How Physicians Should Evaluate Time Off

This is an assortment of ‘time off’ issues that I often find myself repeating during client meetings, so I decided to repeat them all here. This is not meant as a physician wellness blog. To be clear, I am a huge proponent of the physician being in control over time off and taking more than they think they want or need. My experience in speaking with physicians is that the turtle beats the hare, and moving at a long-term sustainable speed is best for your career, health, and life.

I may add or subtract from this list over time. If you see something that I missed, please let me know!

Thoughts on “One Bucket” vs. “Multiple Bucket” time off policies

Contract time off from an employed position can come in many different ways. Some will have one set of days that include holidays, vacation, sick days, and CME days. Under a One Bucket policy, you may be required to use a certain number of those days on set holidays (particularly if you are primarily outpatient clinic), but you can use the rest as you see fit. If you want to use all of those days to go to every annual meeting for every national society you can think of, more power to you. If you want to use all of them on vacations and fit in CMEs on nights or weekends, I believe that should be your right.

Conversely, some policies will break down how you can use contract time off. For example, instead of having a 36-day One Bucket policy, they may say that you get up to 8 federal holidays, up to 20 vacation days, up to 4 CME days, and up to 4 sick days. If you are not sick on all 4 days, then you lose those days and you must come to work. If you are sick for more than 4 days, that would reduce your vacation days. If you are not doing CMEs on 4 days, you must come to work. I can’t recommend anyone lie to their employer about either of these. As such, the employer may tell you that you have ‘more time off’ but they are actually looking for opportunities to reduce this over time.

I have had some success with smaller private practices in converting the multiple bucket policy into a one bucket policy, particularly when the physician is compensated on productivity or collections and the practice is not concerned about losing as much money.

“Paid” Time Off doesn’t really exist when you are compensated on productivity or collections.

The vast majority of physicians, and employed people in any field for that matter, usually use the term “Paid Time Off”… It assumes that you are paid a certain amount, and that compensation will not go down when you are taking your “PTO”. Physicians in residency or fellowship are not compensated on productivity or collections and receive the exact same amount in their bank account every bi-weekly or bi-monthly period. Their paycheck is the same, regardless if they work tons of hours and create tons of RVUs or if they actually were able to take some of their scant time off.

However, this is likely to change as an attending. As soon as ANY part of your compensation package is based on productivity or collections (yes, even if it is “just my bonus” and “my base is protected”… keep reading), YOU ARE NO LONGER PAID FOR YOUR TIME OFF. Your productivity bonus will go down during that time off, which will cause your total compensation will dip.

It is important to understand your compensation package to appreciate how your compensation will change. If your productivity bonus pays you at an increasing rate, well that means your time off will be expensive. This may sound bad, but in some ways it is an ideal problem to have. If your productivity bonus pays you at a decreasing rate, you might as well max it out because you are making less per additional unit of work anyways (oh and by the way, negotiate for open moonlighting instead of maxing out a crappy production bonus).

If your productivity or collections bonus pays you at a crappy decreasing rate, consider negotiating for more time off and moonlight instead!

I love negotiating for open moonlighting. I may be the physician contract lawyer that talks about it the most. An increasing number of physicians are employed by private equity owned private practices, hospital-based private practices, and directly by hospitals. This following analysis is also generally consistent for academic employers. Fewer physicians are finding opportunities to explore pre-partnership track options at fully independent physician-owned private practices, and thus fewer physicians are owning medical practices. Business ownership can be great for your compensation, but fewer have this option. I wish I could reverse this trend, but that’s another topic for another day.

As such, physicians are increasingly trading time for money as an employee. IMO, this should also mean that physicians need not and maybe should not invest themselves into the employer’s business in the same way as if they were moving towards business ownership. When you are simply trading time for money, it is important to understand how your time is valued and paid for. If your employer has a favorable bonus structure that pays you an increasing rate as your productivity increases, then you have a little less motivation to look elsewhere. However, many compensation models pay you at a decreasing rate. As such, if you are deciding on whether you want to add 10-20 days of work to your plate (totally optional… you could also just chill), you will want to do that for the higher bidder. Your primary employer is unlikely to be the higher bidder. That is more likely to be found in a moonlighting capacity in most specialties.

Many employers that pay decreasing rates for bonuses also have exclusivity clauses, requiring you to work only for the employer. Negotiating for more PTO and open moonlighting could be a great way to improve your compensation.

If you want more time off, consider negotiating for a reduced FTE.

FTE means Full Time Equivalent. Many employers will only advertise that they have “1.0 FTE” options, meaning you must work 100% of what they consider full time. However, the vast majority of employers will consider a reduced FTE, meaning you could work .8 or .7 of what they consider ‘full-time’. You will likely need to accept .8 or .7 of their compensation package (look closely here), but many physicians can make that work with their personal finances and will be happier with that extra time.

However, watch out for enforcement mechanisms. IMO, the best way to enforce a reduced FTE is to not be in the building. Be home with your phone and computer off. I find it very hard for an employer and physician to enforce leaving at 4pm instead of 5pm each day, but I find it much easier to never schedule the physician for anything on a Monday or a Friday.

Further, negotiate for an open moonlighting clause and see about diversifying where your income comes from. If you have ample time off, you may find more lucrative locums/per diem options that allow you some flexibility to add and subtract work from your schedule when YOU want, while also being paid a premium and keeping some pressure on your employer to stay current with their compensation package. They have to compete for your time with another income source, which can be very helpful for you.

Finally, the vast majority of employers will let you work more in the future… fewer will voluntarily let you work less. If you want to increase from .7 to 1.0 in the future, they will likely oblige.

Does your employer have coverage for you? Can you actually take all of your allowed time off?

Occasionally, the number of physicians who could cover call is so small that the physician may feel pressure to avoid taking all of the time off provided by the employer. I encourage all physicians to consider whether they will feel any pressure from the employer or their colleagues to waive their contract rights because ‘we don’t do that to each other’ or some other shared misery argument. I also sometimes see this when a highly specialized physician joins a new group and adds on specific services… is there any coverage for those services when the physician is off? There is likely some way to work around this problem, and it should be addressed when the physician has the most leverage, which is right before they sign the contract.

How “off” is your time off? Can you completely unplug, or are you expected to be reached and respond?

This is a great question to ask during the interview process. If you did not ask this before you received the contract, you should make sure you ask before you sign. You should be crystal clear as to expectations when you are not working, particularly on days that are traditionally work days (ie Monday – Friday). Many employers feel you are “off” but should still check and clear your inbox and respond to patient requests regardless of whether you are working or taking a day off. This is a huge moral injury and burnout risk. Never being able to take a day fully off without needing to check in with your employer can lead to immense stress. This can be made more challenging for smaller practices (or small law practices, like mine).


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