Physician employment contracts: the key to fighting burnout and improving working conditions [PODCAST]

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Join us on this insightful podcast episode as we delve into the pressing issue of physician burnout and the challenges physicians face in their careers. Our guest, Dennis Hursh, a veteran attorney with over 40 years of experience in health law, sheds light on the topic. We discuss the impact of overwork and stress on physicians, the need for balance between patient contact hours and administrative duties, and potential solutions to alleviate the burden. Don’t miss this engaging conversation as we explore ways to address physician burnout and improve working conditions.

Dennis Hursh is a veteran attorney with over 40 years of experience in health law. He is founder, Physician Agreements Health Law, which offers a fixed fee review of physician employment agreements to protect physicians in one of the biggest transactions of their careers. He can also be reached on Facebook and LinkedIn.

He shares his story and discusses his KevinMD article, “A tiny step to reduce physician burnout.”

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Ambient intelligence augments human capabilities to make our lives easier. The applications are many, especially in health care. Ambient clinical intelligence is offsetting the most pressing challenges in health care today, such as burnout, physician shortages, physician and patient dissatisfaction, and underperforming financial outcomes, by applying the technology to clinical documentation. 

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome our regular guest, Dennis Hursh. He is a physician contract attorney. His most recent KevinMD article is very relevant to a lot of us. It is titled “A tiny step to reduce physician burnout.” Dennis, welcome back to the show.

Dennis Hursh: Thanks, it’s good to be here.

Kevin Pho: So Dennis has been on the show multiple times, giving valuable advice in terms of how to negotiate your physician contract. Go to KevinMD.com/podcast. In the upper right-hand corner, there’s a search icon. Search for Dennis’s name to see all of his episodes and his story. But let’s talk about your most recent article, which is titled “A tiny step to reduce physician burnout,” and how physician employment contracts can play into that. So before getting to your article, give us some context. Tell us what you think physician burnout is and its prevalence.

Dennis Hursh: Well, I think it’s incredible, and you see it. I see it as a patient all the time, in addition to my work in reviewing contracts. I just think physicians now are expected to do it all. You know, we’re cutting back on staff, so things that we used to have staff do, now we expect the physician to do. And in particular, I think that we figure that you should eat, sleep, and practice medicine. Those are the three things that you should be allowed to do, and in a pinch, I think we’re OK if we take out the eating.

So it’s just the incredible strains that are put on physicians. You know, there’s a shortage, but it’s no problem from a hospital administrator’s perspective. We just keep scheduling you. That one physician, we’ll just have him or her do the work of two or three, and everybody’s happy, except maybe the physician.

Kevin Pho: Now, do you see physicians coming into your office with evidence of burnout and wanting to perhaps renegotiate a current working situation?

Dennis Hursh: I do, a lot. Not so much in the middle of a contract, but people are coming up saying, “My contract’s renewed, and I just can’t keep doing this.” And I have people say, “I’m going to just quit.” And, you know, we talk to them: “Well, can we do something like part-time? Is there anything we can do to kind of make things a little better for you?” But yeah, all the time I have people come in saying, “My contract is up for renewal, but I’m thinking about not renewing it. I’m just going to quit.”

Kevin Pho: So what are some common reasons that they give you for that hesitation in renewing their contract?

Dennis Hursh: One of the most common is, “I’m just working too much.” You know, there’s too much call. Call in and of itself, I think, is hard on people, and there are not too many other professions that have it, you know, where you’re expected to once in a while just give up a night’s sleep and do your job.

But one of the biggest things is just the hours that they’re working. You know, I was talking to a physician who said, “You know, I get into the office maybe 7:30 in the morning. I do a little bit of work. I start seeing patients at 8. I end seeing patients at 5, 5:30. Then I spend a couple hours charting. Then I go home and get something to eat. Then I work on charting. Then I go to bed, and I start over.” And it’s just, literally, he has no life. That’s just what he does.

Kevin Pho: Are you seeing these cases of physicians becoming burned out? Is it becoming more frequent over the years?

Dennis Hursh: Yeah, it is. I didn’t use to hear about it as much as I do now. I think it’s shocking that there is such a thing as, you know, TheHappyMD.com, and I understand they’ve treated 40,000 physicians. I didn’t look before the podcast, but I’m pretty sure if I Googled TheHappyHospitalAdministrator.com, nothing is going to come up. You know, I’m real sure TheHappyLawyer.com isn’t a thing either. It’s just physicians. They’re just being beaten to death on this.

Kevin Pho: Now let’s talk about your most recent KevinMD article and how a physician employment contract can influence that burnout rate. Tell us a little bit more about this article.

Dennis Hursh: Well, a lot of physician contracts quite rightly say that you’re going to do 1.0 FTE, and FTE is corporate-speak for full-time equivalent, and full-time equivalent is generally recognized to be 40 hours a week. That’s fine as far as it goes. Many hospital administrators, when they say 40 hours a week, mean patient contact hours, so you will be face-to-face with a patient for 40 hours a week.

Well, anybody knows that if you are with patients 40 hours a week, you might have, I don’t know, 80, and you probably have a better sense of this than I do, but maybe 80, maybe 90 hours a week, between the charting, between talking to the managed care companies trying to get things approved, committee meetings, all the things you have to do at the hospital. So 40 hours a week maybe isn’t a crazy work requirement, but physicians with a 40-hour patient contact week are going to just get swamped.

So what I’ve been trying to do, and I’ve had some success, is I usually argue that if you’re pure clinical, with no administrative duties, 32 patient contact hours a week is reasonable. Again, is that going to give you 40 hours a week? Absolutely not. But at least you’ll have some time, where it’s not family time, where you actually are in the office and have time to do charting and things like that.

So I shoot for 32 hours. I occasionally get it, but honestly, I think now I’m seeing more and more contracts where people are willing to give 36 patient contact hours a week, which is not great, but at least there’s maybe one day a week where you’re not up late charting and you have a personal life.

Kevin Pho: Now, does this apply to physicians across the specialty spectrum, whether it’s primary care versus specialty? And what about inpatient physicians, in terms of their patient contact hours?

Dennis Hursh: Well, I think for inpatient it’s a little less. If you have shifts, I think that you tend to do your shift, and there usually isn’t a large overhang after your shift where you’re expected to do a lot of things. So for inpatient, I think it’s not quite as important, but I think across all other specialties it really is. It’s extremely important. And, I mean, you see this with surgeons. You see it especially with primary care physicians. They are the ones that are really mauled by this, but surgeons, I think, have the same kind of issue. You know, you’re not just seeing patients or operating. You’ve got tremendous other responsibilities.

Kevin Pho: So I can certainly tell you, with 36 or 40 patient contact hours, how much more administrative time is on top of that. But tell me what you’re seeing, because you talk to a lot more physicians than I do. Give us some stories of when they say 36, 32, or 40 patient contact hours. Give a story of how many actual hours per week that could be, for those non-physicians who may be listening to this.

Dennis Hursh: Well, I haven’t sat down and tried to analyze it, but I told you the story of the physician that basically eats, sleeps, and sees patients Monday through Friday. Assuming a slight commute, he’s probably doing from 6:30 to, let’s say, roughly midnight, and he’s probably taking as much as an hour for personal time to eat and so on. So you do that, what’s that, 18 hours roughly, and say 17 hours a day. He’s doing it five days a week, so that would be 85 hours, and I’m pretty sure he doesn’t get weekends off either, that he’s doing at least some administrative things over the weekend.

And remember, I’m not talking about call. I mean, I’m not saying that in addition, you know, one or two nights a week he’s on call all night. You know, a hospital administrator would say, “Well, you can do your paperwork then,” which I guess is one way of looking at it. But I mean, the hours are literally, I don’t think 80 to 100 hours is an exaggeration of a physician workweek.

Kevin Pho: So tell us the approach that you take to negotiate how many patient contact hours a physician should have. So if a physician is interested in a job, and the job gives them the job requirements saying X amount of patient contact hours, tell us what happens next in the negotiation process.

Dennis Hursh: Well, most commonly they don’t, and that’s the problem. They say you’re a 1.0 FTE, and again, I think most people agree a full-time equivalent is 40 hours. So if you just let it rest, you think you’re working 40 hours a week, and they think you’re seeing patients for 40 hours a week. So a lot of times you have to insert the concept of patient contact hours. You know, “I’m not saying I’m not working. I’m just saying not every waking second is patient contact hours.” And you still see some that say you will do 40 patient contact hours a week, exclusive of call.

More and more, though, it’s just silent, and that’s where I think it gets to be a problem. There need to be patient contact hours, because, I mean, the next thing you know, you’re seeing patients 40 hours a week, and for an FTE, they think, “Well, we have the clinic open Saturday mornings too, so we think that’s an FTE.” So it’s very critical that you put some kind of constraints in. Sometimes you can get four days per week of patient contact. You know, think dermatologists; they classically get that, and some other specialties too. But as I said, you have to talk about patient contact hours, not just working hours. You have to make clear what a working hour is. You’re still going to have a lot more than 40 hours, but at least maybe you won’t get killed.

Kevin Pho: Now, for those contracts that just leave that silent, tell us the spectrum of responses that you receive when you introduce the number of patient contact hours. Let’s say it was silent, and they said, “I only want 32 patient contact hours.” Give us a spectrum of responses from the medical institutions that you’ve seen.

Dennis Hursh: One end of the spectrum is what I call hospitalsplaining: explaining to you that an FTE is 40 hours. “People work 40 hours a week, so that’s what we expect from your client.” And again, so then you’ve got to go back and say, “Well, what is working? You know, so this physician will never be talking to managed care companies? This physician won’t be available to talk to patients anytime he’s not seeing a patient? Is that what you mean?” And you have to really push.

Whereas some come in and say, “No, we’ve already taken care of that, and we have 36 patient contact hours a week.” In some cases, I’ve actually seen some that started at 32 patient contact hours a week. But the one extreme is it’s just not mentioned, and you actually see contracts that say you’ll do basically whatever’s required. So however many patients we have, you’re going to be around and see those patients. Well, you and the other physicians. But again, you know, if we have Saturday hours and we have Monday through Friday, somebody’s got to take them, so guess who that’s going to be. Not the administrator.

Kevin Pho: So in general, for those hospital systems that explicitly state, say, 40 patient contact hours for a full-time FTE, again, what is the room for negotiation? You mentioned a couple of scenarios.

Dennis Hursh: They know, and you just have to say, “Look, you’re not going to get good-quality care from a physician. You know, you can for a while, right up until the point that it’s a totally frazzled physician. So you need to do less.” And you just have to start there. A lot of times they’ll say, “Well, the other physicians are doing that,” you know, and you have to negotiate.

I’ve had some where I actually had a physician agree, which I think is crazy, but they were so frazzled, they agreed that 32 patient contact hours a week was a 0.8 FTE and actually took a pay cut to be treated as a 0.8 FTE. Now, as I said, that physician knew full well she’d be working, you know, way over 40 hours a week, but it just wasn’t worth it to her.

Kevin Pho: Now, you see a lot of physicians just simply sign the contract that’s in front of them. Are you seeing more and more doctors being aware of these nuances, like we’re talking about today?

Dennis Hursh: I think attendings are more aware of it. I still think there’s a large percentage of people that come out of training and say, “Oh, I’m making this much,” and flip through and say, “Oh, they’re offering me that much? Yeah, great. Where do I sign?” So I think attendings, by and large, are learning that these things are negotiable. For newer physicians, I think it’s still kind of, a lot of people sign what’s handed to them.

Kevin Pho: Now let’s talk about call, because we mentioned that earlier, and that plays a large role in terms of how many hours per week one is working. How much negotiation is there around the frequency of call and how much call they should take?

Dennis Hursh: It’s hard. It’s really hard, because they’ll say, “Well, we need to cover our patients. You know, it’s your responsibility to make sure we have patients covered.” So it’s very hard to introduce the concept of a limit. I mean, a couple of things. I always say call should be equitably allocated among all eligible providers, so it’s possible that a nurse practitioner can take call some nights. We may want physician backup, but sometimes maybe a nurse practitioner could do call.

Another thing that I push, and I get it sometimes, a lot of times I don’t, is a ratio. But no matter what: “Look, there are six physicians in the department. Promise me that in a given month I won’t have more than one in five call.” So I’m not saying I will never take call. I’m not saying I’m taking less than the other physicians. And I think you just have to come back and say, “Look, you may have to hire a locum tenens.” You know, the fact is you can’t expect your physicians to keep doing good-quality care if they’re doing that much call.

Kevin Pho: Now, we do have national standards when it comes to things like salary. Are there any national benchmarks when it comes to things like call?

Dennis Hursh: Yeah, there are. MGMA has call, and they tell you the median unpaid on-call hours per week for a specialty, and then also what the median daily rate is, and usually you can get a median hourly rate too. So the backup position, and again, I don’t think it’s as good, is if you have to do a lot of call, at least you should be compensated extra for it. You shouldn’t just take it.

Kevin Pho: So we’ve talked about patient contact hours, and we’ve talked about call. Now, in a physician employment contract, what are some other big factors that directly influence physician burnout?

Dennis Hursh: Well, I think some of it is the automatic renewal. I’m just looking at a physician that had an automatic renewal from a 2018 base salary. I’m sure it was good money in 2018, but now, on top of being hammered with incredible responsibility, she’s also getting paid a lot less than she probably should be. So I think there’s that.

I also think that because of the pandemic, and I think some of it is legitimate and some of it isn’t, hospitals in particular are cutting back on staff, and the patients are still being seen. So if you used to have a dedicated MA, and now you and another physician are sharing an MA, I mean, that becomes stressful when physicians are paid on productivity and you’re sitting in an empty exam room because the MA got distracted. So I think staffing is a huge issue.

And honestly, it’s weird. It seems like over the years, instead of things being passed down, and most industries pass it down, and you delegate as low as you can go, I think it’s just stayed in the health care industry that the physician does it all. I mean, sometimes you need a physician. If you’re talking to a physician at a managed care company, you need a physician; a nurse isn’t going to do that. But there’s an awful lot of physicians talking to nurses at managed care companies, and that just doesn’t make sense. So I do think in this industry it’s weird. Every place else in the world, they delegate. You just don’t see that as much in health care.

Kevin Pho: So let’s talk about that automatic renewal, because that is something that all physicians have to deal with. Do you see a lot of doctors reopening their contract for negotiation, and should they?

Dennis Hursh: I think they should. You don’t see so many, because a lot of times you aren’t even told. You know, you signed a contract four years ago on August 1. August 1 isn’t a big date in your mind, and on August 1 it just flips over for another year. So I don’t see as much as I should. I think, again, because of burnout, more physicians are looking at their contract than they used to, and I think that’s when people see something: “This thing renews August 1,” for example, “and I need to do something. I need to get this fixed before it renews.”

Kevin Pho: We’re talking to Dennis Hursh. He’s a regular guest on The Podcast by KevinMD. He’s a physician contract attorney. His latest KevinMD article is titled “A tiny step to reduce physician burnout.” Dennis, as it relates to physician burnout and contracts, what are some of your take-home messages that you want to leave with the KevinMD audience?

Dennis Hursh: Well, the biggest thing is don’t sign what’s handed to you. And I think consider looking at your contract at renewal. With a physician shortage right now, I think it’s not unreasonable to ask to renegotiate your contract anyway. And when you do, you have to think about, “Why am I burned out, and is there anything I can do?” If you have unreasonable patients, that’s tough, but things like massive patient contact hours, improper staffing, not enough MAs, things like that, those are all things that I think should be brought up in a contract negotiation or renegotiation.

Kevin Pho: Dennis, thank you so much again for coming back on the show and sharing your time and insight.

Dennis Hursh: It was my pleasure.

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