By Dr. Margaret Curtis, WCI Columnist
[Editor's Note: Readers of The White Coat Investor might know our columnist Dr. Margaret Curtis as a pediatrician, half of a dual-physician household, and the proud owner of a sidewalk sofa. She has been around long enough to have seen and experienced all kinds of professional challenges that physicians face. As her alter-ego, Auntie Marge, she shares opinions and gives advice. If you have questions about your work or financial life, Auntie Marge is here for you. The following is a real question posed to a Facebook group, with identifying details changed. This question was not directed at Auntie Marge, but she's going to answer it anyway.]
“I am a hospitalist on the East Coast. I am a W-2 employee, and I've been at this position since I finished residency. Like every other hospital, we are understaffed, and my group in particular has been short at least 1.5 FTE (really, we could use at least another 2.0 FTE). Between understaffing, the usual sick days, vacations, etc., we are stretched way too thin.
Years ago, our group agreed to 24-hour shifts. When I started, we would alternate two shifts in one week, then one shift the next. This felt like enough time to recover between shifts and have some semblance of work-life balance. Now, we are regularly working 24 on/24 off/24 on. In other words, after working all night, I drive home, nap, try to function for a few hours, sleep poorly, and wake up early the next morning to do it all again. This has been my work life for over a year with no end in sight. I don’t know how much more I can do this.
I met with the admin to discuss this situation. I told them that I am worried I am going to fall asleep on my drive home after being awake for 24 hours straight. They did not seem concerned, and they have done nothing to change our schedule.
Please don’t tell me to leave my job. I love my colleagues, and I am fairly compensated. My wife wants to stay in this area, because we are near her family. How can I convince the administration that this schedule is unreasonable?”
You won’t be able to convince your employers to change anything about this situation, because right now, it is working just fine for them. Patients are cared for, and quarterly productivity targets are met. If you get in a car accident on the way home, the liability will be entirely yours. Stop believing that the hospital administration shares your priorities (and before you say that I am being unfair to people who run hospitals: trust me, I know what I’m talking about).
None of this is to say that you have no leverage in this situation, because you do. Physicians are difficult and expensive to replace, especially for a work schedule like yours. If you leave and your hospital can't find a permanent new hire, it will have to use locums, which might cost 50% more. If you leave and the other hospitalists decide to head for the exits as well (and given what you have described, this sounds likely), the hospital will have to replace an entire department. The specialists who rely on your group to admit their patients to your service won’t be happy with any of this. Your hospital needs you as much as—or more than—you need the hospital.
More information here:
You Should Invest Like a 50-Year-Old Woman
Actual Money Fights We’ve Had (and How We Solved Them)
Leaving a Difficult Work Situation
A great deal of the advice for physicians in difficult or toxic work situations is “leave, right away,” but we all know that changing jobs is not that easy. You may have a non-compete clause or other restrictions on where you can practice, and you will have to find a new position in your field. There's also credentialing, licensing, etc. You will probably have to give 4-6 months notice at your current job, so even if you decide to leave, you will have to make it work in the short term.
Even though “leave, right away” might be the best solution, I won’t say that. Not yet. Instead, this is what you should do next:
Figure Out How to Make This Job Work for You
This should include protecting your medical license. Your license is your single most important asset. You didn’t mention unsafe working conditions, but it is common in understaffed practices that physicians and other clinicians are asked to practice outside their scope or without proper support staff. If you are asked to do anything that you feel does not meet standard of care, refuse and be loud about it. Send emails up the chain of command (following whatever grievance procedure is in place, which will be in your employee handbook). Send these emails to your own personal email as well as your work email. This will create a paper trail and hopefully will give you some legal protection in the event of a bad outcome.
Review Your Contract and Your Personnel File
It will be worth the few hundred dollars it costs to have an employment lawyer review your contract and tell you what options you have. A lawyer or internet search can tell you the laws governing the release of personnel files in your state (here, I did it for you). Check to make sure there is nothing in your file that shouldn’t be, and check again after you have raised your concerns. Yours would not be the first hospital to put negative or incriminating language in your file as retaliation for speaking up about your employment or operational issues.
Talk to Your Colleagues
They are probably as miserable as you are, and if so, you have more power as a group than as individuals. If they aren’t willing to make waves, you will have to do it alone. When I was working in a hostile and totally bonkers job, I told all my colleagues what I planned to do and that I would support them in doing whatever they felt was in their own best interest—and then I did just that. I stayed friends with everyone in that group, even those whose interests didn’t align with mine. At the time I wrote this, I am still at the job, and it has gotten better because many of us pushed for change.
Ask for What You Want
Ask for the schedule you want and the salary you want. You say you are fairly compensated, but I doubt it. Unless you are paid for your actual FTE and at the high end of MGMA (to compensate you for the added difficulty of 24-hour shifts), then you are being taken advantage of. And don’t fall into thinking, “I won’t ask for a raise because they are being really nice and giving me a halfway decent schedule.” You are not being unreasonable by asking for a salary that accounts for your skills and training AND a schedule that is not trying to kill you.
More information here:
From Maine to Ukraine: A Physician Finds Meaning in a War Zone
If you do all this and nothing budges, you will have to leave this job. In fact, you should start a job search at the same time you are taking the steps above. Which brings me to my last point: your wife should support you in this, up to and including moving for a better situation. Partners (unlike hospital administrators) prioritize each other’s well-being. Her happiness and time with her family are important, but not if they come at the expense of your sanity.
You deserve a better job.
Have you been in a similar situation during your career? What did you do? How else could this person improve their work life? Comment below!
I agree wholeheartedly with this advice.
It happened to me in internship (36 hours on, 12 off to sleep, then 36 hours on). This was in 1990. I complained that it was unsafe to do deliveries and surgery with this schedule. They changed the rules a little to allow the intern a post call nap. The upper levels all complained. I later left and actually changed fields to get a reasonable schedule. After I quit, they made major changes and had a night float system to the benefit of my former colleagues.
After seven years in my first attending job, the administrators were taking advantage of me, I complained, nothing changed. I quit and took another job an hour away. The commute was a pain, but I did not move my family for a job. I never did. My commutes and “job jumping” had little impact on my wife and children.
In that job, after eleven years of dutiful service, an administrator took advantage of the physicians, and two of the three of us in our specialty quit. The cardiology group left entirely and went across town. I had “job in hand” before I quit. Luckily for me, they closed the defined benefit pension at the same time, removing the “golden handcuffs”. That administrator was fired six months later due to the physician exodus he caused.
Once more, for the fourth time in my three decade career, I was being misused by a department chair, implying “no one can take a vacation” in a “use it or lose it” paid time off system. I quit again with job in hand.
No job is worth your physical or mental health. My mantra was: abuse me and I will quit. I did it four times in twenty eight years. Twice, it caused me a 45-60 minute commute to escape the no compete clauses. Each time, I missed my prior coworkers. Each time it caused me to learn new job duties and the new system.
I still finished full time work at age 58. After the second time, I always had a backup plan. After the third time, I always had a side gig. I also burned no bridges. All my former employers asked me to come back after the dust settled. It’s been quite an adventure…
Quitting can be liberating. I have no regrets.
Great advice and thanks for your story. I like the idea of a “best alternative current option” or BACO which I heard first in a business blog froth Seth Godin. Have another job offer or side gig you can explore and suddenly you have so much more leverage to ask for what you want and less to lose.
https://seths.blog/2010/06/baco-and-your-career/
Good for you for leaving those situations, promptly. Physicians generally have a great deal of leverage, including: our training and our relatively short supply, the difficulty and expense in replacing us, and (hopefully) our ability to care for ourselves financially so we can walk away.
My last position was at a hospital with ridiculously high physician turnover rate. I could never figure out why the highest-ups didn’t try to fix the leaky ship or hold anyone accountable – just the replacement cost of physicians alone must have been astronomical, never mind the loss of patients (who got frustrated and left) and the loss of income as new docs ramped up their practices. My own department went from 7 (4 physicians and 3 NPs) to two (one physician, one NP), over six months. Heartbreaking for the community, and totally avoidable.
Nice! Now why do you feel Auntie Marge had to answer this question? You gave the only answer possible (the same very one the OP asked you not to give!) and got right to the point that administration knows that ultimately most of us choose not to use the only actual leverage we have. We just buckle down and work twice as hard; it must be a disease or at least a defense that allowed us to get through med school and residency.
I’m glad you are talking about it because I have seen many peers stay in positions when they should just hit the road and extend a thumb. They say — well I asked them to change the schedule and they said they’d think about it and nothing ever happened. Nothing ever happens when you ask the administration for change when “it is working just fine for them.”
I’ll just ignore them and maybe they will go away seems to be the status quo for mid-level managers in the hospital. Actually that’s how it works in the C-Suite too!
Thank you for reading, and commenting! Agree, we stay in difficult positions far too long. One of my colleagues at my above-mentioned terrible job had been there 30 years…he kept saying he would retire, but he also kept saying he was going to “say something , in a meeting, one of these days!”. I think he had forgotten what it was like to have a reasonable employer.
And why Auntie Marge? Because she is even crankier than I am.
great advice Auntie Marge! do all hospitals keep a personal file on physicians? I wonder what mine says . . .
Thank you Rikki! I think it’s worth asking to see your personnel file. Maybe your employer is awesome, but even so they can make mistakes. My personnel file included all my CME (which I think is typical), so I wanted to check.
We owe it to our fellow docs to not put up with crap. Especially as we advance in life and have more capacity for risk than the young folk (of course ensuring you aren’t on a financial path requiring huge pay raises and working until your 90s is a crucial part of that).
Here’s my life, with the admission that marrying another doc and living off one income even when we had two is how we could afford this life:
In the Army I tolerated misogyny and the obligation until I was no longer under obligation then separated with regrets that it wasn’t good enough for me to stay 20-40 years. (Spouse made it to COL, I always fancy I might have made BG. Well, if the Army were perfect there’d be way too much competition.)
In the UK I happily lost locums jobs because I wanted £5 more an hour than the new docs. They needed it more than me; I didn’t get my credentials there to foul up the local doctors’ economy. And before that refused their standard training (for FMGs like me) of hospital work 30 minutes away in good weather, working the system until they let me do out patient FP in our town as my half year of their required residency training (and part time as well).
Bargained for 4 not 2 weeks leave instead of a higher salary (should’ve asked for both then backed down) at a job, later on asked for part time and got it. Left when (my version) the boss got a case of the ass and told me I was his bitch and would do as he says (hours and extra duties when I was a single mother during the wars). No I’m not, here’s my 3 months notice.
Left the VA after a too long stay (but at least vested in the TSP matching and my recruitment bonus) hoping they’d listen to my pleas for help after 50% of our providers (though only 30% the workload) retired unreplaced. Offered them part time but no dice.
Held out for 4 weeks leave from Army Civil Service- I might be new to them but I was as old as their docs with my seniority and 4 weeks leave. Took some intervention from a COL to get things moving but I would rather not work than have less vacation than I’d ever had in my life bar internship. Then again tolerated whatever thrown at me with plenty of whinging (rarely addressed but at least listened to- that COL again, my work spouse). Had a great final OIC but she could only get me bonuses not more staff or a part time schedule. With covid working conditions and my health issues I changed from “I’ll do this for the next 15 or more years” to “93 more work days until I am vested in the retirement system”. And left ASAP after giving up on recruiting a job sharer.
A few other jobs in between, part time from the start, I only left because the Army moved my spouse. MY biggest compromise is marrying and following a soldier which prevented having a long term medical practice. Who by the way hasn’t worked in medicine since he left the Army at age 48.
“Left the VA after a too long stay (but at least vested in the TSP matching and my recruitment bonus) hoping they’d listen to my pleas for help after 50% of our providers (though only 30% the workload) retired unreplaced. Offered them part time but no dice.”
Jenn, what’s your take on how systems low ball people and then prove that they are lowballing by acting like they don’t even need to meet the demand? That is, they just put the other work on other people, or they are OK with letting the work sit there, or people not get care for long periods of time. The latter could mean “doctors aren’t needed” but then how can they say they care about patients (blah blah patient care lol)? Dahle, have you opined on such matters?
Also, the VA is weird in that they would rather have no physician at all than someone who will work a different schedule. I offered them several months on then several months off for a job at a site years ago, and they still have the position posted. It must be 5 years in the making. I just didn’t want to be required to be the day to day worker, even with a relatively easy gig, that rarely gets extended time off. Meh, I make as much now doing my own thing and its not w2. ha
Your job sounds awful and you are being pushed into continuing in a completely untenable situation. You are being too soft. Play some hard ball. The strongest negotiating position is being willing and able to walk away.
I think all of this is sound advice and I have an additional point. Why not get another job offer with the schedule etc. you want, then come back to this hospital and say, “They are offering me this. If you can match it I am happy to stay.”
I like that idea.
I think that’s a good negotiating tactic, although some really dysfunctional systems just can’t adapt (and if they could offer a decent schedule, why wouldn’t they just do that when you asked the first few times?). If I were in that position, and I got my desired schedule, I would be forever waiting for the next messed-up thing to come down the pike. In my experience, awful employers are awful in multiple ways. Better to get out if reasonable measures fail.
As Auntie Marge says, admin is not going to solve your problem if it is not also their problem. So, as a group, you have to make it their problem. Present a call/work schedule with every other day open. List those days as “locums coverage”. Then, offer to temporarily provide locums coverage (at locums rates) until additional physicians are hired & the group is properly staffed. If the other members of your group are willing to continue to work these shifts without inflicting financial pain on the administration, you will have to decide if you do the same or if you leave.
I love this. Present it as a done deal, not a request. And work together as a group – a smart administration won’t risk losing an entire group, and an administration that is dumb enough to, isn’t one you want to work for.
Agree entirely with the pathway described.
However, everyone should also develop a “backup” plan for what to do if you have to leave your current job (as the article notes) but the available job opportunities are not optimal either.
I address these issues in my presentation series titled – The Healthcare Workplace – “Should You Stay or Should You Go” – and publish frequently on this topic. One link = https://epmonthly.com/article/should-you-stay-or-should-you-go/
I’m old enough to remember when hospital administrators were there only to staff and administrate the hospital. This was the “box” doctors sent their patients to, and in which the patients had their treatments or tests accomplished. Doctors had several hospitals with whom they had credentials and thus planned their daily schedule. I remember well when a group of lawyers came with a lecture about HMOs , insurance companies plans, and RPUs. “What’s an RPU? “ I asked. “ A revenue- producing unit “ he replied. “What?”, I responded. “ A Doctor “ he answered ! Well, the RPUs have been run into the ground with overwork, electronic documentation, and impossible schedules, I believe that doctors (usually poor business people) relinquished their power, perhaps by presuming they were beyond an outsiders control. I am thankfully retired from anesthesiology at 75, but believe me, until doctors regain some control over their own schedules, not being pushed beyond their limits by insurance companies and administrators holding salaries and fines and job security over their head, quality of medicine and quality of life for doctors will continue to decline.
In ER we take this a step further, and keep at least one 2-shifts-a-month PT gig (and an out-of-state license!) at all times. No re-credentialing, clean transition, or at least an income stream while you transition.
Sometimes you keep the former situation as your new 2-shift-a-monther, because as YourHuckleberry said, the admin that caused the exodus tends to be gone before long (fired or promoted).
I cannot stress enough the importance of recording your personnel file before talking to admin! I know two NorCal ER docs that were blackmailed into an extra year via backdated correspondence to the medical board. THIS HAPPENS. Keep your stick on the ice.
Sad to hear about their situation. I work as a shareholder physician in 100+ privately owned group. It’s easy to hold onto the “yes sir” resident mentality when becoming a new attending even to administrative staff. Not realizing the power and authority we as physicians have. At some point, I was being told by administrative staff “no” when these were “yes” answers. We have to realize it’s our work that pays everyone’s salaries including hospital administration. Yes, we physicians need political power with being in accord about an issue but so much weight to our voice when this happens. That helped put into perspective the power dynamic on how it should be.