Dear Director,
My hospital is making me undergo mandatory EMR training and I think I should get paid for my time. I also think I should get paid for attending our monthly staff meeting and a committee meeting. Don’t nurses get paid for these kinds of things?
-Frustrated Hourly Worker

Many physicians choose emergency medicine so that they won’t have to take their work home with them. When they’re off, they’re really off. Ideally, that would mean pursuing what we want at home, rather than doing extra work in the hospital. Of course, as a medical director who receives a stipend and protected time, I understand that when I’m asked to attend meetings, it’s implied that I should have the available time to do it and not receive extra compensation. But what about everyone else? You can divide extra administrative responsibility into three categories: citizenship (everyone is expected to contribute a minimal amount, such as one committee meeting a month), one time events (like a 3-hour disaster drill) and significant extra admin responsibility (such as chairing a committee). We’ll look at each in turn.

Citizenship and Professionalism
Hospitals rely on physicians to participate in hospital affairs. Usually, this involves committees that meet monthly for an hour. Although I’ve had ER docs ask to be paid for attending committee meetings, as citizens of the hospital, we have a responsibility to participate. Participation can benefit the ED group as a whole, can provide the individual the opportunity to see what happens outside of the ED, and can afford you the opportunity to interact with non-EM colleagues in a more collegial manner. Other physicians around the hospital are also fulfilling their citizenship responsibility by volunteering for committees.

One caveat is that the load must be shared evenly. If only a couple of your group’s physicians are attending a variety of meetings and no one else is expected to participate as citizens of the hospital, then perhaps there should be a compensation arrangement, likely in the form of protected administrative time against the ED budget.

Second, if you are serving on a committee and the hospital administrative team thinks highly enough of you, they may consider asking you to chair the committee. Because of the increased time commitment and responsibility that comes with chairing a committee, hospitals will sometimes have an administrative stipend set aside. If there is no stipend and the time and commitment becomes a “side job,” it is worth discussing with your group about receiving either protected time or administrative compensation. As I’ve had to create and budget for a variety of these positions, my general rule of thumb has been a 2:1 rule. People who aren’t directors usually end up working twice as many admin hours as they’re given in protected time or they are compensated at about half of their clinical rate. This worked out well for me when I was in those positions and the docs who I’ve worked with when I was the chairman thought this was a fair mix.

EMR Training
Fortunately, most EMR training is less than half a day, though I’ve heard of some systems that require more. This falls into my “one and done” category. Obviously, if you’re not effective with the EMR, you won’t be productive in the ED, and that could have financial penalties if you have productivity-based pay. I’ve done online training from my home where it never occurred to me to think about being compensated. I’ve also done half-day classroom training where I was relieved to be taught how to use the EMR. Hospital bylaws could require any provider who works with the hospital EMR to have the proper training and therefore, without the course, you wouldn’t be able to work. Because of the Fair Labor Standards Act (FLSA), hospital employees, such as nurses, can’t be forced to work without being compensated. However, physicians, and in many cases mid-level providers, are exempt from the FLSA, which means that, as professionals, we are paid to accomplish a job or manage a function regardless of the hours per week. So in order to effectively complete our job, we can be required to participate in a disaster drill or undergo EMR training without being compensated for our time. If you’re a hospital employee and your nurses are getting paid, there’s a chance the hospital may pay you as well, but they’re not required to. If you’re a non-hospital employee, you are still required to get the training done but the hospital doesn’t decide if you get paid. While there are some physician groups in EM or in other specialties who don’t pay for this training, there are others who will. Since no one has a new EMR spring up as a surprise, this comes down to a budgeting and philosophical issue for your group. As we make budgets now for next year, there should be consideration for setting aside money for training, though this will likely come at the expense of pulling money out of another pot.

That said, for one day or less of required training, I do believe it’s part of our professional obligation to undergo the training without compensation. And if the decision is made to compensate you for undergoing training, it’s hard to justify getting paid your full clinical rate when EMR training is nowhere near as intense as working clinically and it doesn’t generate revenue. I’ve been on both sides of the fence. I’ve done EMR training without getting compensated, and I’ve been paid a flat rate for completing it. If you’re in a contracted group, it’s reasonable for your group to have a set policy and pay either a flat rate or a reduced hourly rate for undergoing formal EMR training.

Significant Extra Responsibility
As members of the medical staff, we have an obligation to be good citizens of the hospital. This comes at the occasional cost of our time outside of the clinical arena. Likely, we benefit from this as well. A friend of mine is an assistant director at his ED and receives a small stipend and a couple hours of protected time a week. He was “asked” to attend a four-day training program (about three months worth of his protected time) for his company’s administrative team members. Although this was uncompensated and would occur in addition to his regular clinical duties, he could see that there could be some personal benefit by attending. He would receive education and perhaps the downstream benefits of increased responsibilities with an associated bump in protected time and/or administrative stipend. He also recognized that sometimes things just fall under the expectations of a job.

Although we are exempt from the FLSA, which means that we need to do whatever it takes to effectively complete our job, I’d like to think that the time each doc gives outside the clinical arena is similar to what other physicians around the hospital are giving. The good news is that whether you realize it or not, you likely benefit by this participation. Another way to think about your responsibility is to approach your
position so that your hourly compensation includes different professional responsibilities that you pay back as the year goes on. This works whether you’re salaried for a number of hours or you’re a straight IC/hourly worker. Ultimately, I believe that if it’s a one-time, single day event, you’re likely hurting yourself or creating controversy by asking to get paid. For recurrent events, like meeting attendance, if you’re doing significant administrative work above and beyond your colleagues, it may be time to talk about compensation with your chairman.

Michael Silverman, MD, is a partner at Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center.




# Citizenship or Servitudepgy10 2013-12-05 15:46
Dear Dr Silverman,
Thank you for this thought provoking article. This really brings up the topic of business models in EM and what it takes to attend to the administrative needs of a department.
As an independent contractor I am filling the FTE needs of the group contracted with the hospital. The contract group has a duty to fulfill the administrative needs that support its contract as well as to uphold any agenda that would benefit the department as a whole. I am essentially a subcontractor paid for my time to provide excellent clinical care. I have no equity position and the business is not mine to uphold. I am not promised an opportunity to have an equity position and the financial statements of the group are not shared with me. Therefore I am unaware if I were participating on a committee that would require an investment such as increasing FTE to cover an OBS Unit would be feasible financially or in my best interest. If I wasn't at the meeting I could have been moonlighting at another hospital. Therefore there is an opportunity cost of attending admin meetings on behalf of the group. Shouldn't I be paid for that time at the very least? Had I worked a shift I would have made over $1500 so why is there a problem paying me $150 for the hour meeting? It really is a steal for a company to send representatives of our expertise to put forth an agenda to secure the value of the group's contract. If I instead asked you to attend a meeting with my accountant to go over my five-year plan would you feel obligated that was a part of good citizenship to assist your ICs individual business? ICs are not really citizens because there is no equality in the business model. In a democratic group setting its completely different because in that model we all have a duty to support 'our' contract. In that model we are all owners and the behavior follows. I am always surprised that managers do not understand why non-owners will not act like an owner. Its foolish to work for free on behalf of a business not willing to offer you ownership or equity.

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