chronicling her re-entry struggles in a blog. "Every single state has a different policy on re-entry," she said.
Colorado has a one-time, 3-year "re-entry medical license," and the state medical board directed her to the Center for Personalized Education for Physicians (CPEP), a program that could help her apply for a re-entry licence, and monitor her progress. But, after getting her license, and successfully passing the board exam, she had to find a mentor in the community.
Stone contacted rural health programs and the department of public health, thinking primary care clinics would be happy to have an extra set of no-cost hands on deck. But again, Stone said, "people didn't know what to do with someone like me."
With her house on the market, a year out of work, and after spending more than $14,000 on her road to re-entry, Stone thinks she may have found someone willing to preceptor. She thinks.
Congressional Action
"Right now there isn't any systematic approach to re-entry into clinical primary care," Rep. John Sarbanes (D-Md.) told MedPage Today.
Sarbanes worked with the American Medical Association, the American Academy of Pediatrics, the Federation of State Medical Boards (FSMB), and other groups to bring the Primary Care Physician Re-entry Act before Congress.
"We have to invest in the work force," Sarbanes said. "This demonstration project would create a new pipeline into primary care."
Graduate medical education is structured to train new doctors; not retrain returning physicians, Humayun J. Chaudhry, DO, MS, president and CEO of FSMB, said in an interview. "GME doesn't cross over. The money for training isn't there."
FSMB is backing the bill along with the AMA, the AAP, and others.
If the bill passes, organizations and medical schools can apply for grant funding, and design a program for re-entry training. And, malpractice insurance, a major expense for re-entry physicians at upwards of $5,000 per year, will be covered through the Federal Tort Claims Act, a bill backed by both the AMA and the Republican Majority.
The Physician Reentry Act is tied to the Tort Claims Act, which Sarbanes referred to as the "consequential part" of the initiative to gain bipartisan support. However, the Federal Tort Claims Act has repeatedly failed to pass.
Chaudhry applauded physicians' desire return to practice to fill the physician shortage gap "that's great, but you still have to know medicine and know the skill sets behind it," he said.
"I don't want to discourage anyone, but at the same time, I think there should be an understanding that it might not work out for everyone," Chaudhry said. "It's [re-entry] a complicated issue."
Negotiating the Cut-Off
Tara Bishop, MD, left medicine after the combination of being disenchanted by a fellowship in palliative care, and learning she was pregnant with her second child.
But after a year, she knew she wanted to return to the workforce, and then spent another year figuring out a game plan.
"I think the 2-year mark is pretty acceptable. People don't wonder if you've lost your skills. [And] there weren't licensing and certification issues," Bishop, who now splits her time between clinic and health services research in the Weill Cornell Physicians group in New York City, told MedPage Today in an interview.
However, she did encounter some opposition from preceptors. "I had a few people who said to me 'Look, you left medicine. I don't know if you're serious about what you're doing.' And a few people didn't want to be my mentor as a result of that," she said.
Chaudhry confirmed why Bishop didn't hit too many administrative road blocks. "The vast majority of state medical boards don't see a 2-year gap as a problem," he said.
And Chaudhry noted that taking a gap isn't out of the ordinary, "It's almost a common trajectory that may occur in your career. Don't think this isn't going to happen to you, Chaudhry advised. "It may. But prepare for it."
Rocky Road
Once Stone found CPEP, things didn't get much easier. "I thought, this place [CPEP] was going to help me get back on board, but really they're more of an oversight and monitoring organization," she said.
CPEP performs testing, unearths knowledge gaps, designs custom education programs, and tracks progress, but as far as retraining, matching her with a mentor, or job placement, Stone has been on her own. "And, of course, that's the most challenging bit of this."
A year and-a-half into the process, Stone is now a board certified internist who still lacks enough time and experience in clinical preceptorship to practice on her own. She will begin the monthly monitoring program with CPEP, which will continue as long as they see fit. "They get to decide when I'm ready to go out on my own," Stone said.
Stone finally managed to find a practicing physician in an outpatient clinic to shadow 1 day a week to gain clinical skills. But, that physician will not be able to commit to the bi-monthly, 2-hour mentoring sessions CPEP will require for Stone's progress.
Stone is worried she'll lose her re-entry license, which is good for 3 years, and not renewable. "It's very possible that I'm going to time-out," she said.
Get Out the Checkbook
At this point, Stone has paid $7,750 for her state board clinical competency exam to get her re-entry license, and the ABIM's Maintenance of Certification exam cost her $1,675. The CPEP monthly monitoring fee ranges from $625-925 per month depending upon the specialty.
"I've been unemployed now for over a year. I'm throwing my last asset at this re-entry process," she said.
In hindsight, Stone said, "I wouldn't have just taken the plunge. University-based programs offer a more structured approach, but they're very expensive. [On the other hand,] it would have saved time. Either way, I think it's the same amount of money going out."
"I imagine I'll be working for free for a while," Stone said. "It's kind of like where will have me [is] what's open to me."
Altogether, Stone estimated the process will have lasted as long as her initial residency training.
The Programs
There are a handful of re-entry and retraining programs across the country: CPEP, Drexel University in Philadelphia, the Physician Retraining & Reentry program in collaboration with the University of California San Diego, Cedars-Sinai Medical Center in Los Angeles, and Texas A&M KSTAR in College Station, Texas. And they each have their own advantages and disadvantages.
“For us, you do not have to have a license,” Nielufar Varjavand, MD, program Director, Drexel Medicine Physician Refresher/Re-Entry Course, told MedPage Today.
And Drexel doesn't have the same problem of CPEP when it comes to matching trainees with preceptors, because they simply match them with Drexel faculty. But, that means physicians have to physically be in Philadelphia for the clinical training portion of the program.
Varjavand said the enrollment numbers in the Drexel program have remained steady over the years. "[But] this is not the solution to the workforce issues," she said.
From 2006-2010, the Drexel program, which has been around since 1968, successfully graduated 36 physicians. "There don't seem to be gobs of people who are dying to come back to medicine," she said.
With CPEP, physicians don't have to relocate, but then again, they also have to find their own preceptorship.
CPEP has national reach, Beth Angel, assistant manager of education at CPEP, told MedPage Today in an interview. A member of CPEP's public relations team was present during the interview. They've been around for 13 years, but Angel said they maintain an enrollment below 30 students per year.
Both the UCSD and the Cedars-Sinai programs offer mentoring onsite like Drexel, but they only work with physicians who have maintained an active medical license. And at UCSD, they only retrain in primary care.
According to David Bazzo, MD, Chief Medical Officer, Physician Retraining & Reentry, and faculty at the University of California San Diego, Physician Retraining & Re-entry Program, since the start of the program in mid-2013, only five to 10 physicians have completed the program. The cost of the program is $8,500.
Regional Variations
Unlike Colorado's medical board, California's board doesn't have a re-entry practice or license designation. However, at least six states require physicians who have been out of clinical practice for more than 24 months to go through a physician re-entry program (Bower et al). And according to the AMA, more than 20 states do not have a re-entry practice.
Angel said that CPEP did a lot of lobbying to get a re-entry license designation in the state of Colorado. "That way they're able to provide patient care, can be on insurance panels, and carry malpractice insurance," she said.
"Colorado was the first state to have a re-entry license, and it's unique to this state. Other states provide a restricted license, which has a stigma. The re-entry license makes it so that you don't have to report a lower-level license," Angel said.
And According to Angel, Florida and Louisiana are giving tax breaks to preceptors for re-entry nurses and NPs.
"There needs to be a national path, and not individualized by state," Angel said.
Varjavand said that the re-entry process is much more streamlined in Canada and Europe. "It's far more established," she said.
The Planned Hiatus
Chaudhry said that young physicians should plan ahead even if they don't think they'll ever take time off, and stay current during any breaks. "Even if you're not in clinical care for whatever reason, staying current is so vital because medicine moves ahead so quickly. It's hard to keep up with the medications, let alone the diagnostic approaches, the clinical guidelines, the algorithms, and [technology]," he said.
In a 2008 AMA survey of nearly 5,000 physicians under 65 years of age, 38% of respondents said they had left medicine for health reasons, which was listed as the top reason for leaving practice.
And despite what the AAP has been saying about women leaving the physician workforce to raise families, the data suggests more men leave. And that doctors leave for all kinds of reasons.