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 feel guilty about taking my paid time off (PTO). When I do, I make sure I am available for time-sensitive issues. Is that the right decision?”
Auntie Marge wants you to be happy and successful. She also wants you to make sense.
You are probably early in your career. Many physicians come out of training brimming with enthusiasm, an overdeveloped sense of responsibility, and maybe a little bit of a hero complex. We are set up perfectly for guilt and overwork. Your work ethic is admirable, but you will at some point come up against the hard reality of practicing medicine which is: it’s exhausting, and your time and energy are finite. Create some healthy boundaries now or you will find yourself miserable, exhausted, and maybe even the subject of a business school study.
Keeping yourself “available” is not really taking time off. Just about everything we do is “time-sensitive” and all your colleagues and staff will have different thresholds for contacting you. Some will call you only when they have exhausted every other avenue, and some will call you as soon as they see your name on a lab result—not out of malice necessarily but because you are the shortest distance between them and the point of getting this thing off their desktop.
I could give you all the data on physician burnout, but you are smart enough to know all that. Instead, I'm going to give you other reasons why you should always take all the time off that is afforded to you.
Reasons Why You Need to Take PTO
You Have a Job That Actually Pays You on Your Days Off
You may not always have that. You may someday be solely productivity-based or have your own practice, and your days out of the office will cost you money. Enjoy PTO while you can.
There are reasons a physician should feel guilty: taking shortcuts, gossiping, being rude to the front desk staff. (Unfortunately, the people most likely to commit these offenses are also, generally, the ones least likely to have insight into their own behavior and therefore don’t feel guilty—ever. So, if you have ever wondered if you are on this list, you are probably not.)
Not a reason to feel guilty: following the terms of your contract. You are surely doing all that your contract requires of you in terms of patient care, call, and maintaining your skills. You should expect your employer to keep its side of the bargain by paying your agreed-upon salary and benefits. You should also, therefore, take the paid time off that is in your contract. I can assure you it is not excessive.
The people who hired you did not allot you a certain amount of time off out of the goodness of their hearts. They did it because if they didn’t, they wouldn’t be able to hire anyone. Even the most starry-eyed resident knows that somewhere in their new attending contract there should be some mention of vacation. Your contract includes stipulations about time off that are in keeping with the market for physicians in your location and specialty. Nothing to feel bad about.
Whatever you hear about “wellness” and “work-life balance,” you can’t rely on the people who run your hospital to look out for your best interests. I am going to tell you a story that illustrates my point. This is also the Auntie Marge Origin Story, part 1:
I had a job that paid entirely based on productivity. Both my contract and the physician handbook mentioned “paid time off.” My colleagues (who had the same contract) and I all assumed that “paid time off” meant exactly that. Then, COVID hit, and I took a 40% pay cut because I was seeing few patients and because I was still in arrears from a week of vacation I had taken IN OCTOBER 2019. I combed through all my employment documents and had my lawyer review them. The language was incredibly slippery. I requested a meeting with my supervisor and a guy from finance to clarify. It went like this:
Me: “So, we do not get paid time off.”
Supervisor: “You can take time off and get a paycheck as usual.”
Me: “But we don’t get paid time off.”
Supervisor: “You get paid for your RVUs.”
Me: “And if we take time off, we still have to earn RVUs to cover the paycheck we get while we are taking time off.”
Supervisor: “I think of it as an opportunity: the opportunity to see more patients instead of taking time off . . .”
Me: “So, we do not get paid time off.”
Finance guy: “You do not get paid time off.”
This was just one step on my journey from an idealistic new grad to the hard-bitten veteran that I am today. I will still do just about anything for my team and my patients, but I no longer spare even a moment’s thought to the desires of people like that supervisor.
More information here:
How Can I Make My Terrible Doctor Job Less Terrible?: Auntie Marge Explains It All
You Need to Keep Your Work in Perspective
If you start thinking that no one else can possibly take care of your patients as well as you can, you run the risk of becoming a narcissist. I would not want that for you.
Maybe your reluctance to use your PTO comes from a kind of perfectionism that just about every physician experiences at some point. If so, come on over to the Club of Imperfect People. It’s a much more enjoyable place to hang out than where you are now. I’ll save you a seat.
You Can
Life is short, and the world is wide. Someday, you will be too old to go have all the fun you could be having right now. The people who matter—your friends and family—need you to spend uninterrupted time with them. They need you to be happy.
If what I’ve written here doesn’t convince you to enjoy your time off, it may be time for some therapy to help you understand why it is hard for you to step out of the traces. I do not feel the slightest bit guilty about taking time off, and neither should you. So compose that “out of office” email, grab your backpack or your beach towel or your opera glasses or whatever your little heart desires, and go have fun. If you need help deciding what to do with your vacation—or you just need more convincing—I’m here for you.
More information here:
You Should Invest Like a 50-Year-Old Woman
From Maine to Ukraine: A Physician Finds Meaning in a War Zone
Today’s bonus question is an amalgam of multiple questions posted in multiple online physician forums.
“I sign charts for a nurse practitioner at a remote site/medispa/nursing home who does botox injections/knee aspirations/high colonics. My question is: what should I ask for as compensation?”
Your question should be, “How can I extricate myself as quickly as possible?”
I was once approached by a clinic owner who asked if I wanted to be on staff so their acupuncturist could bill services as “incident to” mine. I explained how “incident to” billing works. I explained that, as a pediatrician, I would find it hard to convince Medicare investigators that I had done an initial evaluation and plan of care for elders with back pain. I explained that this would constitute Medicare fraud, and on the scale of stupid decisions, Medicare fraud falls somewhere between “I’m going to outrun this cop” and “I’m going to invade Russia in winter.” Then, I stopped explaining because, while I am a proud member of the Club of Imperfect People, I do not have time for nonsense.
My scenario wasn’t even courting the serious medical liability in yours so stop with the nonsense. Call whoever is using your medical license and your reputation and tell them that your credentials are no longer for rent. Check your malpractice coverage and hope there are no claims against you for whatever the heck happened at this remote site. Lastly, vow never to let yourself be put in this position again. If you do all these things, I will be here for you.
Do you feel guilty about taking PTO? Does your employer have a problem with it? Do you have any other questions for Auntie Marge? Comment below!
Thank you for the column. Your last question caught my attention, regarding compensation for supervising a midlevel; different, I understand than covering “incident billing” when I’m not exactly caring for these patients. In summary, I am in a VERY understaffed area with regards to most medical fields, but particularly urology. As a urologist, me and another are currently managing the volume of 4 urologists with sporadic and needed locums coverage along the way and no solution in the future. Regardless, there is a real need for a mid-level in our hospital employed situation. However, I have indicated that I will require compensation to supervise, I worry about liability-a lot. However, I have no idea what that compensation should be. If you are able, could you or someone with more experience comment on what is appropriate compensation to supervise a mid-level in a hospital employed, production based model? Thanks!
Thank you for reading!
The question of physician supervision of midlevels is complicated. The answer some people will give you is: there is no amount of money that is worth renting out your license. And there is some truth to that, but in the real world and in an area with an acute shortage of care, the answer may also be more nuanced. (I’m married to a urologist, so I am particularly sensitive to understaffing in urology departments.) Having midlevel help may free you up to give care that is more appropriate to your training (“working at the top of your license”) and give more patients access to the care they need.
But – hospital administrations have shown that they are more than willing to staff departments with midlevels who are not experienced or trained in that field and ask physicians to assume the liability. The administrators are happy because midlevels are less expensive (and order more tests – but that’s me being cynical) and they (admin) no longer have to do the difficult job of recruiting new physicians.
So I think the answer to your question has to be multilayered:
1. no dollar amount is worth remote supervision of a midlevel you don’t know and trust, whose work you cannot actually supervise. Especially if the midlevel in question is newly out of training and needs a lot of mentoring. If you cannot be sure the care given is up to your standards, then you can’t sign off on it.
2. if the midlevel is known to you, you are confident in the care they can give and you have a good working relationship – then set a rate that is commensurate with the effort it will take you. If you are RVU-based, then this rate should reflect the decrease in your productivity that will result. If you are salaried, you should get dedicated time to supervise without a decrease in your pay. If you want to set an hourly rate, figure out what your current hourly comes out to (or check MGMA).
3. make sure your employer-provided malpractice coverage includes your supervision of midlevels. You should be protected and be sure that your employer and insurer will have your back if the event of a bad outcome. If anyone tells you “oh the NP carries their own malpractice so you are all set”, push back on that. Hard. You will be sued alongside the NP if your name is on the chart (and maybe even if it’s not, because lawsuits are like that), so make sure you have adequate coverage.
This should all be spelled out in a contract addendum. It might even be worth getting your own lawyer to review the language of the addendum and the malpractice insurance to make sure you are adequately protected. And if you think this is overkill – ask my husband about the patient who went to a medispa and got “penile enhancement” treatment from an NP. My husband had nothing to do with that medispa but a lot to do with the follow-up care of that patient.
And if you want to talk more – I’m happy to chat.
Well, malpractice risk is pretty low in general so a fair amount is probably less than most docs think. I’ll bet there’s a pretty wide range from nothing to tens of thousands a year.
Excellent article. Like you, working in corporate medicine, I found out early that you had to have your own back.
I always took all of my PTO. It eventually became very generous: 30 days plus 11 holidays.
That’s over seven weeks. With weekends off, I was able to sell a few to the highest bidder (inpatient side gig) and partly fund an earlier exit from full time work.
I quit one job partly because they “suspended PTO for the next six months”, violating the contract. A good amount of PTO was the ticket to family vacations and reduced burnout. Luckily, the market in Psychiatry came to be at least 30 days plus one or two weeks for CME.
Well done Dr Ellis! and thank you for reading.
Taking time off, feeling indispensable:
1- when you are dead/ retired someday (or if you are suddenly ill or dead today or tomorrow) your job will get done, in some manner, without you. Make sure along the way that things will go well then by ensuring the place can function without you a few days at a time before then.
2- I think I read on WCI that an employee who never takes time off- especially one who handles money- might be stealing or doing something else they don’t want discovered. (Also higher risk burnout etc.) So hopefully all your coworkers and office staff take at least some of their time off as well. If it’s in your control, require it!
Bonus question issue: A dying hospital a county over asked me to be the supervisor for an NP- ie sign charts and be on telephone call (she couldn’t work independently in our state then). The old hospital board didn’t want folks to have to drive 15 miles to see a doctor/ ER at the nearest bigger town so this was their plan as everything else at the hospital folded. Her twin sister, also an NP, had worked in the same place I worked but I barely knew her. She had suggested me to her sister since I was looking for parttime work.
Having experienced remote supervision of a PA- older and with more years than me and whom I repeatedly counseled about at least one error on his part (I don’t mind he wasn’t 100% perfect, just that he did the same thing again after I advised he was doing wrong)- and being satisfied with the other midlevels I have worked side by side with (and with much less legal liability for their care given the liability structure of the group)- I was certain I had to know her and her skills better.
So I proposed I work at the place alongside her for a few weeks full time, then weekly a day or two for several months, and do onsite chart reviews about weekly. At an appropriate rate for a BC FP MD. Funny, never heard back from them.
What you proposed is exactly how supervision is supposed to work: you are supposed to actually supervise. What many facilities seem to request instead is a remote signature service.
We are all sensitive to patient needs and that is how they get us. “Think of the patients!” In peds it is even worse: “think of the children!”. But what is really best for our patients is skilled care by people who have been trained to give it.
Good on you for standing firm on that. And I agree about PTO – just use it. Thanks for reading and commenting!
Yea, that’s my big problem with getting paid to supervise APCs. It’s not so much the pay as it is the fact that APCs actually do need real supervision and too few are getting it.
Awesome, Margaret as always! in terms of the experience of not getting PTO did you try to renegotiate your contract for some sort of PTO? If so, what was the compromise? Maybe a baseline salary that you get paid when you’re off? I myself am RVU based, and there is a baseline salary of RVUs that I get paid, and I still get paid that baseline even that week I take off. Every quarter I either exceeded that baseline RVU salary which is deducted from my next few paychecks or if I exceed the RVU baseline I get paid more as a bonus.
One job I asked for 4 weeks leave instead of the offered 2 and didn’t ask for higher pay. Not sure why I figured that amount- guess since moving from part time, sabbatical, and military with 30 days leave (and being middle aged with family) I didn’t want the standard starting vacation time for 20 year olds. They accepted that without countering. Another job same thing- last job with the VA had 28 days leave, Army civil service offered 2 weeks. I demanded 4 weeks, no movement on the hiring action, then the LTC who wanted me saw me in the hall (clinic where I got my own care, and volunteered) and asked about the hold up. Told him and he held HR’s feet to the fire and got me credited with my 20+ years prior experience for leave purposes. Unfortunately my pay stub ever after said I had 20 or more years in and the retirement calculator always said “you can retire now” inaccurately. Also unfortunately (though not for my ethics) they only paid me as agreed, didn’t bump me up in GS pay tables to 20 years in that pay grade. BTW tried to negotiate pay with the VA and they refused so I took their offer (but if they’d not offered 4 weeks leave I wouldn’t have taken the post).
Hi Rikki! thank you for reading.
I did not re-negotiate that contract, and I’m sure I would not have made any headway if I had tried because every physician had the same pay structure, which was just what you have now. I think the bigger issue was the total lack of transparency around PTO. Our contracts referenced a staff handbook, the staff handbook referenced a “physician pay packet” and no one, including HR, could track down a physician pay document for me to review. I’m no longer at that job and, not surprisingly, there were bigger problems there than physician PTO.
I think that kind of pure RVU model can work for some physicians, but unfortunately it discourages people taking their much-needed time off and can encourage over-treating, over-charging etc. If you ask me the best physician pay model is salaried, with a productivity bonus.
Everyone is entitled to their own opinion, but no way would I choose salary as the best way for physicians to be paid. I have zero interest in being an employee ever again. My pay might be variable, but it’s almost always higher than what I would make as an employee.
Great article! As a retired pharmacist, I too for many years was salaried with PTO benefits. It wasn’t until mid-career when I made an employment change that I realized that PTO wasn’t truly PTO. I, like many pharmacists encountered situations all too often that I couldn’t take time off due to lack of sufficient staff. It’s not only unavailable at desired times, but is not available at all. Like physicians, most of us show up for the patients and our co-workers. Or as you mentioned, in some practice settings, if one were to take a day off, or observe a holiday, the work does not automatically go to another co-worker (if there is one) nor does it magically go away. It simply gets shifted, making one feel like you have to put in extra work in order to earn that supposed PTO benefit. As an employer, I always encouraged employees to take their time off. You’ve more than earned it!
Feeling overworked when a colleague takes vacation / falls ill is not a problem caused by that coworker but a problem caused by management’s poor staffing and schedule management. (paraphrased FB meme)
It’s an awful reflection on the job and your coping skills when- for me in the military and in my frequent moves later as a military spouse- you feel like the only time you can have a decent vacation is when you change jobs. (That catching up all your stuff not done in your absence hanging over your head when you return really saps the refreshment of the vacation.)
Vacation time in the military can often be taken as “terminal leave.” I owed the military 48 months of active duty time. By saving up vacation, I actually only had to give them 47.
Agree, for many RVU based physicians this PTO issue is huge and needs to be brought to light more to change the market. It is not fair that 95%+ of the rest of the hospital gets paid time off but RVU based physicians do not. In addition, those physicians that are not RVU based (ER, Anasthesia etc) get true PTO whereas those RVU based do not. Its a double standard that should be brought to the forefront. To clarify, its not that we cannot take PTO, its that when we do its basically unpaid.
Regarding the RVU based pay vs salary with PTO comments: don’t the hospitals/employers take this into account when setting salary levels? I would think that any competent employer would base an employee’s pay on the assumption that the person is going to take every single day off offered, and if they don’t then it’s a bonus for the employer.
Yes, salary levels take into account time off (both personal/vacation and sick leave). In a productivity model, the pay per RVU is calculated with a complex metric. Payment in this model doesn’t account for time off – you only get paid for the number of RVUs you generate.
Agree about the double standard. Non-RVU based physicians generally get PTO, and so do physician groups that are smart enough to negotiate for it.