Published in the June 2013 issue of Today’s Hospitalist.
MANIKANDAN NAGENDRAN, MD, is already planning a three-week sojourn back to India for his brother’s wedding at the end of November. It’s one of two international trips he usually takes every year. And those are on top of travels within the U.S. every other month with his wife and 9-year-old son to destinations like New York and Disney World.
Dr. Nagendran, who goes by “Dr. Mani,” takes his vacations during time off from his block schedule, so he’s not technically receiving paid time off (PTO). That’s an important detail because Dr. Mani practices at the 100-bed Dauterive Hospital in New Iberia, La. The program there is run by the Schumacher Group, a national physician management company that has a no-PTO policy.
But Dr. Mani has no complaints with Schumacher’s lack of PTO. His block schedule, typically six or seven days on with a commitment of 15 shifts per month, is ideal for traveling, he says. For his brother’s wedding, he’ll string together two weeks at the end of November with a third at the beginning of December. He’ll make up that time by working 14 days straight before his trip.
“I like my schedule because I can change it according to how I want it,” says Dr. Mani, director of the hospitalist program. “The lifestyle is awesome.”
As far as he is concerned, he doesn’t need any additional paid time off. In fact, when he’s not traveling, he often works some shifts at another Schumacher group during his scheduled weeks off. “It pays my traveling expenses,” he says.
A disappearing option?
Dr. Mani’s casual dismissal of paid time off may help explain why PTO for hospitalists seems to be on the decline nationally. The 2012 Today’s Hospitalist Compensation & Career Survey, for instance, found that 51% of all full-time respondents don’t receive any PTO, instead working vacation into their scheduled days off. That’s up from 45% in 2009.
Entrepreneurial-minded hospitalists like Jeff Gill, MD, MBA, say that data suggesting less PTO in hospital medicine make sense to them. That’s because in their eyes, the whole issue of PTO is little more than a matter of semantics.
“I can essentially either pay all doctors as much as I can per shift and let them take any vacation off and not pay extra,” says Dr. Gill, who is a pediatric hospitalist with Inpatient Specialists Medical Group Inc. in Brea, Calif., a local private group. “Or I can pay less per shift to hire someone else to cover them while they’re off. In the end, it’s a wash.”
But not everyone agrees with that one-pot-of-money concept. Particularly in hospital-employed groups where physicians aren’t paid on a per-shift basis, PTO can be a key lifestyle consideration, one that gives programs a recruiting edge. Even program administrators who find it tough to support the finances of PTO relent when recruitment and retention are brought into the picture.
They are concerned for good reason. Not having additional paid time off from what can be a demanding block schedule “is one of the largest drivers of hospitalist burnout,” contends Brian Kendall, MD, medical director of hospitalist services at the 286-bed Regional Medical Center of Orangeburg and Calhoun Counties in Orangeburg, S.C.
“I don’t think hospitalists should be punished for squeezing two weeks of work into one,” says Dr. Kendall, referring to the common schedule of working 10or 12hour shifts for a block of many days in a row. “Why should they be penalized in terms of vacation?”
Kenneth Simone, DO, is founder and president of Hospitalist and Practice Solutions, a hospitalist practice management company in Veazie, Maine. He points out that opinions on PTO fall into different philosophical camps depending on a practice’s employment model and location and, to some degree, the age of the hospitalist.
Newer graduates, Dr. Simone says, are very attuned to work-life balance, so look for additional time off when they’re interviewing. And because physicians in hospital-employed groups typically derive most of their income from a base salary, they aren’t incentivized to work more hours as are their colleagues in private-practice models.
“Although providers may receive a productivity incentive,” Dr. Simone says, “it usually isn’t enough to lure them away from PTO. The private practice model, however, self-selects for doctors who are more entrepreneurial and are willing to work longer hours or more days on-call for more money.”
In Orangeburg, Dr. Kendall points out that the hospital-employed physicians in his group work shorter shifts but more days than the typical seven-on/seven-off schedule for a total of 18 10-hour shifts per month. They also each receive 200 hours of PTO and 40 hours of CME per year, although the pay rates for that PTO time decrease if doctors cash out those hours at the end of the year, rather than use them for actual vacation.
“PTO is definitely something that we discuss with candidates early in the interview process and they are impressed with it,” he says. It’s also a practice issue that he pays close attention to in terms of other programs in his state.
“It has really come on the radar within the last year, and I know of two programs that eliminated PTO to cut costs, while another is fairly close to eliminating it,” says Dr. Kendall. “We use it as a marketing advantage.”
Dr. Simone agrees that PTO can be a powerful recruiting tool. “You can pay candidates only so much in terms of attracting them,” he explains. “You need other perks like more time off, more benefits, time to pursue your interests.”
More money vs. PTO
But pediatric hospitalist Dr. Gill prefers a scheduling system that gives doctors who want to work “and earn ” more the option to take shifts from others who want more time off and are willing to make less accordingly. Everyone settles into his or her own preferred schedule, he notes, which is fine as long as a hospital’s required number of FTEs is met.
Frankly, Dr. Gill says, adding PTO in the mix just confuses the issue “and physicians. “PTO is not real money. It’s on paper,” he says. “The problem is, doctors think it’s real.”
And Dr. Gill points out that not using your PTO if you have it is putting money back into your employer’s pockets. That’s another reason why he advocates for paying doctors more per shift in lieu of PTO. “I’d rather give control to the doctor than to the employer,” he explains.
To give hospitalists that kind of direct control over their pay, the Schumacher Group enforces its no-PTO policy even when it takes over programs that have previously given physicians paid time off. Schumacher determines the dollar value of the PTO and adjusts the base salary of physicians accordingly. If doctors receive $1,000 per shift and used to have 10 PTO shifts per year, Schumacher will add $10,000 to their compensation plan.
David Grace, MD, senior medical officer with the Schumacher Group, thinks more programs are coming to share his company’s view of PTO. He points to data from the Society of Hospital Medicine, which show that since 2007, 20% fewer groups offer PTO “and those that do offer 20% less of it. During that same time, he notes, average hospitalist pay has increased by 30%.
In Dr. Grace’s mind, those data indicate that hospitalist programs would much rather put money into physician salaries, not PTO, and that hospitalists aren’t pushing back.
One reason hospitalist groups may be ditching PTO has to do with how hard it is to manage both paid and scheduled time off. And groups that offer PTO quickly run into an even more basic problem: accurately defining and compensating hospitalists for a unit of work, which can be far from an apples-to-apples comparison.
Shifts are commonly 12 hours, for example, but swing shifts may be eight hours, while nocturnists’ shifts may be the same length but more (or less) rigorous. Then there’s the fact that many hospitalists who may be technically scheduled for 12-hour shifts during the day routinely leave a few hours early if their work is done. Should those hours count toward paid time off?
“You can tell hospitalists that they’ll get a certain number of shifts off,” Dr. Grace says, “but not all shifts are equal.” Comparing these units of time in terms of PTO can become confusing. “The math gets very muddy,” he adds. “That’s why we take the simple approach: We don’t have PTO.”
Instead, providers with Schumacher work 15 days per month averaged over a quarter. As a result, physicians like Dr. Mani don’t have to make up time missed within one month.
“We do our best to always accommodate hospitalists’ need for time off beyond the routine schedule pattern because ‘life happens,’ ” Dr. Grace notes. “In return, our hospitalists understand the need to maintain schedule continuity.”
Making PTO work
But in hospitals where PTO is the norm, practice administrators say they find a way to make it work. Cooley Dickinson Hospital, for instance, offers its newly hired FTE hospitalists six weeks of PTO a year (vacation plus sick time), plus one week of CME.
Doctors work as a group to build the schedule as long as they meet the FTE minimum of 45 shifts per quarter. Amy LaRochelle, MBA, practice manager at the Northampton, Mass.-based facility, says she looks not only to internal doctors to make coverage work, but community physicians, midlevel providers from within the practice and ICU midlevel providers. Often, physicians providing PTO coverage are steered to admissions instead of rounding to minimize the impact on continuity of care.
Hospitalists welcomed Cooley Dickinson’s move in 2010 from a more complicated sick, vacation and holiday bank to its current PTO model, says Ms. LaRochelle. “The hospital redid it to give more flexibility,” she notes. “Physicians really appreciated that because they don’t typically call out sick” and couldn’t use sick days for scheduled time off. She also notes that PTO is definitely being offered within other hospitalist groups in her market.
Recruiting and retention
Despite scheduling issues, proponents of PTO say its benefits outweigh the hassles. James Leyhane, MD, for instance, notes that PTO is standard for hospitalists in the Syracuse, N.Y., market where he is based, although no other programs follow the seven-on/seven-off, 12-hour shift model that his group uses. Doctors in his group are allowed to swap shifts within reason, he notes, “but we don’t let our doctors work more than 10 days in a row.”
He credits his group’s two-week PTO policy, which began in 2008, with keeping his turnover rate at an enviable 5%. “It would be easier if people had less time off, but our turnover rate is extremely low and I wouldn’t want to give that up,” says Dr. Leyhane, hospitalist director of the 20-physician group at St. Joseph’s Hospital Health Center.
Lexington Hospitalists Inc. in Altoona, Pa., offers its 13 hospitalists one week off. “It helps with recruiting for some newer hospitalists who want the seven-on/seven-off schedule and that additional time off,” says Gregory Martinek, DO, medical director. The extra time can be used in a block, as separate days or for CME.
And while Dr. Martinek appreciates the leg up PTO gives his group in recruiting, he also notes that having that additional week off is essential to offset some of the stress associated with working seven-on/seven-off.
“It’s a brutal stretch and I worry about burnout,” he says. “If we didn’t have the week of vacation, I don’t know if seven-on/seven-off would work for our group.”
Dr. Leyhane says the trickiest part of offering two weeks paid time off is that he’s essentially short staffed all the time. With 20 doctors having basically three weeks off, that leaves him with 60 weeks to cover. “Two physicians are out each week most weeks, especially in the summer, though that’s generally not our busiest time” he says. To make coverage ends meet, he or the assistant director takes on more patients. If the census is particularly high, they bring in “and the administration pays for “a moonlighter.
To avoid coverage crises, most practices limit the number of physicians who can take off at the same time, often going with a first-come, first-served system. Dr. Martinek typically asks for a four-week notice but opens the schedule at the beginning of the calendar year to begin taking requests for time off. Dr. Leyhane uses a board in the group’s main office with vacation times posted; hospitalists e-mail their requests, usually three to six months in advance.
Dr. Kendall uses computerized scheduling software that allows everyone to see what’s already been booked, a program that lets doctors plan two years ahead. “I review requests every month and the software allows me to grant approval immediately or leave it pending,” he says.
With 13 hospitalists and several midlevel providers, he says he can guarantee time off for the first three providers who request the same specific date. For holidays, all hospitalists rank their preferences, and Dr. Kendall honors those requests by seniority. Last year, he points out, “Everyone got his or her first choice.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.