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Effective URL: https://edhub.ama-assn.org/steps-forward/module/2820183?utm_source=silverchair_edhub&utm_campaign=activity_alert-edhub&utm_...
Submission: On June 19 via manual from US — Scanned from CA
Effective URL: https://edhub.ama-assn.org/steps-forward/module/2820183?utm_source=silverchair_edhub&utm_campaign=activity_alert-edhub&utm_...
Submission: On June 19 via manual from US — Scanned from CA
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<div>Published Online: <span class="epub"><span class="month">June </span><span class="day">11, </span><span class="year">2024</span></span></div>
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<div class="wi-fullname brand-fg"><a href="/searchresults?author=Diane+Shannon&q=Diane+Shannon&hd=edhub" target="_blank">Diane Shannon, MD, MPH<sup class="no-link-sup">a</sup>; </a></div>
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<p class="para">This toolkit will help organizations understand and remove barriers that prevent physicians from taking time off, such as a culture of constant accessibility, inadequate clinical coverage provisions during
time off, and compensation plans that don't reflect time off. Taking time off can be challenging for physicians, given both individual and organizational commitments to high-quality, accessible care, but a positive
workplace culture that protects and encourages paid time off (PTO) will prevent burnout among physicians which in turn translates into better patient care.</p>
<a class="article-section-id-anchor" id="section-249752826"></a>
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<a class="article-section-id-anchor" id="section-249752827"></a>
<p class="para">A health system's human resources department contacts a physician leader with a specific request: “Can you please ask your physicians to document their vacations? They're not recording their days off.” The
investigation reveals it is not a failure to document—the physicians simply are not taking any time away from work. The barriers are just too high.</p> <a class="article-section-id-anchor" id="section-249752828"></a>
<p class="para">According to survey data, physicians are allotted an average of 25 to 35 days of PTO each
year.<sup><a href="#r1" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">1</a></sup><sup>,<a href="#r2" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">2</a></sup> Some
physicians receive an additional 5 to 10 PTO days annually for continuing medical education (CME). And yet, in a 2023 study of over 3000 US physicians across multiple organizations and specialties, approximately 60% of
physicians reported taking 15 or fewer days of vacation per year, and 20% reported taking 5 or fewer days per year.<sup><a href="#r3" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">3</a></sup></p>
<a class="article-section-id-anchor" id="section-249752829"></a>
<p class="para"><strong>And the result of not taking time off? Increased burnout.</strong></p> <a class="article-section-id-anchor" id="section-249752830"></a>
<p class="para">The same study showed that spending more than 30 minutes a day on patient-related work during vacation was associated with higher odds of
burnout.<sup><a href="#r3" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">3</a></sup> On the flipside, taking more than 3 weeks of vacation per year and having full electronic health record (EHR)
inbox coverage while on vacation were associated with lower odds of burnout. Time away from work responsibilities to rest and recover from work-related physical, mental, cognitive, and emotional demands is crucial for
maintaining a viable
workforce.<sup><a href="#r4" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">4</a></sup><sup>,<a href="#r5" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">5</a></sup></p>
<a class="article-section-id-anchor" id="section-249752831"></a>
<p class="para"><strong>Why don't physicians take PTO?</strong></p> <a class="article-section-id-anchor" id="section-249752832"></a>
<p class="para">A few prominent barriers prevent the use of PTO. First, there is inadequate clinical coverage for patient care tasks, including EHR inbox coverage, during physicians' time off. Thus, most physicians are still
logging into the EHR during their PTO because they feel this is the only way that 1) they won't compromise patient care, 2) they won't burden their colleagues, and 3) they won't face an impossible load of EHR work upon
their return. Survey data show 70% of physicians reported working while on vacation on a typical vacation day.<sup><a href="#r3" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">3</a></sup> As a
result, their PTO is not truly “time off”—so what's the point in taking it?</p> <a class="article-section-id-anchor" id="section-249752833"></a>
<p class="para">Second, physicians are not billing RVUs while on PTO. This becomes problematic if the benchmarks for RVU productivity and bonuses—as well as projected compensation calculators—do not take PTO time fully into
account (eg, if the productivity targets are based on the potential RVUs generated over anything more than 44-45 weeks of productive time per year). This gives physicians the impression that they are losing money by taking
their PTO and creates internal and external pressures to reach those unrealistic goals.</p> <a class="article-section-id-anchor" id="section-249752834"></a>
<p class="para">Third, the culture of self-sacrifice and 24/7 availability is infused into medicine as a calling—physicians choose the field because they want to help and heal, which inherently involves some degree of
self-sacrifice and work outside of traditional work hours. However, when taken to the extreme, this culture harms both physician well-being and patient care.</p> <a class="article-legacy-id-anchor" id="f4"></a>
<a class="article-section-id-anchor" id="section-249752835"></a>
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<a href="https://cdn.edhub.ama-assn.org/ama/content_public/journal/steps-forward/937327/ama-2024-0000500-f003_1718220906.23693.png?Expires=1721822534&Signature=WdLT6jxw6l4BFhPvat3xhAuv1yxc5zAunfGmJJWIw5Wo8o6ZUUF9EvkRFIyPV~k~MHaUIMDMgtHEUT0Zes9nYo9YnJ04TRp-Sn~Zjjb5kAzHq9br2gEiWoieQYDYRLECJOmeKs6oheXqlGBurtDPCf5xYiL1HpaJPQg9uU5lyeISKbWrJFMT92WXSfPmvklgvDbE1baqme-rsd~5o64VXh~uv5nkAiABBjHjqZn0LUedi~U0XJ45Km8LHJuOjlOLsTlDQ-W9MyYGo~vi1g2iOFaXH4LKZYguC39UEeBk1aJhgXtm63E6DSjqERbeosvtXRGwWfZ1bLxVsHPHBNfKUg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" target="_blank" path-from-xml="ama-2024-0000500-f003.png" rel="nofollow"><img data-original="https://cdn.edhub.ama-assn.org/ama/content_public/journal/steps-forward/937327/m_ama-2024-0000500-f003_1718220906.23693.png?Expires=1721822534&Signature=QuJ6STZb1W~nbN3XoWUhiHCWArPqKXrhXYTnNmKPYxriTzxxtdE1g1iA~BcXeS7Sw5fHFKeMXeVWojDlwQF7YSHJTsCAfcKmD9ruDqPKBmCZ-sKylFZrfhFMo7XsiC9QHrtj8Ubjn-6TpZBMFg-5Lu0PLM1hJuJ0ayYc6Qw4H7jjOIFa8--UDLsAS294XSDSGu35eIkvaLBDxxREJGW7hCQeFZIcI28WdREhBYQzZQqOCsmlLIHXuhIMfgy2ZAracGD68O~H9bAvMKFTUEaWnfSGTJE6hIzJ6tPHSU5KAVJuJm0DGNl5iGbgwgHlcP~0dQ8Rtmj4MAA5pvmkcERJ1w__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" alt="Image description not available." class="content-img lazy " path-from-xml="ama-2024-0000500-f003.png"></a>
</div>
</div>
</div> <a class="article-section-id-anchor" id="section-249752836"></a>
<div class="h3 cb section-type-section ">
<div data-xref-sec-id="h1-3" class="heading-text thm-col"> Seven STEPS to Give Physicians “Real PTO” </div>
</div>
<a class="article-section-id-anchor" id="section-249752837"></a>
<p class="para"></p>
<ol class="number">
<li>
<p class="para"><a href="#" data-xref-sec-dest-id="h1-4" class="js-xref-sec-jumplink">Embrace 3 Components of Real PTO</a></p>
</li>
<li>
<p class="para"><a href="#" data-xref-sec-dest-id="h1-5" class="js-xref-sec-jumplink">Understand the Business Case for Real PTO</a></p>
</li>
<li>
<p class="para"><a href="#" data-xref-sec-dest-id="h1-6" class="js-xref-sec-jumplink">Normalize the Culture of Taking Time Off</a></p>
</li>
<li>
<p class="para"><a href="#" data-xref-sec-dest-id="h1-7" class="js-xref-sec-jumplink">Provide Adequate Coverage, Including EHR Inbox Coverage</a></p>
</li>
<li>
<p class="para"><a href="#" data-xref-sec-dest-id="h1-8" class="js-xref-sec-jumplink">Enact Reasonable On- and Off-Ramp Policies for Taking Time Off</a></p>
</li>
<li>
<p class="para"><a href="#" data-xref-sec-dest-id="h1-9" class="js-xref-sec-jumplink">Design a Compensation Model to Adequately Include Time Off</a></p>
</li>
<li>
<p class="para"><a href="#" data-xref-sec-dest-id="h1-10" class="js-xref-sec-jumplink">Track Time Off to Ensure Fairness</a></p>
</li>
</ol>
<p></p> <a class="article-section-id-anchor" id="section-249752838"></a>
<div class="h3 cb section-type-section ">
<div data-xref-sec-id="h1-4" class="heading-text thm-col steps-heading-wrap">
<span class="styled-content-steps-heading">STEP 1</span> Embrace 3 Components of Real PTO
</div>
</div>
<a class="article-section-id-anchor" id="section-249752839"></a>
<p class="para">Paid time off can vary in definition among different organizations, but generally includes vacation, holidays, sick days, personal days, CME days, medical leave, parental or family leave, and disability
leave. This toolkit will focus on the first 5 categories of <strong>vacation, holidays, sick days, personal days,</strong> and <strong>CME days,</strong> which apply to all physicians, as opposed to the latter categories
for more extended absences, which affect fewer physicians and typically involve different compensation and coverage models.</p> <a class="article-section-id-anchor" id="section-249752840"></a>
<p class="para"><strong>This toolkit emphasizes the importance of “Real PTO”</strong> (<a href="#f1" class="figure-link section-jump-link" data-tab-toggle=".tab-nav-figure-table">Figure 1</a>); a framework for time off for
physicians that:</p> <a class="article-section-id-anchor" id="section-249752841"></a>
<p class="para">1) Transitions all patient care and EHR responsibilities to other team members without feelings of guilt about burdening colleagues</p> <a class="article-section-id-anchor" id="section-249752842"></a>
<p class="para">2) Provides adequate lead-in and catch-up time before and after time away</p> <a class="article-section-id-anchor" id="section-249752843"></a>
<p class="para">3) Adequately accounts for PTO in compensation models</p> <a class="article-legacy-id-anchor" id="f1"></a>
<a class="article-section-id-anchor" id="section-249752844"></a>
<div class="figure-table-wrapper thm-bd-top">
<div class="figure-label">Figure 1. Three Components of Real PTO</div><a id="ama-2024-0000500-f001.png" class="figure-table-anchor"> </a>
<div class="figure-table cf cb">
<div class="figure-table-image">
<a href="https://cdn.edhub.ama-assn.org/ama/content_public/journal/steps-forward/937327/ama-2024-0000500-f001_1718220906.31402.png?Expires=1721822534&Signature=03rGiB6YhogZVp8mp3p~5X1~vxBkojgkSRCkgaqu2CRu662A7cBkL5b1r~24yBkSgqnUYi0wunh1R98yQYLUZI3hVD0WTcZeHUIObB1i-sRfuMhjNZntLRhyncZHurs~3pu37bAHRlhnNeAeL2CdAhK~P2o1hpeZT5lmi1LkhJ4r75hDIQMh8KlL3yQfjxPyhDQy4y1PDP6NqbY71q0ulqnHbXh6xc1EanWVUX1oexv472JcImCTVMQVOqwvNugzMRclEGja2p3lpLVGJsEmuauo7CUyCHSJujeoTujYs917PbB4ARppoMN7hJfZokTnakZJjg-U2Vwpo2yXzI3aRw__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" target="_blank" path-from-xml="ama-2024-0000500-f001.png" rel="nofollow"><img data-original="https://cdn.edhub.ama-assn.org/ama/content_public/journal/steps-forward/937327/m_ama-2024-0000500-f001_1718220906.31402.png?Expires=1721822534&Signature=1MISXro008VsxTUld1bq9xRUrRoDKscsfn~6XB1lJol1-smxFI1Pab99AhfLGavlouMB151UXyXMzumc1ym9-oIVqSQEyXWY6kqoBksziAhCQRekM9mlL0TFSVvpz7eFmuFxCo1141zRny5gGiVo8jUQjgzWU2W6hDUPxSL2wTophFJ2KOUOOe4UfzV6Sg4nj9LcIvl8q9ljccfNRWmVcB4Fr35IGvunUSNXI3PZbdVuRquDik9EGcZzj4~RjveT8ypU9FgK87-52FM2eM3l0tqBlR-EQkKItmRBLZmGOxMVZkqU7io~gefmQCoa5vSQVBFcMZpBJ0CHfu1~WwPo9Q__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" alt="" class="content-img lazy " path-from-xml="ama-2024-0000500-f001.png"></a>
</div>
</div>
</div> <a class="article-section-id-anchor" id="section-249752845"></a>
<div class="h3 cb section-type-section ">
<div data-xref-sec-id="h1-5" class="heading-text thm-col steps-heading-wrap">
<span class="styled-content-steps-heading">STEP 2</span> Understand the Business Case for Real PTO
</div>
</div>
<a class="article-section-id-anchor" id="section-249752846"></a>
<p class="para"><strong>Real PTO is a strategy for health systems and practices to reduce burnout and increase loyalty and retention of physicians.</strong></p>
<a class="article-section-id-anchor" id="section-249752847"></a>
<p class="para">Real PTO is a short-term expense offset by long-term benefits for individuals and health systems. There is a strong business case for giving physicians opportunities to recharge and pursue a satisfying life
outside of medicine. Two fundamental factors drive the business case for Real PTO: 1) reducing burnout and 2) building trust.</p> <a class="article-section-id-anchor" id="section-249752848"></a>
<p class="para"><strong>The Benefits of Real PTO</strong></p> <a class="article-section-id-anchor" id="section-249752849"></a>
<p class="para">A 2023 study showed that taking more than 3 weeks of vacation per year and having full EHR inbox coverage while on vacation were associated with lower odds of burnout, while spending more than 30 minutes a
day on patient-related work tasks while on vacation was associated with higher odds of burnout.<sup><a href="#r3" class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references">3</a></sup></p>
<a class="article-section-id-anchor" id="section-249752850"></a>
<p class="para">Thus, long-term benefits of successful Real PTO may include:</p> <a class="article-section-id-anchor" id="section-249752851"></a>
<p class="para"></p>
<ul class="bullet">
<li>
<p class="para">Reduced physician burnout, which may reduce turnover, leading to increased patient access and improved continuity of care</p>
</li>
<li>
<p class="para">Improved engagement and vitality of the physician workforce</p>
</li>
<li>
<p class="para">Reduced costs for the organization related to physician burnout</p>
</li>
</ul>
<p></p> <a class="article-section-id-anchor" id="section-249752852"></a>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/interactive/16830405">Access the Costs of Physician Burnout to an Organization Calculator</a></p>
<a class="article-section-id-anchor" id="section-249752853"></a>
<p class="para">In addition to the cost of burnout, when physicians in an organization don't take PTO, the organization experiences soft costs in the form of eroded trust, resentment, and apathy.</p>
<a class="article-section-id-anchor" id="section-249752854"></a>
<p class="para"><strong>In Their Own Words: The Costs of Not Having Real PTO</strong></p> <a class="article-section-id-anchor" id="section-249752855"></a>
<blockquote class="blockquote thm-bd-color">
<p class="para">“We are supposed to be empathetic but don't receive empathy in return. We can never be sick. It makes me really angry.”</p>
<div class="attrib"><i>—Academic general internal medicine physician</i></div>
</blockquote> <a class="article-section-id-anchor" id="section-249752856"></a>
<blockquote class="blockquote thm-bd-color">
<p class="para">“Physicians just a few years out of training are so upset about PTO that they are leaving our organization for places where they have more control over their time. We are losing brilliant young physicians.”
</p>
<div class="attrib"><i>—Mid-career academic physician</i></div>
</blockquote> <a class="article-section-id-anchor" id="section-249752857"></a>
<div class="h3 cb section-type-section ">
<div data-xref-sec-id="h1-6" class="heading-text thm-col steps-heading-wrap">
<span class="styled-content-steps-heading">STEP 3</span> Normalize the Culture of Taking Time Away From Work
</div>
</div>
<a class="article-section-id-anchor" id="section-249752858"></a>
<p class="para">The professional culture of medicine has traditionally been one that encourages self-sacrifice and constant accessibility. While taking personal responsibility and ownership of all things related to patient
care is important for high-quality care while at work, when taken to the extreme and applied to time away from work, it is unhealthy for physicians, health care organizations, and ultimately their patients. Physicians and
health system leaders need to shift the culture of medicine away from the ideas that “self-care is selfish” or “time off is slacking” and toward recognizing that physicians are not superhuman and need both self-care and
time off in order to best serve their patients. As one clinical professor described it, “Time away is part of one's responsibility as a physician, professionally and ethically.”</p>
<a class="article-section-id-anchor" id="section-249752859"></a>
<p class="para"><strong>How Leaders and Organizations Can Shift This Culture</strong></p> <a class="article-section-id-anchor" id="section-249752860"></a>
<p class="para"></p>
<ol class="number">
<li>
<p class="para"><strong> Ensure that leaders model taking time off themselves.</strong></p>
<p class="para">Leaders who rarely take time off send the message that time off is not valued by the organization. On the flip side, when a leader takes time away and writes an out-of-office message that specifies that
they are taking PTO, this sends a message to the organization that taking time off is both acceptable and respected.</p>
</li>
<li>
<p class="para"><strong> Incorporate respect for time off into professional etiquette.</strong></p>
<p class="para">Encourage physicians to hone the mental discipline needed to avoid replying to emails and messages while away. Help them understand that one reply starts a volley of correspondence that will mentally
engage them rather than allow for cognitive decompression. Similarly, if you know a physician is taking PTO, do not send work communications with a disclaimer that they do not need to respond. Delay sending the
communication or use the email feature to schedule delivery after they return.</p>
</li>
<li>
<p class="para"><strong> Check the tone of communications regarding time off.</strong></p>
<p class="para">Whether in person or over email, leaders or colleagues sometimes inadvertently praise those who don't take time off or who work while taking PTO to stay on top of things. For example, if someone takes
their laptop on vacation with them to check their EHR inbox, one could respond with “Wow, that's so impressive”—which sends a message of approval for this self-sacrifice. An alternative message might be: “I'm sorry you
had to do that, let's try to fix this problem.” For some earlier-career physicians, seeking approval and praise from superiors and peers is deeply rooted in their years of training, and these words about working during
time off can perpetuate that unhealthy culture.</p>
<p class="para">Communication breakdowns may also occur when accusatory tones get in the way of messages, for example, when an administrator asks a physician to substantiate their time away for a CME conference. Simple
shifts in language and using a trusting tone can help change the culture and lessen the barriers for physicians to take time away.</p>
</li>
<li>
<p class="para"><strong> Make PTO policies transparent and easily accessible.</strong></p>
<p class="para">A human resources department should make it easy for physicians to find and understand their PTO policy. When a physician must jump through hoops to find out how many vacation or CME days they have, they
receive the message that using PTO is discouraged. Rather, setting up a standardized, proactive way to share this information (not just during onboarding but at regular intervals during the year) sends a message that
using PTO is encouraged.</p>
</li>
<li>
<p class="para"><strong> Proactively block off PTO into physician templates.</strong></p>
<p class="para">If a physician has 4 to 6 weeks of vacation and CME time per year, consider building their schedule templates with this number of weeks automatically blocked off, just like with national or local
holidays. Physicians should be encouraged to request these weeks off in advance, with the reassurance that these dates are not “locked” and can be changed later. It is much easier to reschedule patients from one week
to another when there is already adequate time blocked off, rather than finding slots to add them afterwards.</p>
<p class="para">Furthermore, a responsive management team that immediately acts upon rescheduling patients when a PTO change request comes through (rather than letting the task sit for a week or more) can boost both
physician and patient satisfaction.</p>
</li>
<li>
<p class="para"><strong> Engage individual physicians and work unit leaders for feedback and brainstorming.</strong></p>
<p class="para">Recognize that each work group or department will have different barriers to taking PTO and different needs for overcoming these barriers. Leaders and organizations must have a process to
<a href="https://edhub.ama-assn.org/steps-forward/module/2813036">engage work unit leaders and individual physicians</a> for input on solutions, and take on a true diversity mindset when implementing them.</p>
</li>
<li>
<p class="para"><strong> Celebrate time away</strong></p>
<p class="para">Especially with CME and vacations, ask returning physicians what they did, and encourage sharing with the group at the next meeting. Physicians returning from CME could also share key takeaways or lessons
learned.</p>
</li>
</ol>
<p></p> <a class="article-section-id-anchor" id="section-249752861"></a>
<div class="h3 cb section-type-section ">
<div data-xref-sec-id="h1-7" class="heading-text thm-col steps-heading-wrap">
<span class="styled-content-steps-heading">STEP 4</span> Provide Adequate Coverage, Including EHR Inbox Coverage
</div>
</div>
<a class="article-section-id-anchor" id="section-249752862"></a>
<p class="para">A significant deterrent to taking time away from work—and from truly unplugging while away —is the weight of patient care tasks that grow heavier during a physician's time off. Based on their commitment to
high-quality care, physicians may postpone or forego taking PTO out of concern about patient care responsibilities falling through the cracks. Physicians may also feel guilt over burdening colleagues to cover for them and,
perhaps most significantly, dread the mountain of EHR inbox messages they will find on their return.</p> <a class="article-section-id-anchor" id="section-249752863"></a>
<blockquote class="blockquote thm-bd-color">
<p class="para">“Physicians are faced with a moral dilemma: they need time off, but they know they will pay psychologically in many ways for taking time away.”</p>
<div class="attrib"><i>– Physician leader</i></div>
</blockquote> <a class="article-section-id-anchor" id="section-249752864"></a>
<blockquote class="blockquote thm-bd-color">
<p class="para">“I cannot find help to cross-cover my patients, and as a junior faculty member I feel uncomfortable asking more senior colleagues.”</p>
<div class="attrib"><i>– Early career academic physician</i></div>
</blockquote> <a class="article-section-id-anchor" id="section-249752865"></a>
<p class="para"><strong>How Organizations Can Improve Coverage</strong></p> <a class="article-section-id-anchor" id="section-249752866"></a>
<p class="para"></p>
<ol class="number">
<li>
<p class="para"><strong> Acknowledge that clinical and EHR inbox tasks are the responsibility of the organization, not the individual physician or team member.</strong></p>
<p class="para">Leaders should adopt a mindset of “How do <i>we</i> manage the clinical care responsibilities for physicians taking time off?” The inbox should not be referred to as the “physician's inbox” but rather as
the “practice inbox.” Make it clear to leaders that an EHR inbox is not like a personal email inbox—everything in it is related to patient care.</p>
</li>
<li>
<p class="para"><strong> Redesign </strong><a href="https://edhub.ama-assn.org/steps-forward/module/2798925"><strong>EHR inbox system workflows</strong></a><strong>.</strong></p>
<p class="para">A team-based workflow can improve efficiency and minimize the inbox burden in the first place. The AMA STEPS Forward® program includes numerous
<a href="https://edhub.ama-assn.org/steps-forward/pages/ehr-improvements">resources for reducing the burden of EHR work,</a> including the
<a href="https://edhub.ama-assn.org/steps-forward/module/2813407">Taming the EHR Playbook</a>.</p>
</li>
<li>
<p class="para"><strong> Improve the policy for EHR inbox coverage.</strong></p>
<p class="para">Allow physicians to completely unplug and not access their EHR inbox at all when taking PTO <i>without guilt about burdening their physician colleagues</i>. The best way to achieve this is with a strong
team of medical assistants, nurses, or advanced practice providers to handle the EHR inbox while the physician is away. A dedicated physician “doc of the day” or physician coverage team is also an option, but these
models take up physician resources and potentially reduce patient access. If none of these options is feasible and coverage falls upon colleagues with already full clinical schedules, consider a nominal stipend for the
covering physician as a last resort. See <a href="#t1" class="figure-link section-jump-link" data-tab-toggle=".tab-nav-figure-table">Table 1</a> for examples of various coverage models.</p>
</li>
<li>
<p class="para"><strong> Mitigate patient access issues.</strong></p>
<p class="para">Inevitably, there will be some reduction in patient access and/or continuity when a physician is taking PTO. This can be mitigated in part by having covering clinicians offer additional office visits or
procedural slots, but some patients with less urgent concerns will prefer to wait for their doctor's return. It may be helpful to reserve slots during the first week the physician is back at work to allow for same-day
appointments. This is separate from protected “catch-up” time for administrative tasks (see STEP 5.)</p>
</li>
<li>
<p class="para"><strong> Consider creating a group compact between physicians and the practice or hospital.</strong></p>
<p class="para">Such a document would lay out the expectations about what physicians will do and what the practice or organization will do. It signals the value placed on taking Real PTO.</p>
</li>
</ol>
<p></p> <a class="article-legacy-id-anchor" id="t1"></a>
<a class="article-section-id-anchor" id="section-249752867"></a>
<div class="figure-table-wrapper thm-bd-top">
<div class="figure-label">Table 1: EHR Inbox Coverage Models</div><a id="ama-2024-0000500-T001.png" class="figure-table-anchor"> </a>
<div class="figure-table cf cb">
<div class="figure-table-image">
<a href="https://cdn.edhub.ama-assn.org/ama/content_public/journal/steps-forward/937327/ama-2024-0000500-t001_1718220906.37901.png?Expires=1721822534&Signature=akS1JtRanC2iuJWbzxMzUdVXVeqh1qWbiyico3Hkk5J9W04uIeyPnpcuUlh7C3cYTTBwwzzmxCbm3dvObw6W96UYntqdYBVUDJtHgLr0LmqoOk~oFjCmDf21w5vmfQwU6AhLxCzQyxpkqZnAn96fqqb-0j-5WRRG2ifUui0m~aud8BotxfuAsZ6x28ncpDkA~46eb-SLyOdnfa5DjpafiwZW5wKon-yh9OAgbnpnfAt~f6XxORxm~TUgxGa28pDQg~Wh4ESJODsNWk~MOv1rzN4OYkmM-k3VDNfn2d8~edYUMmbMslPrYT2it7y9Yba4Csnvj39Cs1XHD~V-Kzz3gw__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" target="_blank" path-from-xml="ama-2024-0000500-T001.png" rel="nofollow"><img data-original="https://cdn.edhub.ama-assn.org/ama/content_public/journal/steps-forward/937327/m_ama-2024-0000500-t001_1718220906.37901.png?Expires=1721822534&Signature=mpfFgoOs65CIx~pYLAy51KnLpuQsOyop2DOlbox6mstJh5dBg6oqat9ouz66h~qHYFf2AjMVRV96EHLSJ7XmtMIUSQJ~9nz714QPCwdHlAtOL6mLYJ8rHbAczJcnAgGUWSEQyk64cLPz~byGIGGgxlIwuAI7Bx~Cqlpg1A1dKJivBfMGOgHj5xBtWP7-DOxM4d9vJs0VpwYRMztTjhTWBmW5etlnwyFRxREZr2grNGatFqhHk99FKrtdibuLYadV-GgdL144YecppGVn8b1ij145c8q4b3BA0UgJRnRNtTUero0Bv3Ma2sBOmV1RqffmEBzY07iduMesrLbxHseonQ__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" alt="" class="content-img lazy " path-from-xml="ama-2024-0000500-T001.png"></a>
</div>
</div>
</div> <a class="article-section-id-anchor" id="section-249752868"></a>
<div class="h3 cb section-type-section ">
<div data-xref-sec-id="h1-8" class="heading-text thm-col steps-heading-wrap">
<span class="styled-content-steps-heading">STEP 5</span> Enact Reasonable On- and Off-Ramp Policies for Taking Time Off
</div>
</div>
<a class="article-section-id-anchor" id="section-249752869"></a>
<p class="para">It is imperative to have policies that facilitate an easier transition into and out of PTO.</p> <a class="article-section-id-anchor" id="section-249752870"></a>
<p class="para"><strong>Before PTO</strong></p> <a class="article-section-id-anchor" id="section-249752871"></a>
<p class="para"></p>
<ul class="bullet">
<li>
<p class="para">Develop a clear PTO request and approval process. The lead time requirement for requesting PTO should balance reducing the need for patient rescheduling with maximizing flexibility for physicians'
work-life integration. This lead time will vary by department and specialty, and should be data-driven and optimized by operational leaders. Furthermore, different lead times may be used for generally predictable
events (eg, a wedding) vs generally less predictable events (eg, state finals that a physician's child may or may not make it to). Some organizations use the terms “freeze” and “unfreeze” for uncertain events—it is
better to freeze the time just in case and unfreeze it later. Whatever the terminology, organizations that fail to develop policies to support planning ahead for the occasional day away may create a perverse incentive
to call out sick at the last minute, which results in more burden on coworkers, patients, and administrators.</p>
</li>
<li>
<p class="para">Manage patient expectations about physicians' taking time away from work. Proactively communicate policies about cross-coverage and the handling and timing of responses to inbox messages. Consider
providing an autoreply informing patients of the date of return as well as whom to contact during their physician's time away.</p>
</li>
<li>
<p class="para">For truly unplanned/emergency PTO, separate backup systems should be in place to support physicians, care teams, and patients.</p>
</li>
</ul>
<p></p> <a class="article-section-id-anchor" id="section-249752872"></a>
<p class="para"><strong>After PTO</strong></p> <a class="article-section-id-anchor" id="section-249752873"></a>
<p class="para"></p>
<ul class="bullet">
<li>
<p class="para">Provide reasonable catch-up time for administrative and clinical tasks. For example, ambulatory care physicians might block a certain percentage of slots during the first week back to work. Communicate
closely with schedulers to ensure that some same-day slots are available to patients to avoid double booking.</p>
</li>
</ul>
<p></p> <a class="article-section-id-anchor" id="section-249752874"></a>
<div class="h3 cb section-type-section ">
<div data-xref-sec-id="h1-9" class="heading-text thm-col steps-heading-wrap">
<span class="styled-content-steps-heading">STEP 6</span> Design a Compensation Model to Adequately Include Time Off
</div>
</div>
<a class="article-section-id-anchor" id="section-249752875"></a>
<p class="para">Payment mechanisms can influence compensation models. Capitated payment systems may lead to more salary-based compensation, whereas fee-for-service (FFS) payment models may lead to more productivity-based
compensation. There are pros and cons to each model. Salary-based models in which the physicians are paid the same regardless of volume or productivity can create a disincentive for physicians to provide greater access to
their own patients or to new patients. On the other hand, productivity-based compensation models can create financial disincentives for the physician to take all their PTO. Addressing these inherent disincentives is
critical for supporting physicians to take time away from work.</p> <a class="article-section-id-anchor" id="section-249752876"></a>
<p class="para">Whatever the compensation model, it is important for health care organizations to appropriately budget for time away. A thought leader in physician peer support put it this way: “If you don't put some slack
in the system to allow for time away from work, especially after a traumatic event like an adverse event, chances are high that physicians will leave or cut back. They need time to heal. Not providing time off will catch
up with the organization and will be way more costly.”</p> <a class="article-legacy-id-anchor" id="t2"></a>
<a class="article-section-id-anchor" id="section-249752877"></a>
<div class="figure-table-wrapper thm-bd-top">
<div class="figure-label">Table 2. Designing Compensation to Support PTO</div><a id="ama-2024-0000500-T002.png" class="figure-table-anchor"> </a>
<div class="figure-table cf cb">
<div class="figure-table-image">
<a href="https://cdn.edhub.ama-assn.org/ama/content_public/journal/steps-forward/937327/ama-2024-0000500-t002_1718220906.40401.png?Expires=1721822534&Signature=burpWNKPnjGQmxXLDeboGYuOAhnXbJt8K5uWpTaRCAiVn2ReTbuFOHiggbjYc7hXJh7RZY9iCS5y0rEUCf5RNWBXTXYiVFHHvjD1ZLGwUUOE-ErdG-QVY-i94v6h2U6kzaFKnNcg6i4siu-xdMfzYyGW2QVUlOY7xCuzeqbowUM0oM2VM1De7HcSgveqc91UgPqM9Ur6caLgV5IucQkSD8xucPSyXaafG1ZMiGDzU3MYCjoHarRORhMZNf4--xH9KiiywHMLXJUURxLLuENp3hFC9aiyLGw-pUB680t1vQjyMdwdJ05LB7V4KdJ61~TPtgew2x3jKyjqsziYG7O9Iw__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" target="_blank" path-from-xml="ama-2024-0000500-T002.png" rel="nofollow"><img data-original="https://cdn.edhub.ama-assn.org/ama/content_public/journal/steps-forward/937327/m_ama-2024-0000500-t002_1718220906.40401.png?Expires=1721822534&Signature=nIiJ0nay7D5anFQgp-14VpC67mjoPeqM0tV9mO6x56T9OhAtriklGIwa4L1yirUCBuqm6NVa6ackF2BJYYCMk5zjwpukRTmZATVdosBdkcWACL~tkGXd-2NcQEldwaBLnkz8bSJwXmg6aFnPHwp5cBR3Wzl1zJjL1ZJ62kQvcC8m~81tLSR9mnjMkSg1V5YLI0SVuP0Uq17Hc65SZP9hbloer-8GMbINs54r5iLv0DtdEe1MRLXgRfaQn4MPNh-3tJDSBNHDfbErIw8uNsWOTU9Gzn~3PiEjmAedQj~3W2JfXjqOsCSvCyXDZL10wiBqlqBkCnDj3CexMjIuhzz9Wg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" alt="" class="content-img lazy " path-from-xml="ama-2024-0000500-T002.png"></a>
</div>
</div>
</div> <a class="article-section-id-anchor" id="section-249752878"></a>
<div class="figure-table-wrapper thm-bd-top"><a name="boxed-textQA1"><span style="display:none;">Box Section Ref ID</span></a>
<div class="box-section question-answer clip-last-child thm-bg">
<h4 class="box-section--title">Q&A</h4>
<ul class="simple">
<li>
<p class="paraquestion"><span class="relatedArticleLink">What if a physician wants to work more than 44 weeks a year in order to generate additional RVUs?</span></p>
<p class="paraanswer visuallyhidden">Physicians may still be compensated via RVUs for working extra weeks, but the organization should make clear that there is not an <i>expectation</i> to do so—a subtle but crucial
distinction. Organizations should set their own RVU benchmarks and bonus tiers for individual physicians based on an expected 44 weeks per year of productive time, and a realistically attainable number of RVUs per
week for those 44 weeks. These organizational benchmarks may differ from national benchmark data (from Medicare or the Medical Group Management Association) based on organization-specific factors.</p>
</li>
</ul>
</div>
</div> <a class="article-section-id-anchor" id="section-249752879"></a>
<div class="h3 cb section-type-section ">
<div data-xref-sec-id="h1-10" class="heading-text thm-col steps-heading-wrap">
<span class="styled-content-steps-heading">STEP 7</span> Track PTO to Ensure Fairness
</div>
</div>
<a class="article-section-id-anchor" id="section-249752880"></a>
<p class="para">The issue of how to respectfully track PTO can be a tough one. Some physicians feel that tracking is micromanaging and signals distrust from leaders. Others feel that lack of tracking means the organization
doesn't value PTO, because if you value something, you measure it.</p> <a class="article-section-id-anchor" id="section-249752881"></a>
<p class="para">There are also fairness concerns—for example, at academic institutions, if PTO days are not tracked consistently, physicians with more research or administrative time may only submit PTO for their clinic days
(ie, if they need to take a day off on a nonclinical day they don't feel the need to officially “submit” it as a PTO day), whereas physicians who are fully clinical submit all of their PTO days. This can prompt leaders to
inaccurately believe that the more clinically-focused physicians take more time off than the more research-focused physicians.</p> <a class="article-section-id-anchor" id="section-249752882"></a>
<p class="para">Ideally, a PTO tracking system for PTO should use:</p> <a class="article-section-id-anchor" id="section-249752883"></a>
<p class="para"></p>
<ul class="bullet">
<li>
<p class="para">A system that does not require physicians to fill out timecards, which can feel demeaning and creates unnecessary administrative burdens on physicians. One tracking system may involve a practice manager
or other administrator keeping track of physician days off on a live, shared calendar that physicians can update themselves. Other tracking programs and apps are available.</p>
</li>
<li>
<p class="para">Real-time data on physicians' time off, both at the level of the individual physician and at the unit/departmental level. Individuals not taking enough time should be flagged, prompting leaders and
managers to investigate why and proactively encourage time off. All team members should be able to easily view their remaining PTO balance.</p>
</li>
<li>
<p class="para">EHR audit log data will show whether physicians are accessing the EHR during PTO.</p>
</li>
<li>
<p class="para">Aggregate PTO taken by physicians can help build a scorecard for organizational performance.</p>
</li>
</ul>
<p></p> <a class="article-section-id-anchor" id="section-249752884"></a>
<div class="h3 cb section-type-section ">
<div data-xref-sec-id="h1-11" class="heading-text thm-col"> Conclusion </div>
</div>
<a class="article-section-id-anchor" id="section-249752885"></a>
<p class="para">Effectively supporting PTO for physicians requires more than creating new policies and benefits packages. As one physician leader put it, “It is not just the policies on paper that matter but how they are
executed.” In other words, the number of PTO days a physician has is meaningless if none of them is actually being used. Removing key barriers to PTO use and normalizing the culture of taking protected PTO are essential to
creating an environment where physicians, patients, and health care organizations can thrive.</p> <a class="article-section-id-anchor" id="section-249752886"></a>
<div class="figure-table-wrapper thm-bd-top"><a name="ama-pearls"><span style="display:none;">Box Section Ref ID</span></a>
<div class="box-section clip-last-child thm-bg"><a id="f3" class="jumplink-placeholder"></a><a name="ama-2024-227-pearl.png"><span style="display:none;">Graphic Jump Location</span></a>
<div class="figure-table cf cb">
<div class="figure-table-image">
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</div>
</div>
<h4 class="box-section--title">AMA Pearls</h4>
<ul class="bullet">
<li>
<p class="para">Invest in the resources needed for Real PTO by correlating PTO days with burnout scores, turnover rates, and engagement scores.</p>
</li>
<li>
<p class="para">Create PTO and related compensation policies that are easy to understand and communicate them clearly to physicians.</p>
</li>
<li>
<p class="para">Take responsibility for providing full clinical coverage for physicians on PTO—this burden should not fall on physicians themselves.</p>
</li>
<li>
<p class="para">Lead by example—take time off as a leader.</p>
</li>
</ul>
</div>
</div> <a class="article-section-id-anchor" id="section-249752887"></a>
<div class="h3 cb section-type-section ">
<div data-xref-sec-id="h1-12" class="heading-text thm-col"> Further Reading </div>
</div>
<a class="article-section-id-anchor" id="section-249752888"></a>
<p class="para"><strong>Journal Articles and Other Publications</strong></p> <a class="article-section-id-anchor" id="section-249752889"></a>
<p class="para"></p>
<ul class="bullet">
<li>
<p class="para">Zucker R. How taking a vacation improves your well-being. <i>Harvard Business Review</i>. July 19, 2023. Accessed February 7, 2024.
<a href="https://hbr.org/2023/07/how-taking-a-vacation-improves-your-well-being">https://hbr.org/2023/07/how-taking-a-vacation-improves-your-well-being</a></p>
</li>
<li>
<p class="para">Nelson J. Physicians are vehement: vacations are needed to recharge. <i>Medscape</i>. June 28, 2022. Accessed March 14, 2024.
<a href="https://www.medscape.com/viewarticle/976333?form=fpf">https://www.medscape.com/viewarticle/976333?form=fpf</a></p>
</li>
</ul>
<p></p> <a class="article-section-id-anchor" id="section-249752890"></a>
<div class="h3 cb section-type-section ">
<div data-xref-sec-id="h1-13" class="heading-text thm-col"> Related AMA STEPS Forward® Content </div>
</div>
<a class="article-section-id-anchor" id="section-249752891"></a>
<p class="para"><strong>Education (Playbooks, Toolkits, MOC/CME)</strong></p> <a class="article-section-id-anchor" id="section-249752892"></a>
<p class="para"></p>
<ul class="simple">
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/module/2813422">Wellness-Centered Leadership playbook</a></p>
</li>
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/module/2813034">Saving Time playbook</a></p>
</li>
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/module/2813407">Taming the EHR playbook</a></p>
</li>
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/module/2702513">Team-Based Care toolkit</a></p>
</li>
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/module/2810481">Wave Scheduling toolkit</a></p>
</li>
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/module/2813036">Listening Campaign toolkit</a></p>
</li>
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/module/2767098">What to Look for in your First or Next Practice toolkit</a></p>
</li>
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/module/2702598">Team Documentation toolkit</a></p>
</li>
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/module/2798925">EHR Inbox Management toolkit</a></p>
</li>
</ul>
<p></p> <a class="article-section-id-anchor" id="section-249752893"></a>
<p class="para"><strong>Podcasts</strong></p> <a class="article-section-id-anchor" id="section-249752894"></a>
<p class="para"></p>
<ul class="simple">
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/audio-player/18793087">Team-Based Care Model</a></p>
</li>
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/audio-player/18793056">What to Look for in Your First or Next Practice</a></p>
</li>
<li>
<p class="para"><a href="https://www.ama-assn.org/practice-management/physician-health/reducing-pajama-time-and-work-outside-work-wow">Reducing Pajama Time or WOW</a></p>
</li>
<li>
<p class="para"><a href="https://www.ama-assn.org/practice-management/physician-health/creating-culture-supports-well-being">Creating a Culture That Supports Well-Being</a></p>
</li>
<li>
<p class="para"><a href="https://www.ama-assn.org/practice-management/digital/improve-practice-efficiency-ehr-quick-wins">Improve Practice Efficiency with EHR “Quick Wins”</a></p>
</li>
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/audio-player/18786189">Setting Boundaries</a></p>
</li>
</ul>
<p></p> <a class="article-section-id-anchor" id="section-249752895"></a>
<p class="para"><strong>Success Stories</strong></p> <a class="article-section-id-anchor" id="section-249752896"></a>
<p class="para"></p>
<ul class="simple">
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/module/2702522">Implementing Strategies to Optimize Efficiency and Workflow to Improve Physician Satisfaction</a></p>
</li>
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/module/2702550">Creating a Seven-On, Seven-Off Scheduling Option for Primary Care</a></p>
</li>
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/module/2702537">Effective Team-Based Care Could Save 8 Hours of Free Time Per Week</a></p>
</li>
</ul>
<p></p> <a class="article-section-id-anchor" id="section-249752897"></a>
<p class="para"><strong>Webinars and Videos</strong></p> <a class="article-section-id-anchor" id="section-249752898"></a>
<p class="para"></p>
<ul class="simple">
<li>
<p class="para"><a href="https://www.ama-assn.org/about/events/setting-boundaries-preventing-fatigue-and-building-resilience">Setting Boundaries to Prevent Fatigue and Build Resilience</a></p>
</li>
<li>
<p class="para"><a href="https://gateway.on24.com/wcc/eh/3346741/lp/3795705/parenting-as-a-physician-it-takes-a-lot-of-patience">Parenting as a Physician: It Takes a lot of Patience</a></p>
</li>
<li>
<p class="para"><a href="https://gateway.on24.com/wcc/eh/3346741/lp/3545159/physician-burnout-its-not-a-resiliency-deficit">Physician Burnout: It's not a resiliency deficit</a></p>
</li>
<li>
<p class="para"><a href="https://gateway.on24.com/wcc/eh/3346741/lp/4178594/a-system-level-approach-to-ehr-inbox-reduction">A System-Level Approach to EHR Inbox Reduction</a></p>
</li>
<li>
<p class="para"><a href="https://edhub.ama-assn.org/steps-forward/video-player/16798424">Video: Implementing Team-Based Care</a></p>
</li>
</ul>
<p></p>
</div>
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<p class="para"><strong>Disclaimer:</strong> AMA STEPS Forward® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed
to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward® content provides information on commercial products,
processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward® content is not an endorsement or
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<p class="para"><strong>About the AMA Professional Satisfaction and Practice Sustainability Group</strong></p>
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<div class="heading-text thm-col"> References </div>
</div>
<div class="references">
<div class="reference"><a class="reference-number" id="r1">1.</a>
<div class="reference-content">Nabity J. Physician Employee Benefits: Paid Time Off. Physicians Thrive. Updated October 23, 2023. Accessed February 7, 2024.
<a href="https://physiciansthrive.com/contract-review/paid-time-off/">https://physiciansthrive.com/contract-review/paid-time-off/</a></div>
</div>
<div class="reference"><a class="reference-number" id="r2">2.</a>
<div class="reference-content">Cotter Sullivan. Atrracting and retaining physicians through benefits. 2017. Accessed February 7, 2024.
<a href="https://sullivancotter.com/attracting-and-retaining-physicians-through-benefits/">https://sullivancotter.com/attracting-and-retaining-physicians-through-benefits/</a></div>
</div>
<div class="reference"><a class="reference-number" id="r3">3.</a>
<div class="reference-content">Sinsky CA, Trockel MT, Dyrbye LN, et al. Vacation Days Taken, Work During Vacation, and Burnout Among US
Physicians. <i xmlns:helper="urn:XsltStringHelper"> JAMA Netw Open</i>. 2024;7(1):e2351635. Published 2024 Jan 2 .
doi:<a href="http://dx.doi.org/10.1001/jamanetworkopen.2023.51635" class="doiLink" target="_blank">10.1001/jamanetworkopen.2023.51635</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Vacation%20Days%20Taken%2C%20Work%20During%20Vacation%2C%20and%20Burnout%20Among%20US%20Physicians.&author=CA%20Sinsky&author=MT%20Trockel&author=LN%20Dyrbye&publication_year=2024&journal=JAMA%20Netw%20Open&volume=7&pages=e2351635" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a><a href="https://doi.org/10.1001/jamanetworkopen.2023.51635" class="crossref-doi" target="_blank" xmlns:helper="urn:XsltStringHelper">Crossref</a><span
class="inst-open-url-holders" data-targetid="10.1001/jamanetworkopen.2023.51635" xmlns:helper="urn:XsltStringHelper"> </span></div>
</div>
<div class="reference"><a class="reference-number" id="r4">4.</a>
<div class="reference-content">Rodriguez T. Is it time for a break? Prioritizing vacation time for physicians. <i xmlns:helper="urn:XsltStringHelper"> Neurology Advisor</i>. July 14 , 2023. Accessed
December 21, 2023.
<a href="https://www.neurologyadvisor.com/general-medicine/is-it-time-for-a-break-prioritizing-vacation-time-for-physicians-2/">https://www.neurologyadvisor.com/general-medicine/is-it-time-for-a-break-prioritizing-vacation-time-for-physicians-2/</a><a class="google-scholar-ref-link" href="https://scholar.google.com/scholar_lookup?title=Is%20it%20time%20for%20a%20break%3F%20Prioritizing%20vacation%20time%20for%20physicians.&author=T%20Rodriguez&publication_year=2023&journal=Neurology%20Advisor&volume=&pages=" target="_blank" xmlns:helper="urn:XsltStringHelper">Google Scholar</a>
</div>
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<div class="reference"><a class="reference-number" id="r5">5.</a>
<div class="reference-content">American Medical Association. Organizational Cost of Physician Burnout. September 12 , 2018. Updated 2023.
<a href="https://edhub.ama-assn.org/steps-forward/interactive/16830405">https://edhub.ama-assn.org/steps-forward/interactive/16830405</a></div>
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Outline
How Will This Toolkit Help Me? Introduction Seven STEPS to Give Physicians “Real
PTO” STEP 1 Embrace 3 Components of Real PTO STEP 2 Understand the Business Case
for Real PTO STEP 3 Normalize the Culture of Taking Time Away From Work STEP 4
Provide Adequate Coverage, Including EHR Inbox Coverage STEP 5 Enact Reasonable
On- and Off-Ramp Policies for Taking Time Off STEP 6 Design a Compensation Model
to Adequately Include Time Off STEP 7 Track PTO to Ensure Fairness Conclusion
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Professional Well-being
“REAL PTO” FOR PHYSICIANSREDUCE BARRIERS TO TAKING TIME OFF
0.25 Credit
AMA STEPS Forward
Published Online: June 11, 2024
STEPS Forward Toolkit
Activity Information and Disclosures
Diane Shannon, MD, MPHa;
Jill Jin, MD, MPHb;
Marie Brown, MD, MACPc
Author Affiliations
* aFounder, Shannon Coaching for Life
* bClinical Associate Professor of Medicine, Northwestern University Feinberg
School of Medicine; Senior Physician Advisor, AMA
* cDirector of Practice Redesign, AMA
Reducing Pajama Time and Work Outside of Work (WOW) (Podcast)
Creating a Culture that Supports Well-Being (Podcast)
Improve Practice Efficiencies with EHR "Quick Wins" (Podcast)
Setting Boundaries to Prevent Fatigue and Build Resilience (Webinar)
Parenting as a Physician: It Takes a lot of Patience (Webinar)
Physician Burnout: It's not a resiliency deficit (Webinar)
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How Will This Toolkit Help Me?
This toolkit will help organizations understand and remove barriers that prevent
physicians from taking time off, such as a culture of constant accessibility,
inadequate clinical coverage provisions during time off, and compensation plans
that don't reflect time off. Taking time off can be challenging for physicians,
given both individual and organizational commitments to high-quality, accessible
care, but a positive workplace culture that protects and encourages paid time
off (PTO) will prevent burnout among physicians which in turn translates into
better patient care.
Introduction
A health system's human resources department contacts a physician leader with a
specific request: “Can you please ask your physicians to document their
vacations? They're not recording their days off.” The investigation reveals it
is not a failure to document—the physicians simply are not taking any time away
from work. The barriers are just too high.
According to survey data, physicians are allotted an average of 25 to 35 days of
PTO each year.1,2 Some physicians receive an additional 5 to 10 PTO days
annually for continuing medical education (CME). And yet, in a 2023 study of
over 3000 US physicians across multiple organizations and specialties,
approximately 60% of physicians reported taking 15 or fewer days of vacation per
year, and 20% reported taking 5 or fewer days per year.3
And the result of not taking time off? Increased burnout.
The same study showed that spending more than 30 minutes a day on
patient-related work during vacation was associated with higher odds of
burnout.3 On the flipside, taking more than 3 weeks of vacation per year and
having full electronic health record (EHR) inbox coverage while on vacation were
associated with lower odds of burnout. Time away from work responsibilities to
rest and recover from work-related physical, mental, cognitive, and emotional
demands is crucial for maintaining a viable workforce.4,5
Why don't physicians take PTO?
A few prominent barriers prevent the use of PTO. First, there is inadequate
clinical coverage for patient care tasks, including EHR inbox coverage, during
physicians' time off. Thus, most physicians are still logging into the EHR
during their PTO because they feel this is the only way that 1) they won't
compromise patient care, 2) they won't burden their colleagues, and 3) they
won't face an impossible load of EHR work upon their return. Survey data show
70% of physicians reported working while on vacation on a typical vacation day.3
As a result, their PTO is not truly “time off”—so what's the point in taking it?
Second, physicians are not billing RVUs while on PTO. This becomes problematic
if the benchmarks for RVU productivity and bonuses—as well as projected
compensation calculators—do not take PTO time fully into account (eg, if the
productivity targets are based on the potential RVUs generated over anything
more than 44-45 weeks of productive time per year). This gives physicians the
impression that they are losing money by taking their PTO and creates internal
and external pressures to reach those unrealistic goals.
Third, the culture of self-sacrifice and 24/7 availability is infused into
medicine as a calling—physicians choose the field because they want to help and
heal, which inherently involves some degree of self-sacrifice and work outside
of traditional work hours. However, when taken to the extreme, this culture
harms both physician well-being and patient care.
Seven STEPS to Give Physicians “Real PTO”
1. Embrace 3 Components of Real PTO
2. Understand the Business Case for Real PTO
3. Normalize the Culture of Taking Time Off
4. Provide Adequate Coverage, Including EHR Inbox Coverage
5. Enact Reasonable On- and Off-Ramp Policies for Taking Time Off
6. Design a Compensation Model to Adequately Include Time Off
7. Track Time Off to Ensure Fairness
STEP 1 Embrace 3 Components of Real PTO
Paid time off can vary in definition among different organizations, but
generally includes vacation, holidays, sick days, personal days, CME days,
medical leave, parental or family leave, and disability leave. This toolkit will
focus on the first 5 categories of vacation, holidays, sick days, personal days,
and CME days, which apply to all physicians, as opposed to the latter categories
for more extended absences, which affect fewer physicians and typically involve
different compensation and coverage models.
This toolkit emphasizes the importance of “Real PTO” (Figure 1); a framework for
time off for physicians that:
1) Transitions all patient care and EHR responsibilities to other team members
without feelings of guilt about burdening colleagues
2) Provides adequate lead-in and catch-up time before and after time away
3) Adequately accounts for PTO in compensation models
Figure 1. Three Components of Real PTO
STEP 2 Understand the Business Case for Real PTO
Real PTO is a strategy for health systems and practices to reduce burnout and
increase loyalty and retention of physicians.
Real PTO is a short-term expense offset by long-term benefits for individuals
and health systems. There is a strong business case for giving physicians
opportunities to recharge and pursue a satisfying life outside of medicine. Two
fundamental factors drive the business case for Real PTO: 1) reducing burnout
and 2) building trust.
The Benefits of Real PTO
A 2023 study showed that taking more than 3 weeks of vacation per year and
having full EHR inbox coverage while on vacation were associated with lower odds
of burnout, while spending more than 30 minutes a day on patient-related work
tasks while on vacation was associated with higher odds of burnout.3
Thus, long-term benefits of successful Real PTO may include:
* Reduced physician burnout, which may reduce turnover, leading to increased
patient access and improved continuity of care
* Improved engagement and vitality of the physician workforce
* Reduced costs for the organization related to physician burnout
Access the Costs of Physician Burnout to an Organization Calculator
In addition to the cost of burnout, when physicians in an organization don't
take PTO, the organization experiences soft costs in the form of eroded trust,
resentment, and apathy.
In Their Own Words: The Costs of Not Having Real PTO
> “We are supposed to be empathetic but don't receive empathy in return. We can
> never be sick. It makes me really angry.”
>
> —Academic general internal medicine physician
> “Physicians just a few years out of training are so upset about PTO that they
> are leaving our organization for places where they have more control over
> their time. We are losing brilliant young physicians.”
>
> —Mid-career academic physician
STEP 3 Normalize the Culture of Taking Time Away From Work
The professional culture of medicine has traditionally been one that encourages
self-sacrifice and constant accessibility. While taking personal responsibility
and ownership of all things related to patient care is important for
high-quality care while at work, when taken to the extreme and applied to time
away from work, it is unhealthy for physicians, health care organizations, and
ultimately their patients. Physicians and health system leaders need to shift
the culture of medicine away from the ideas that “self-care is selfish” or “time
off is slacking” and toward recognizing that physicians are not superhuman and
need both self-care and time off in order to best serve their patients. As one
clinical professor described it, “Time away is part of one's responsibility as a
physician, professionally and ethically.”
How Leaders and Organizations Can Shift This Culture
1. Ensure that leaders model taking time off themselves.
Leaders who rarely take time off send the message that time off is not
valued by the organization. On the flip side, when a leader takes time away
and writes an out-of-office message that specifies that they are taking PTO,
this sends a message to the organization that taking time off is both
acceptable and respected.
2. Incorporate respect for time off into professional etiquette.
Encourage physicians to hone the mental discipline needed to avoid replying
to emails and messages while away. Help them understand that one reply
starts a volley of correspondence that will mentally engage them rather than
allow for cognitive decompression. Similarly, if you know a physician is
taking PTO, do not send work communications with a disclaimer that they do
not need to respond. Delay sending the communication or use the email
feature to schedule delivery after they return.
3. Check the tone of communications regarding time off.
Whether in person or over email, leaders or colleagues sometimes
inadvertently praise those who don't take time off or who work while taking
PTO to stay on top of things. For example, if someone takes their laptop on
vacation with them to check their EHR inbox, one could respond with “Wow,
that's so impressive”—which sends a message of approval for this
self-sacrifice. An alternative message might be: “I'm sorry you had to do
that, let's try to fix this problem.” For some earlier-career physicians,
seeking approval and praise from superiors and peers is deeply rooted in
their years of training, and these words about working during time off can
perpetuate that unhealthy culture.
Communication breakdowns may also occur when accusatory tones get in the way
of messages, for example, when an administrator asks a physician to
substantiate their time away for a CME conference. Simple shifts in language
and using a trusting tone can help change the culture and lessen the
barriers for physicians to take time away.
4. Make PTO policies transparent and easily accessible.
A human resources department should make it easy for physicians to find and
understand their PTO policy. When a physician must jump through hoops to
find out how many vacation or CME days they have, they receive the message
that using PTO is discouraged. Rather, setting up a standardized, proactive
way to share this information (not just during onboarding but at regular
intervals during the year) sends a message that using PTO is encouraged.
5. Proactively block off PTO into physician templates.
If a physician has 4 to 6 weeks of vacation and CME time per year, consider
building their schedule templates with this number of weeks automatically
blocked off, just like with national or local holidays. Physicians should be
encouraged to request these weeks off in advance, with the reassurance that
these dates are not “locked” and can be changed later. It is much easier to
reschedule patients from one week to another when there is already adequate
time blocked off, rather than finding slots to add them afterwards.
Furthermore, a responsive management team that immediately acts upon
rescheduling patients when a PTO change request comes through (rather than
letting the task sit for a week or more) can boost both physician and
patient satisfaction.
6. Engage individual physicians and work unit leaders for feedback and
brainstorming.
Recognize that each work group or department will have different barriers to
taking PTO and different needs for overcoming these barriers. Leaders and
organizations must have a process to engage work unit leaders and individual
physicians for input on solutions, and take on a true diversity mindset when
implementing them.
7. Celebrate time away
Especially with CME and vacations, ask returning physicians what they did,
and encourage sharing with the group at the next meeting. Physicians
returning from CME could also share key takeaways or lessons learned.
STEP 4 Provide Adequate Coverage, Including EHR Inbox Coverage
A significant deterrent to taking time away from work—and from truly unplugging
while away —is the weight of patient care tasks that grow heavier during a
physician's time off. Based on their commitment to high-quality care, physicians
may postpone or forego taking PTO out of concern about patient care
responsibilities falling through the cracks. Physicians may also feel guilt over
burdening colleagues to cover for them and, perhaps most significantly, dread
the mountain of EHR inbox messages they will find on their return.
> “Physicians are faced with a moral dilemma: they need time off, but they know
> they will pay psychologically in many ways for taking time away.”
>
> – Physician leader
> “I cannot find help to cross-cover my patients, and as a junior faculty member
> I feel uncomfortable asking more senior colleagues.”
>
> – Early career academic physician
How Organizations Can Improve Coverage
1. Acknowledge that clinical and EHR inbox tasks are the responsibility of the
organization, not the individual physician or team member.
Leaders should adopt a mindset of “How do we manage the clinical care
responsibilities for physicians taking time off?” The inbox should not be
referred to as the “physician's inbox” but rather as the “practice inbox.”
Make it clear to leaders that an EHR inbox is not like a personal email
inbox—everything in it is related to patient care.
2. Redesign EHR inbox system workflows.
A team-based workflow can improve efficiency and minimize the inbox burden
in the first place. The AMA STEPS Forward® program includes numerous
resources for reducing the burden of EHR work, including the Taming the EHR
Playbook.
3. Improve the policy for EHR inbox coverage.
Allow physicians to completely unplug and not access their EHR inbox at all
when taking PTO without guilt about burdening their physician colleagues.
The best way to achieve this is with a strong team of medical assistants,
nurses, or advanced practice providers to handle the EHR inbox while the
physician is away. A dedicated physician “doc of the day” or physician
coverage team is also an option, but these models take up physician
resources and potentially reduce patient access. If none of these options is
feasible and coverage falls upon colleagues with already full clinical
schedules, consider a nominal stipend for the covering physician as a last
resort. See Table 1 for examples of various coverage models.
4. Mitigate patient access issues.
Inevitably, there will be some reduction in patient access and/or continuity
when a physician is taking PTO. This can be mitigated in part by having
covering clinicians offer additional office visits or procedural slots, but
some patients with less urgent concerns will prefer to wait for their
doctor's return. It may be helpful to reserve slots during the first week
the physician is back at work to allow for same-day appointments. This is
separate from protected “catch-up” time for administrative tasks (see STEP
5.)
5. Consider creating a group compact between physicians and the practice or
hospital.
Such a document would lay out the expectations about what physicians will do
and what the practice or organization will do. It signals the value placed
on taking Real PTO.
Table 1: EHR Inbox Coverage Models
STEP 5 Enact Reasonable On- and Off-Ramp Policies for Taking Time Off
It is imperative to have policies that facilitate an easier transition into and
out of PTO.
Before PTO
* Develop a clear PTO request and approval process. The lead time requirement
for requesting PTO should balance reducing the need for patient rescheduling
with maximizing flexibility for physicians' work-life integration. This lead
time will vary by department and specialty, and should be data-driven and
optimized by operational leaders. Furthermore, different lead times may be
used for generally predictable events (eg, a wedding) vs generally less
predictable events (eg, state finals that a physician's child may or may not
make it to). Some organizations use the terms “freeze” and “unfreeze” for
uncertain events—it is better to freeze the time just in case and unfreeze it
later. Whatever the terminology, organizations that fail to develop policies
to support planning ahead for the occasional day away may create a perverse
incentive to call out sick at the last minute, which results in more burden
on coworkers, patients, and administrators.
* Manage patient expectations about physicians' taking time away from work.
Proactively communicate policies about cross-coverage and the handling and
timing of responses to inbox messages. Consider providing an autoreply
informing patients of the date of return as well as whom to contact during
their physician's time away.
* For truly unplanned/emergency PTO, separate backup systems should be in place
to support physicians, care teams, and patients.
After PTO
* Provide reasonable catch-up time for administrative and clinical tasks. For
example, ambulatory care physicians might block a certain percentage of slots
during the first week back to work. Communicate closely with schedulers to
ensure that some same-day slots are available to patients to avoid double
booking.
STEP 6 Design a Compensation Model to Adequately Include Time Off
Payment mechanisms can influence compensation models. Capitated payment systems
may lead to more salary-based compensation, whereas fee-for-service (FFS)
payment models may lead to more productivity-based compensation. There are pros
and cons to each model. Salary-based models in which the physicians are paid the
same regardless of volume or productivity can create a disincentive for
physicians to provide greater access to their own patients or to new patients.
On the other hand, productivity-based compensation models can create financial
disincentives for the physician to take all their PTO. Addressing these inherent
disincentives is critical for supporting physicians to take time away from work.
Whatever the compensation model, it is important for health care organizations
to appropriately budget for time away. A thought leader in physician peer
support put it this way: “If you don't put some slack in the system to allow for
time away from work, especially after a traumatic event like an adverse event,
chances are high that physicians will leave or cut back. They need time to heal.
Not providing time off will catch up with the organization and will be way more
costly.”
Table 2. Designing Compensation to Support PTO
Box Section Ref ID
Q&A
* What if a physician wants to work more than 44 weeks a year in order to
generate additional RVUs?
Physicians may still be compensated via RVUs for working extra weeks, but the
organization should make clear that there is not an expectation to do so—a
subtle but crucial distinction. Organizations should set their own RVU
benchmarks and bonus tiers for individual physicians based on an expected 44
weeks per year of productive time, and a realistically attainable number of
RVUs per week for those 44 weeks. These organizational benchmarks may differ
from national benchmark data (from Medicare or the Medical Group Management
Association) based on organization-specific factors.
STEP 7 Track PTO to Ensure Fairness
The issue of how to respectfully track PTO can be a tough one. Some physicians
feel that tracking is micromanaging and signals distrust from leaders. Others
feel that lack of tracking means the organization doesn't value PTO, because if
you value something, you measure it.
There are also fairness concerns—for example, at academic institutions, if PTO
days are not tracked consistently, physicians with more research or
administrative time may only submit PTO for their clinic days (ie, if they need
to take a day off on a nonclinical day they don't feel the need to officially
“submit” it as a PTO day), whereas physicians who are fully clinical submit all
of their PTO days. This can prompt leaders to inaccurately believe that the more
clinically-focused physicians take more time off than the more research-focused
physicians.
Ideally, a PTO tracking system for PTO should use:
* A system that does not require physicians to fill out timecards, which can
feel demeaning and creates unnecessary administrative burdens on physicians.
One tracking system may involve a practice manager or other administrator
keeping track of physician days off on a live, shared calendar that
physicians can update themselves. Other tracking programs and apps are
available.
* Real-time data on physicians' time off, both at the level of the individual
physician and at the unit/departmental level. Individuals not taking enough
time should be flagged, prompting leaders and managers to investigate why and
proactively encourage time off. All team members should be able to easily
view their remaining PTO balance.
* EHR audit log data will show whether physicians are accessing the EHR during
PTO.
* Aggregate PTO taken by physicians can help build a scorecard for
organizational performance.
Conclusion
Effectively supporting PTO for physicians requires more than creating new
policies and benefits packages. As one physician leader put it, “It is not just
the policies on paper that matter but how they are executed.” In other words,
the number of PTO days a physician has is meaningless if none of them is
actually being used. Removing key barriers to PTO use and normalizing the
culture of taking protected PTO are essential to creating an environment where
physicians, patients, and health care organizations can thrive.
Box Section Ref ID
Graphic Jump Location
AMA PEARLS
* Invest in the resources needed for Real PTO by correlating PTO days with
burnout scores, turnover rates, and engagement scores.
* Create PTO and related compensation policies that are easy to understand and
communicate them clearly to physicians.
* Take responsibility for providing full clinical coverage for physicians on
PTO—this burden should not fall on physicians themselves.
* Lead by example—take time off as a leader.
Further Reading
Journal Articles and Other Publications
* Zucker R. How taking a vacation improves your well-being. Harvard Business
Review. July 19, 2023. Accessed February 7, 2024.
https://hbr.org/2023/07/how-taking-a-vacation-improves-your-well-being
* Nelson J. Physicians are vehement: vacations are needed to recharge.
Medscape. June 28, 2022. Accessed March 14, 2024.
https://www.medscape.com/viewarticle/976333?form=fpf
Related AMA STEPS Forward® Content
Education (Playbooks, Toolkits, MOC/CME)
* Wellness-Centered Leadership playbook
* Saving Time playbook
* Taming the EHR playbook
* Team-Based Care toolkit
* Wave Scheduling toolkit
* Listening Campaign toolkit
* What to Look for in your First or Next Practice toolkit
* Team Documentation toolkit
* EHR Inbox Management toolkit
Podcasts
* Team-Based Care Model
* What to Look for in Your First or Next Practice
* Reducing Pajama Time or WOW
* Creating a Culture That Supports Well-Being
* Improve Practice Efficiency with EHR “Quick Wins”
* Setting Boundaries
Success Stories
* Implementing Strategies to Optimize Efficiency and Workflow to Improve
Physician Satisfaction
* Creating a Seven-On, Seven-Off Scheduling Option for Primary Care
* Effective Team-Based Care Could Save 8 Hours of Free Time Per Week
Webinars and Videos
* Setting Boundaries to Prevent Fatigue and Build Resilience
* Parenting as a Physician: It Takes a lot of Patience
* Physician Burnout: It's not a resiliency deficit
* A System-Level Approach to EHR Inbox Reduction
* Video: Implementing Team-Based Care
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Article Information
Disclaimer: AMA STEPS Forward® content is provided for informational purposes
only, is believed to be current and accurate at the time of posting, and is not
intended as, and should not be construed to be, legal, financial, medical, or
consulting advice. Physicians and other users should seek competent legal,
financial, medical, and consulting advice. AMA STEPS Forward® content provides
information on commercial products, processes, and services for informational
purposes only. The AMA does not endorse or recommend any commercial products,
processes, or services and mention of the same in AMA STEPS Forward® content is
not an endorsement or recommendation. The AMA hereby disclaims all express and
implied warranties of any kind related to any third-party content or offering.
The AMA expressly disclaims all liability for damages of any kind arising out of
use, reference to, or reliance on AMA STEPS Forward® content.
About the AMA Professional Satisfaction and Practice Sustainability Group
The AMA Professional Satisfaction and Practice Sustainability group is committed
to making the patient–physician relationship more valued than paperwork,
technology an asset and not a burden, and physician burnout a thing of the past.
We are focused on improving—and setting a positive future path for—the
operational, financial, and technological aspects of a physician's practice. To
learn more, visit stepsforward.org
References
1.
Nabity J. Physician Employee Benefits: Paid Time Off. Physicians Thrive.
Updated October 23, 2023. Accessed February 7, 2024.
https://physiciansthrive.com/contract-review/paid-time-off/
2.
Cotter Sullivan. Atrracting and retaining physicians through benefits. 2017.
Accessed February 7, 2024.
https://sullivancotter.com/attracting-and-retaining-physicians-through-benefits/
3.
Sinsky CA, Trockel MT, Dyrbye LN, et al. Vacation Days Taken, Work During
Vacation, and Burnout Among US Physicians. JAMA Netw Open. 2024;7(1):e2351635.
Published 2024 Jan 2 . doi:10.1001/jamanetworkopen.2023.51635Google
ScholarCrossref
4.
Rodriguez T. Is it time for a break? Prioritizing vacation time for
physicians. Neurology Advisor. July 14 , 2023. Accessed December 21, 2023.
https://www.neurologyadvisor.com/general-medicine/is-it-time-for-a-break-prioritizing-vacation-time-for-physicians-2/Google
Scholar
5.
American Medical Association. Organizational Cost of Physician Burnout.
September 12 , 2018. Updated 2023.
https://edhub.ama-assn.org/steps-forward/interactive/16830405
Disclaimer: AMA STEPS Forward® content is provided for informational purposes
only, is believed to be current and accurate at the time of posting, and is not
intended as, and should not be construed to be, legal, financial, medical, or
consulting advice. Physicians and other users should seek competent legal,
financial, medical, and consulting advice. AMA STEPS Forward® content provides
information on commercial products, processes, and services for informational
purposes only. The AMA does not endorse or recommend any commercial products,
processes, or services and mention of the same in AMA STEPS Forward® content is
not an endorsement or recommendation. The AMA hereby disclaims all express and
implied warranties of any kind related to any third-party content or offering.
The AMA expressly disclaims all liability for damages of any kind arising out of
use, reference to, or reliance on AMA STEPS Forward® content.
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