A leave of absence may be prompted by the birth of a child, the death of a parent or your need for a break. Regardless of the catalyst, a leave of absence is an emotionally charged event in a physician's career: Doctor-patient relationships are suspended, partners are burdened and financial security is at risk. Creating a leave plan to minimize financial risks, maintain strong patient and partner relationships and protect your hospital privileges is key to making a positive return to your practice. This article discusses the steps you should take to make your leave of absence successful. The advice given here is intended primarily for employed physicians who practice in medium and large groups and who have the opportunity to do some planning prior to taking a leave of absence.

1. Do your homework

The first step in planning your leave is to learn your employer's rules regarding absences. You should also check with any hospitals, universities or other institutions with which you are affiliated because they may have additional restrictions. The human resources department should be able to help answer your questions.

Rules may vary depending on the type of leave (e.g., parental, armed services or sabbatical), the length of time that you have been with your current employer and how long you plan to be off work. The Family and Medical Leave Act may apply in certain circumstances.¹ To use this benefit, you must give 30 days' notice for planned absences. In medical practices, a minimum of three months' notice may be needed to allow ample time for blocking appointment schedules and rearranging call schedules.

You should also determine how your leave will affect your benefits:

• Consider how your employer will classify your leave (e.g., vacation leave or sick leave). How the leave is classified may affect your pay and benefits such as insurance premiums (health, disability and malpractice) and retirement contributions.

• Find out whether your leave will affect how much you have to pay for your benefits while you're away; you may want to determine whether you're eligible for coverage through the insurance policy of your spouse or significant other.

• If your paycheck is deposited directly into your bank account or if you have premiums or other payments automatically withdrawn from your account, make sure you understand how these will be handled while you're away and upon your return.

• If you're a faculty member in an academic practice, the way your leave is classified by your employer may affect your eligibility for tenure promotion. Check with your promotion committee about the rules.

2. Make your request known

Your employer may require that you file a formal leave request. If so, do this as soon as possible. Several levels of review may be needed before your leave of absence is approved. Be sure to keep files of all correspondence regarding your leave to document the required authorizations.

Although your leave of absence may be for personal reasons, don't underestimate the need to discuss with others the impact that your leave will have on them. Your absence will likely increase the workload of physicians and other clinic team members. Including them in the planning for your leave will likely increase their acceptance of the plan. Talk openly with your employer and partners well in advance of your leave to allow time for developing creative staffing solutions. The practice has many possibilities for temporarily filling your vacancy: close the practice to new patients until you return; hire a locum tenens physician; arrange group visits; add a midlevel provider or clinical support staff; or increase the clinical hours of one or more physicians in the group. Your nurse or medical assistant will be invaluable in helping the covering physicians manage your patients while you are gone; make sure you communicate your expectations as appropriate.

Be sure to discuss with your employer your unique responsibilities that may not be easily assumed by the persons covering while you are away. For example, are you the family medicine representative to the hospital board? Do you teach colposcopy to residents? Is a student scheduled to shadow you in the clinic? Are you instrumental in ordering equipment and supplies for the group? If possible, initiate some cross-training before you leave.

3. Arrange call coverage

Arranging for call coverage deserves as much attention as you can give it; your hospital privileges may depend on it, and covering your call duties may be the most diffi cult burden for your partners. You may be expected to make up any call you miss as a result of your leave. You should consider taking extra call before your leave. This may be a better alternative than making up call upon your return, particularly if you anticipate that child care responsibilities or recovery from surgery might make call more challenging. Another option is to pay another physician to take call in your absence. Be sure to consider whether holiday call requires special arrangements.

If the physicians in your practice cannot take extra call, you could consider recruiting another group of local physicians to cover for you in exchange for payment or reciprocity. Your agreement should be detailed in writing.

4. Notify your patients and arrange to meet their needs

Let your patients know about your leave in advance by telling them in person or sending them a letter. The news may worry some, but it gives them flexibility in determining how to find care in your absence and the reassurance that you are keeping them informed.

Telling your patients in advance also allows time for you to develop individual care plans for patients who need them. Schedule office visits and authorize medication refills in advance, if possible. In the weeks before you leave, adjust your schedule to accommodate increased administrative work and longer office visits. You may want to consider referring new patients to other clinicians during this time.

It may be appropriate for some complex patients to be assigned to specific physicians during your leave. These individuals could meet with their new physician in advance of your leave to discuss their needs.

Patients who may benefit from an advance visit are homebound patients, nursing home residents, obstetric patients, patients who take narcotics for chronic pain, patients with multiple medical problems, high-need patients and others you see frequently.

Additionally, you should consider scheduling these patients for an office visit a few days before you leave to review care plans and attend to last-minute concerns.

A large number of medical errors occur during handoffs.² Because this risk may be heightened during your absence, make sure your group has and understands procedures for identifying and reporting abnormal labs, radiology studies and consultations. Ensure that patients know that no news is not good news. Empower them to seek out results if they do not receive prompt follow-up after tests or referrals.

5. Delegate in-box management

All communication channels should be accounted for in your leave plan (see “Getting the word out about your leave”). Persons who contact you regarding patient care need to be informed of your absence and told who is receiving your messages. Your in-boxes do not have to be covered by the same individuals covering your call; distributing this work between two or more people may be more practical and help prevent burnout.

It may be possible for you to make arrangements to pick up mail and other items from your practice or have the practice forward your mail to you. Be aware that the U.S. Postal Service will only forward personal mail for 60 days. Depending on how long you anticipate being away, you may want to file change of address forms for medical journals, state licensing boards, the federal (and state, if applicable) Drug Enforcement Agency and professional organizations including the AAFP and the American Board of Family Medicine.

6. Protect your hospital privileges

Because of the challenges associated with maintaining hospital privileges, you should give some thought to the scope of practice you would like to return to after your leave. For example, a personal health concern may motivate you to give up inpatient care. If you don't anticipate making any changes, you'll want to ensure that your privileges won't lapse while you're on leave. Regaining lost privileges is much harder than maintaining privileges, and leave time compounds the difficulty by diluting procedural experience. A period of proctored procedures or retraining may be needed.

Ask the hospital office staff for information on the requirements for maintaining privileges (including continuing professional development requirements) and the dates by which you must renew. Your clinic may have additional privileging requirements for procedures like vasectomy, flexible sigmoidoscopy and colposcopy.

7. Keep in touch

During your leave, it is important to stay in contact with your practice. Be sure to keep up with operational changes at your clinic and hospital. One way to accomplish this is by requesting copies of meeting minutes. Don't forget to submit preferences for upcoming call and rounding schedules as appropriate and requests for vacation time. Maintaining regular contact with your office manager is a good idea.

Staying in touch with patients while you are away requires careful consideration. You may be tempted to manage patient care via telephone or the Web, but if you are not physically well enough to make clinical decisions, if you are not regularly available or if your malpractice insurance is compromised by your leave status, your good intentions could have devastating consequences.

8. Prepare for your return

Returning from leave may prompt feelings of inadequacy, guilt or frustration, and your colleagues may be overworked or resentful of your time off.³ These challenges may inhibit your productivity. The following strategies will help you prepare for a fully functional return:

• Notify human resources of your return to restart your paycheck and benefits.

• Make sure your passwords, badges and door combinations work.

• Consider a reorientation session, which could be as simple as a conversation with your clinic manager about procedural updates or as in depth as a continuing professional development course to refresh your knowledge.

• Speak with computer support personnel about whether any software or hardware upgrades are needed and to reestablish access to e-mail, electronic health records and pagers as necessary.

• Meet with the physicians who cared for your complex patients and discuss how to reestablish care.

• Speak with hospital staff about hospital operations, privilege requirements or bylaw changes that occurred during your absence.

• Review practice procedures on coding, billing and medical records.

• Consider your scheduling needs. Do you want to try open-access or modified-wave scheduling? Depending on the reason for your absence, do you now need time for breast milk pumping, longer appointments for physicals or fewer days in clinic so you can attend physical therapy? Even if you are not permanently redesigning your schedule, you will need time free of patient visits to attend to non-urgent medical concerns, patient phone calls and medication refill requests that accumulated in your absence.

• Prepare a newspaper advertisement or a letter of reintroduction to patients and the medical community if appropriate.

9. Say thank you

A well-constructed leave plan will ease your mind and the minds of your patients and partners. Working through the details of your responsibilities with your partners helps minimize errors and feelings of resentment, helps you enjoy your time away and makes your return a smooth one.

And don't forget to thank your colleagues for making your leave possible.