Is Work–Life Balance a False Hope?

Words matter. While doing research as a National Institutes of Health postdoctoral research fellow, I learned that person-first language (“child with a disability” versus “disabled child”) is more respectful and less dehumanizing. This is true in other contexts, such as “work–life balance.” By placing “work” first, we are allowing society to frame the issue and prioritize work over life. We will never achieve balance if we prioritize work over our lives.

An article on resident unionization in the August 2023 issue of Clinical Orthopaedics and Related Research noted that the contradiction between residents’ desire to connect with patients and provide high-quality clinical care and “the reality of their experiences is a core driver in the increasing rates of burnout throughout training.” The rates of burnout in practicing orthopaedic surgeons tell us that residents are not alone in their feelings. The illusory goal of balance places the onus on orthopaedic surgeons to be more efficient, see more patients, and perform more surgeries. The demands on our time continue to increase. Balance implies a counterweight, but we are ignored when we say the demands are too much.

In the fall of 2017, I felt like the proverbial hamster on a wheel. I was serving as the ortho/spine service line leader. It required spending 30 percent of my time on administrative work, trying to maintain a full elective adult reconstruction practice, and taking 50 percent of the call at a community hospital. I was also working at two hospitals with no physician assistant (doing my own rounding and discharge summaries). I was burned out, and something needed to change. Instead of leaving clinical medicine, I resigned from the service line leadership role and negotiated to reduce my call at the community hospital, with no off-call clinical responsibilities. This began my journey to develop a part-time model that worked for me.

Volunteer activities can add to the burnout of clinical workload. Over the next year, I stepped down as president of the Washington State Orthopaedic Association and handed off the lead role for Clinical Practice Guidelines on the AAOS Evidence-Based Quality and Value Committee to another committee member.

Although I was working part-time, staying with my current healthcare system made it very difficult to change my behavior. I was still performing elective surgery, and I was responsible for my patients even if I was not on call. I also worked as an employed part-time orthopaedic surgeon in another state, but I was not a good fit for the group. At a national meeting, a colleague let me know that the sole orthopaedic surgeon at a critical access hospital in North Dakota had resigned. Having grown up in South Dakota and worked in a rural practice in Minnesota after my fellowship, I was willing to look at the opportunity.

Because the hospital was unable to recruit a full-time orthopaedic surgeon, the leadership was willing to explore alternative employment models to offer scheduling flexibility. By working 130 to 135 days per year, I would be considered a 0.5 full-time equivalent and receive full benefits.

With a partner I recruited, we cover approximately 75 percent of the year. We are both fellowship-trained and are building elective practices. The hospital also employs a full-time nurse practitioner. There is a junior college in town, and I get to provide game coverage. Being employed by the hospital means there is no locum tenens company taking a piece of the pie.

The biggest downside of this model is time away from home, but working in another location allows me to compartmentalize work. When I am home, I am more emotionally present than when I was working full-time and never able to disengage from work duties. I am on call the entire 1 to 2 weeks that I am in North Dakota, but call is much less hectic and easily manageable. Individuals used to an urban environment with vast opportunities and activities may find a rural practice mundane, but I find the slower pace refreshing.

When you are a student, you have time but no money; when you are working full-time, you have money but no time. Working part-time at a rural critical access hospital offered me a balance of income with time to travel and pursue other opportunities. In 2020, I completed my training as a surgeon coach. I am coaching early-career surgeons (orthopaedic surgery, plastic surgery, and ophthalmology). I have also been able to reengage in professional volunteer work, serving on the Ruth Jackson Orthopaedic Society Mentoring Committee. Coaching and mentoring are helping me recover from burnout. Additionally, because I am practicing general orthopaedics in a rural community, I volunteer as an American Board of Orthopaedic Surgery oral examiner to diversify the examiner pool.

In 2022, my wife and I walked the Camino de Santiago from Lisbon, Portugal, to Santiago, Spain. This year, we spent 3 weeks touring Switzerland with our former high school foreign exchange student. My spouse and I have built fences and a loafing shed for our goats. I helped put a new deck on our home. These are activities I previously never had the time or energy for while I was working full-time.

Aside from the part-time opportunity I was able to secure, another alternative part-time model is as an orthopaedic hospitalist. The model at my previous hospital had three orthopaedic surgeons working as hospitalists, each covering 10 days per month. They shared call with other orthopaedic surgeons and assumed care of trauma patients the next morning if they were not on call. Clinic was limited to postoperative and nonoperative fracture care. Typically, hospitalists do not perform elective surgery. If the hospitalists are employed by the hospital, they may be able to negotiate a higher salary without a locum tenens company.

The locum tenens model, where a surgeon is contracted to work in a particular practice for a prespecified amount of time, offers schedule flexibility, and you can accept or decline positions based on your preferences. Because locum tenens orthopaedic surgeons are independent contractors, there are tax benefits for work-expense deductions.

The flexibility of part-time employment can provide much more than opportunities and experiences when you are not working. Ed Sullivan said, “If you do a good job for others, you heal yourself at the same time, because a dose of joy is a spiritual cure. It transcends all barriers.” Providing orthopaedic care in an underserved critical access hospital has provided balance in my life and cured my burnout, for which I will be forever grateful.

Gregory A. Brown, MD, PhD, FAAOS, is a general orthopaedic surgeon at a critical access hospital in Williston, North Dakota.