INTRODUCTION. During their careers, physicians may have periods of clinical inactivity for a variety of reasons. Concerns have been raised about the impact of clinical inactivity on the growing physician workforce shortage. It is unknown how these periods of clinical inactivity impact physician competence and patient safety. With this study we sought to determine the rates of clinical inactivity, the duration of periods of inactivity, professional activities during those periods, and the perspective of pediatricians regarding future requirements of competency for return to clinical practice.
PATIENTS AND METHODS. A random sample of 6757 American Board of Pediatrics diplomates aged ≤65 years received a structured questionnaire by mail. The survey explored the prevalence of and reasons for clinical inactivity and perspectives on the return to clinical practice. Clinical inactivity was defined as a period of absence of ≥12 months from any direct or consultative clinical care.
RESULTS. The response rate was 74%. Of respondents, 88% (n = 4176) were currently engaged in pediatric clinical care. Twelve percent (n = 554) indicated that they had experienced a period of clinical inactivity lasting ≥12 months. Women were more likely than men (16% vs 7%) to have had periods of clinical inactivity. Controlling for gender, generalists were no more likely than subspecialists to report a past period of clinical inactivity. More than one third of the respondents (n = 1672 [36%]) agreed that pediatricians who return from clinical inactivity after >1 year should undergo a competency evaluation.
CONCLUSIONS. Almost 1 in 8 pediatricians has suspended clinical care for ≥1 year, and a similar proportion of respondents were inactive at the time of our survey. Currently, all of these physicians may maintain both their licensure and board certification during these periods. The impact of clinical inactivity on patient care and patient safety is unknown.
During their careers, physicians may have periods of clinical inactivity for a variety of reasons. Physicians may choose to take a leave of absence from clinical activity to provide care for children or other family members, accommodate new or increased administrative responsibilities, or undertake a sabbatical. Few data exist regarding the rates of clinical inactivity among physicians, duration of such periods, and type or scope of professional activities during those intervals.1 A recent survey conducted by the American Academy of Pediatricians of 1158 pediatricians over the age of 50 years found that 22.0% of women and 6.5% of men had taken an extended leave of absence of ≥6 months from clinical practice at some point during their careers.2 There are no data describing whether clinically inactive physicians maintain their licensure and/or board certification during these absences.3,4
Concerns have been raised about the impact of clinical inactivity on the apparent growing physician workforce shortage.5–7 Clinical inactivity is also of growing importance as patient safety issues have become more prominent in the minds of the public, as well as among professional organizations. Studies have demonstrated that physicians with lower procedure volumes or less experience may be more likely to have poorer outcomes from the care they provide.8–16 This may also be true for physicians who return to the practice of medicine after prolonged periods of clinical inactivity.
These concerns have recently been the focus of deliberations by the Federation of State Medical Boards (FSMB). The FSMB convened a Special Committee on Maintenance of Licensure to study how states may ensure that licensees remain competent over the course of their professional careers.17 To determine the rates of clinical inactivity, the duration of periods of inactivity, professional activities during those periods, and the perspective of pediatricians regarding future requirements of competency for return to clinical practice, we conducted a study among a national random sample of pediatricians.
The American Board of Pediatrics (ABP) maintains a database of all physicians who are certified as generalists or subspecialists within the field of pediatrics (N = 88 041). The list includes those who have ever been board certified and whether their general or subspecialty certification status is permanent, time limited, or expired. A permanent certificate holder earned his or her certification before 1988, when certificates were awarded without a time limit. All subspecialists must have had a general pediatrics board certification before certification in a subspecialty. To characterize the practices and quantify the rates of clinical inactivity among pediatricians, we selected a sample of 6757 ABP diplomates aged ≤65 years with a US mailing address (N = 56 195). The total sample included a 10% random sample of pediatric generalists with permanent certificates (n = 1062), a 10% random sample of pediatric generalists with time-limited active certificates (n = 3025), a 50% random sample of pediatric generalists with expired certificates (n = 1176), a 10% random sample of pediatricians with ≥1 permanent subspecialty certificate (n = 232), a 10% random sample of pediatricians with ≥1 time-limited active subspecialty certificate (n = 1045), and a 100% sample of pediatricians with expired time-limited subspecialty certificates (n = 217).
In collaboration with the ABP Research Advisory Committee, we developed a structured questionnaire to be administered by mail. The survey contained 25 items and was designed to be completed in ≤10 minutes. The survey explored the incidence and prevalence of clinical inactivity among pediatricians, reasons for clinical inactivity, and perspectives on the return to clinical practice. Clinical inactivity was defined as a period of absence of ≥12 months from any direct or consultative clinical care. This time period was selected to ensure that those in an academic setting, who may attend 1 month per year, were classified as clinically active. The questionnaire was composed of a mixture of fixed-choice, Likert-scale, and open-ended questions.
Survey packets containing a personalized and signed cover letter, the survey instrument, a business reply mail envelope, and a $5 bill as an incentive to complete the questionnaire were sent in April of 2007 via priority mail to the 6757 physicians in the sample. Two additional mailings were sent to nonrespondents in May and June 2007. The second and third mailings were sent via first-class mail, and contained a personalized cover letter, the instrument, and a business reply mail envelope.
Frequency distributions were calculated for all of the survey items. Additional analyses on the impact of gender, specialty, and academic appointment (ie, full-time, part-time, adjunct, or none) on the prevalence of and plans for clinical inactivity were conducted. χ2 statistics were used to determine the level of association between the outcome variables and the predictor variables. A P value of <.05 was considered statistically significant. The study was approved by the University of Michigan Medical School Institutional Review Board.
Of the 6757 survey packets mailed, 310 were returned as undeliverable by the postal service, and 4756 physicians returned the survey. This yielded an overall response rate of 74%. Of the 4756 respondents, 90 physicians were ineligible because they had changed disciplines or were >65 years old. Thus, the final sample for analysis was 4666.
Among eligible respondents (n = 4666), the response rates of generalists (n = 3586 [72%]) and subspecialists (n = 1080 [76%]) were similar. ABP diplomates who held permanent certificates (n = 913 [75%]) and diplomates who held time-limited certificates (n = 3093 [78%]) also had similar response rates. However, diplomates who held expired time-limited certificates had a lower response rate when compared with the other groups (n = 660 [52%]). Because not every pediatrician responded to every question, the total number for each question may differ slightly because of missing responses.
More than half of the respondents were women (54%), and 69% were between 36 and 55 years old. Most respondents were employed full-time (79%) and primarily focused on direct patient care (89%). Of those who did not consider patient care to be their primary activity, research (39%) and administrative roles (34%) were most common (Table 1).
Generalist respondents were more likely than subspecialists to be female (58% vs 42%; P < .0001). Therefore, we have presented these data controlling for gender. We found no significant differences in any analyses between male generalists and male subspecialists. Full-time faculty respondents were more likely than non–full-time faculty to be men (52% vs 44%; P < .0001) and subspecialists (56% vs 14%; P < .0001).
Current Status of Clinical Activity
Of our eligible respondents, 89% (n = 4176) were engaged in direct and/or consultative pediatric clinical care. Of the remaining 11%, 6% (n = 272) reported that they may resume pediatric clinical care at some time in the future, 4% (n = 170) did not plan to return to clinical care, and 1% (n = 46) were retired.
Among pediatricians surveyed, 12% (n = 554) indicated that they had experienced a period of clinical inactivity lasting ≥12 months. Women were more likely than men (16% vs 7%; P < .0001) to have had periods of clinical inactivity. Generalists were no more likely than subspecialists to report a past period of clinical inactivity of ≥12 months (Table 2). Generalists or subspecialists with expired certification were more likely than physicians with active or permanent certification to report a period of clinical inactivity (32% vs 7% vs 13%; P < .0001).
The majority (80%) of these physicians had only experienced 1 period of inactivity at the time of the survey. The duration of the longest period of clinical inactivity varied among respondents, with 23% reporting an inactive period of 1 to 2 years, 25% reporting an inactive period of 2 to 5 years, and 23% reporting an inactive period of 5 to 10 years.
The most commonly cited reason by women for absence from clinical activity was to provide care for children (n = 220 [55%]), whereas men were most likely to report a change in career to a nonclinical position. Among women physicians, generalists were more likely than subspecialists to have had periods of clinical activity to provide care for children or family members (59% vs 32%; P = .0014), whereas subspecialists were more likely to have been clinically inactive because of a change in career (39% vs 16%; P = .0014; Table 3).
The majority of respondents reported that they had no professional activity during their leave of absence from clinical pediatrics (n = 293 [54%]). Less than one fifth of respondents indicated that they switched to administrative (14%) or research (14%) positions during their period of clinical inactivity. Differences were seen according to gender and faculty status (Table 4).
A majority of respondents did not register for an inactive medical license during their period of clinical inactivity (n = 312 [57%]). The most common reason was the respondent's preference to maintain an active license at all times (55%), whereas 15% of respondents were unaware of this option. More than half of the respondents (n = 286 [52%]) maintained active board certification during their period of clinical inactivity, whereas almost one third (n = 170 [31%]) allowed their board certification to expire.
The majority of respondents (n = 3994 [86%]) reported that they were unlikely to take a leave of absence from clinical activity in the future. Only a small difference was seen by gender, with 7% of men and 8% of women stating that they were likely to take a leave of absence in the future. Male and female generalists were no more likely than subspecialists to report plans for a future leave of absence from clinical activity of ≥12 months.
Respondents who had experienced a period of clinical inactivity at the time of the survey were more likely to report plans for future inactivity (30% vs 5%; P < .0001) or were unsure about their plans for future clinical inactivity (15% vs 5%; P < .0001). Among those respondents whose future plans may have included a period of clinical inactivity, more than one third planned a potential leave to make a career change to a nonclinical position (n = 222 [36%]). More women than men (40% vs 6%; P < .0001) and less full-time faculty (18% vs 30%; P = .02) reported that they may take a leave of absence from clinical practice to provide care to their children.
Survey respondents were asked to indicate the extent to which they agreed or disagreed with a series of 5 statements regarding physician licensure and reentry into clinical practice. The majority of respondents agreed that licensure policies should be standardized across states (n = 4364 [95%]) and that all states should offer an inactive medical license (n = 3838 [86%]). Sixty percent (N = 2761) of respondents believed that the ABP should require pediatricians with 2 years of clinical inactivity to complete a reentry program as part of maintenance of certification. Pediatricians who had been clinically inactive were less likely than those who had not been inactive to agree that a reentry program should be required for pediatricians who have been inactive for >2 years (49% vs 62%; P < .0001). More than a third of respondents (n = 1672 [36%]) agreed that pediatricians who return from clinical inactivity after >1 year should undergo a competency evaluation (Table 5).
The most important finding from our study was that ∼1 in 8 pediatricians has suspended clinical care for ≥1 year over the course of their careers. A similar proportion of respondents were clinically inactive from pediatric care at the time of our survey. This proportion was comparable to the findings of the American Academy of Pediatricians survey of physicians >50 years of age.2
More than half of the respondents reported that they maintained their active license and/or board certification during these periods. Although some state medical boards require competency evaluations for lapsed or inactive medical licenses, to our knowledge, competency assessments are not required for physicians who maintain an active license.18,19 This is significant because of the unknown impact of clinical inactivity on patient care and patient safety. Although previous literature has documented poorer quality of care among some physicians who see lower volumes of patients, no study has explored the patient care implications of extended clinical inactivity.8–16 However, it is reasonable to consider that the findings of physicians with lower patient volumes may apply to those who see no patients for an extended period of time.
Recently, the FSMB Special Committee on Maintenance of Licensure developed a model policy for state regulations that would require physicians to demonstrate their continuing competence on a periodic basis.20 Respondents were mixed on the need for such assessments: although 23% believed that physicians should never be required to undergo competency evaluations regardless of the duration of clinical inactivity, a third of the respondents believed that physicians returning to clinical practice after 1 year of clinical inactivity should be evaluated before their return. No data exist to inform this debate or our understanding of the slope of degradation of clinical skills during a period of inactivity. There are only data regarding the association of a volume of clinical care with clinical outcomes. Currently, most state boards use a 2-year time frame when considering requirements for licensees who seek to return to clinical practice.
When queried whether the ABP should require a special reentry program to maintain certification after ≥2 years of clinical inactivity, 60% of respondents supported such a program, including 49% of those who had experienced a previous period of clinical inactivity. Currently, the ABP Maintenance of Certification Program does not require clinical activity but accommodates those who are not clinically active with specially designed components. A clearer and more transparent designation of board certification to differentiate those who are from those who are not clinically active may be appropriate. All 24 boards of the American Boards of Medical Specialties have now agreed to develop plans for such designations.
We also found gender differences associated with clinical inactivity. Similar to the findings of previous studies, we found that significantly different proportions of men and women pediatricians have periods of clinical inactivity and for markedly different reasons.3,4,21 Because women make up an increasing percentage of pediatricians, this variation may have significant workforce implications in the future.
Although women are more likely to pursue careers in general pediatrics over subspecialty practice,22 the proportions of female generalists and subspecialists who take extended leaves from clinical activity are comparable. The biggest differences were seen in the primary reasons for clinical inactivity and the primary professional activity conducted during those periods. Female physicians in general practice were more likely than subspecialists to report taking periods of clinical inactivity to care for children and to have no professional activity during those periods.
Areas for Future Research
These findings suggest several areas for future research. One important issue is the extent to which extended periods of clinical inactivity, as well as the duration of these periods, impact patient care and clinical outcomes. Periodic re-examination of the prevalence of inactivity is also warranted to assess changes over time.
Clinical inactivity is a significant phenomenon in pediatrics for regulatory, patient safety, and workforce issues. The issues raised from this study will need to be addressed by governmental agencies and professional organizations that are charged with acting on behalf of the public to ensure safe care.
- Accepted May 30, 2008.
- Address correspondence to Gary L. Freed, MD, MPH, University of Michigan, 300 N Ingalls, Building 6E08, Ann Arbor, MI 48109-0456. E-mail:
The authors have indicated they have no financial relationships relevant to this article to disclose.
What's Known on This Subject
During their careers, physicians may choose to take a leave of absence from clinical activity. Few data exist regarding the rates of clinical inactivity among physicians and the type or scope of professional activities during those periods.
What This Study Adds
This study provides national rates of clinical inactivity among pediatricians. We found that ∼1 in 8 pediatricians has suspended clinical care for ≥1 year.
- ↵Mulvey H, Jewett E. Physician reentry into the workforce. In: Physician Reentry Into the Workforce Project. Elk Grove Village, IL: American Academy of Pediatrics, Division of Workforce and Medical Education Policy; 2008
- Hillner BE, Smith TJ, Desch CE. Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care. J Clin Oncol.2000;18 (11):2327– 2340
- ↵Federation of State Medical Boards. Maintenance of licensure. Available at: www.fsmb.org/m_mol.html. Accessed May 22, 2008
- ↵Pennachio D. Finding a Job: Returning to Practice. North Olmsted, OH: Medical Economics; 2005:74– 78
- ↵Federation of State Medical Boards. Federation of State Medical Boards Takes Interim Steps Toward Maintenance of Licensure Model Policy. Dallas, TX: Federation of State Medical Boards; 2008
- ↵American Board of Pediatrics. Workforce Data. Chapel Hill, NC: American Board of Pediatrics; 2006
- Copyright © 2009 by the American Academy of Pediatrics