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When did volunteering stop being a choice and start being a condition of professionalism? Pediatrician, certified coach, and mindfulness and yoga teacher Jessie Mahoney realized she had donated over 2,000 hours of uncompensated work as a volunteer clinical professor, all while holding leadership roles and raising three kids, and she had never once questioned it. Her episode is based on her KevinMD article, “The hidden cost of uncompensated work on physician burnout,” Mahoney traces how residency culture normalized unpaid labor and how systems now depend on it, framing obligation as generosity and penalizing anyone who pushes back. You will hear why she believes uncompensated work is low-hanging fruit in the fight against physician burnout and how the expectation of free labor disproportionately affects women, who now make up roughly 60 percent of the physician workforce. She offers practical language for setting boundaries, including the phrase “I wish I could, but I don’t have capacity right now,” and explains why compensation does not have to mean money alone. Mahoney also explores how generational tension among physicians reinforces the cycle and why collective action, from retreats to unionization, may be what finally shifts the culture. If you have ever felt guilty for questioning what medicine asks of you for free, this conversation will reframe that instinct entirely.

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Transcript

Kevin Pho: Hi, welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Jessie Mahoney, pediatrician and coach. Today’s KevinMD article is “The Hidden Cost of Uncompensated Work on Physician Burnout.” Jessie, welcome back to the show.

Jessie Mahoney: Nice to be here again.

Kevin Pho: All right, so tell us what this latest article is about.

Jessie Mahoney: It’s about the normalized unpaid labor in medicine that we call professionalism. It’s noticed and, for the most part, also not noticed. This came out of a recognition of my own. I had been a volunteer clinical professor for years, and at some point I added up the hours they were asking me to fill in paperwork to get promoted. I had donated over 2,000 hours of work, which is more than a year of work. I’m married to someone whose job requires you to record hours, so I knew what a robust year of work looked like, and this was a robust year, not just a short one.

I realized I had never even considered the impact of it, and I did all of that while having a couple of leadership roles and raising three kids. And I thought: While I love teaching and it’s meaningful, and I think all of us as physicians are good people. We’re committed, we’re purpose-driven, we want to help. It becomes not really a choice. It becomes the default. A good physician volunteers teaching hours. Even in our evaluations, and I’m guilty of this as someone who wrote a lot of feedback evaluations, it’s, “What are you contributing? What unpaid work are you contributing?” That’s the expectation.

Our jobs are so hard that adding in unpaid work is really a significant added driver of burnout that I don’t hear us talking about much. We say it’s generosity, we say it’s service. But is it, when it’s expected?

Kevin Pho: I definitely hear what you’re saying. There is a lot of expected uncompensated work physicians are being asked to do. How did our culture get to be like this?

Jessie Mahoney: We normalized it. It’s just what’s expected. If we go back to our training, it was expected, and it was hardly paid if you broke it down to an hourly salary. So we’re used to giving of ourselves beyond what’s expected. And in fact, if we don’t, there are repercussions, even just for speaking up about it. It’s also often assigned, and we’re taught not to question assigned work. If someone thinks something is your job in medicine, it becomes your job.

We’re also trained to prioritize others, prioritize service, prioritize generosity. Sacrifice and overgiving become equated with goodness. It’s just what a good person does. It’s risky to say no, or you’re seen as disloyal, as someone who’s not contributing.

From the teaching standpoint, and it isn’t that I don’t think we should teach, I actually think we just need to decide how much we’re going to teach, be aware of how much we’re going to teach, and potentially have some compensation for it built in more than it is already. Sometimes we’re not grateful for all the people who donated their time to us, and so this has become one of those things we just do, whether it’s leadership at night, handling things on off hours, or charting. There are so many pieces of volunteer work. Volunteer work is OK. But not when it’s expected. It should be seen as generosity and as a gift.

It’s not really generosity if it’s expected. It’s obligation. When we’re looking at things we can do to help physicians, acknowledging that, honoring that, and at least having it be seen is a really valuable point.

It’s also interesting that we’ve built a system that relies on it. Our entire medical education system relies on volunteers, and yet people are paying a lot to be a part of it. The whole symbiosis is fascinating. Our leadership structure, our clinic structure, the way we see patients: All of it is dependent on this. Nobody could get the work done during their paid time. It wouldn’t be humanly possible. I’m not even sure AI could get the work done in that time. If it were a robot, the quality wouldn’t be as good. Either way, I don’t think it’s possible. So the system depends on us doing this and believing it’s part of our mission. It capitalizes on the mission-driven, purpose-driven piece of our work as physicians.

Kevin Pho: Whenever physicians try to set boundaries against these uncompensated obligations, invariably administrators respond by saying, “It’s a calling. You made a commitment to your patients. This is what you signed up for. It’s in our oath,” some variation of that. What’s the most effective way to push back against that response?

Jessie Mahoney: I think it’s honesty and directness. Contributing 2,000 hours of unpaid labor couldn’t possibly be what’s expected. The other question is: would they expect that? Is that a reasonable expectation? We have to be brave enough to say it. In some settings we can speak up; in some settings, people cannot. In academics it’s much harder for people to speak up. But we have to begin having the conversation and putting it out there.

When more of us speak up, even in tiny ways, I often help people say no with phrases like, “I wish I could, but I don’t have capacity for that,” or, “I can do one lecture this year, but I can’t do a monthly lecture unless time is taken out of clinic, or I’m given time to travel.” I remember if you had to travel to give a talk, you would have to use your own accrued vacation time to get there and back, because you couldn’t possibly see patients and get somewhere to give a talk, even for residents.

The idea is changing the standards and having the conversations. Even the awareness changes things. When each one of us begins to speak up and question it, because we expect everyone to do it and so the expectation continues, at a bare minimum we begin to ask, “Is there compensation? I wish I could, but without compensation.” We could be creative. It could be time. There could be other ways to do it. Or systems need to build it in.

This is unsustainable. For some people it’s risky, so I don’t think we should say everyone needs to speak up. But those of us who can need to speak up. Those of us who are leaders can acknowledge what’s happening and acknowledge that it’s volunteer work. We need to call it out for what it is: “Oh, you mean you’re asking me to donate all of these hours?” Then the ask becomes clear, as opposed to the expectation.

The other thing is, we’re often assigned things that are free labor. If you’re assigned something, ask: “What is the compensation for it? Am I going to be given time for it?” Because if we don’t value our time, it doesn’t change.

It reminds me a bit of this: We used to have residency with no work-hour limitations. For a while we were like, “Well, it just has to be that way.” This strikes me as similar. It doesn’t have to be this way. It’s become the norm, but we can change it if we choose to, and if we support one another. Our culture is kind of to talk on the back end: “Oh, they weren’t doing this,” or “They’re not doing their part,” or “They’re not a team player.” We need to change that conversation, each and every one of us. If someone sets a boundary and says, “I don’t have capacity for that at this time,” we can show up with non-judgment.

Kevin Pho: One of the things you mentioned: Some physicians don’t speak up because they have a fear of being judged, or being labeled as selfish if they start saying no to extra tasks. So it just takes one, especially leaders, to speak up, and others to join that leader to get this out in the open. Hopefully that prevents physicians from that fear.

Jessie Mahoney: Yes. Anytime we do something hard or change something, there’s fear. In medicine we’re trained that if there’s fear, you don’t do it. And yet I would say we should have fear about continuing to do it, because it’s a huge driver of why people are leaving professions they love. We need to have doctors in the future. So making it a sustainable practice is critical.

I know of no other profession where they just donate all this time. It’s a norm in health care, but is it a norm in other disciplines? Even nurses don’t take this approach. They get overtime. It comes from that culture of residency, and from this sense that if you don’t serve to the end of the earth, perhaps until you drop dead, you aren’t valuing your work, you aren’t loyal or committed or professional. So it’s about changing our definitions of professionalism.

Kevin Pho: I’ve noticed that sometimes some of that pressure to take uncompensated work comes from our fellow physicians, people from a generation where they did sacrifice everything for medicine. So if a physician sets a boundary, they’re looked down upon by their fellow physicians, not necessarily administration. Do you see the same thing?

Jessie Mahoney: Absolutely. We cannot look down on others. We have some generational issues in medicine where we make a lot of comments about the generation behind us and how it’s different. But my thought is: medicine is different. We could do this culturally in a time when we weren’t seeing a patient every 15 minutes, and when doctors had compensation more aligned with the work they do and more aligned with other professions. These days we don’t. There’s really not this room. This is something that’s been carried forth that no longer fits our current model.

For women with small children, apparently 60 percent of the physician workforce is now women, we just need to begin speaking up. This is actually not possible if you’re balancing all of these things. I love the phrase, “I wish I could, but I don’t have capacity right now.” And then the offer is, “Well, I could do it if I don’t do X, Y, or Z.” Or if it’s paid and it replaces something else, then we’re changing the conversation.

But we will be judged. Whenever anyone goes first, you are judged. Part of that is checking in with my future self: “Will she wish she had spoken up? Will she wish she had spoken up on behalf of someone else?” We often look back and say, “Wow, I really participated in a system that I don’t actually believe in,” the way we treat residents, for example. If we want it to change, we can’t just say, “Well, it was that way when I was there.” We have to be able to move forward. Otherwise, medicine is not going to move forward.

Kevin Pho: You’ve worked in several organizations. Can you give us an example or scenario where we had this snowball effect of physicians setting boundaries and eventually having that group of physicians affect policy change for the better? Is there an example of that working?

Jessie Mahoney: What comes to mind is the Lorna Breen Act, and that was how we got work hours. It took a lawsuit, honestly, to get work hours. I’ve actually seen that happen in many cases in medicine. There was an issue when I was a resident. I was a resident in California, and we have a lot of employment laws. I ended up getting some payout 10 years later because of overtime, or whatever it was.

Part of it is speaking up. Part of it is speaking up collectively. I’ve also seen locations drop certain roles or certain contributions. There’s always a hoop about it, and then it settles out, and there’s more time and space for people. But it takes time, and it takes individuals to start. Then it becomes acceptable to teach or not teach, acceptable to volunteer here or not. You get to choose. But if we don’t set boundaries, we won’t get there.

I’ve seen a lot of physicians begin to unionize, and that’s really where you start to get the shift. I realize that sounds stark. It doesn’t have to be a legal thing. But until we all begin to have each other’s backs as leaders and as fellow physicians, and aren’t judging one another, and we did a podcast about that, that’s what it’s going to take for the culture to change and for us to support one another.

One other thing I’ve seen be very powerful, actually not within one institution: When I do retreats, people come from all over the country and all different institutions, and they start to see what happens in different spaces. “Oh, this isn’t the expectation there. And this isn’t the expectation there.” So it’s not actually normative. That helps people begin to speak up.

Kevin Pho: We’re talking to Jessie Mahoney, pediatrician and coach. Today’s KevinMD article is “The Hidden Cost of Uncompensated Work on Physician Burnout.” Jessie, as always, let’s end with take-home messages you want to leave with the KevinMD audience.

Jessie Mahoney: My take-home message would be to track your extra hours. Not to feel resentful, but to make a conscious decision about how you’re spending them. When you track them, it becomes easier to speak up on your own behalf, and to support others who do speak up.

Then, as institutions and leaders, we need to begin to look at this as one of the drivers of burnout. Institutions and leaders across the country are trying to solve this problem, and to me this is low-hanging fruit. There are some easier solutions, whether that’s finding some kind of compensation or no longer making it a default expectation.

Kevin Pho: Jessie, as always, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Jessie Mahoney: Happy to be here.