By N. Adam Brown, MD, MBA

If you worked retail or behind a fast-food counter in the pre-digital age, you may remember the time clock and cha-chunk sound it made when you signed in and out of your job. (Okay, it was not really a cha-chunk sound, but everyone noticed when you came and went because the sound was...forceful.) If you remember that sound, you will also remember that once you clocked out, you were free. No more obligations!

For many emergency department doctors, hospitalists, intensivists, and other clinicians today, there is no such freedom. When the shift ends, they keep working, documenting, or "signing out" (briefing the clinician who is there to relieve them). Because many staffing companies and hospitals do not schedule any overlap in shifts, this work is "off the clock." In other words, the time is uncompensated when doctors are paid hourly (as many of us are).

When this happens, staffing firms and hospitals are, wittingly or unwittingly, making clinicians choose between their own financial well-being and caring for patients. Businesses would face significant pushback and legal ramifications if they tried to take advantage of hourly workers in this manner. But due to physicians' ethical and cultural sense of duty, they stay and rarely complain.

Uncompensated Time Inside and Outside the Hospital

While most staffing firms create approval mechanisms for requesting compensation for hours worked over a shift-end time, requesting extra time is often looked upon negatively unless there is a direct patient need; it also requires extraordinary circumstances for approval.

But "sign-out" is a direct patient need, documentation is a direct patient need, and both are a required part of many healthcare jobs. Sometimes, sign-out takes just a few minutes to brief colleagues about patients in their care, but more often, it takes much longer to give a comprehensive report. Every practitioner knows that "sign-out" is a part of their job to provide safe continuity of care. Every practitioner also knows that "sign-out" is prone to errors and liability.

What's worse, this uncompensated work does not end with the shift change. Often, clinicians sit in the corner after their shift, go to a back office, or go home to finish documentation and answer clinical and administrative emails. Again, when doctors are hourly workers, the time is not compensated. A dollar here and a few dollars there, and suddenly you are talking about real money. The practice of "pajama time" or working outside of a shift also overestimates the operational efficiencies of the practice. Why? Because clinicians are completing their required, uncompensated tasks off the clock.

But there's more to the story. Scheduling clinicians without adequate overlap for sign-out, or building staffing matrices without considering uncompensated administrative hours, places clinicians in dissonant, binary space. Clinicians either provide the best patient care, clear the waiting room, and do documentation, or they forego wages. This creates a slow, steady chipping away of one's values, leading to a moral injury.

When clinicians are already overworked, under stress, and in short supply, we cannot allow the problem of uncompensated time to go unaddressed.

Wage Theft Goes Beyond Clinicians

Emergency department or hourly wage clinicians are not the only ones working several hours a day for free. Long term care facilities are routinely accused of stealing the wages of their trained healthcare workers. In 2021, 148 care workers in California alleged they cared for elderly residents at one facility 24 hours a day, 6 days a week, but were only compensated for 6 hours each day.

At the 2018 Congress of Delegates, family practice physicians testified about the amount of uncompensated time they spend providing documentation for prior authorizations, a problem they argued increased physician burnout.

In 2017, nurses and respiratory therapists at St. Charles Health System Inc. were required to take tests and earn certifications without being paid overtime. In 2010, healthcare workers at Beth Israel Deaconess Medical Center and other CareGroup Inc. affiliates sued their employer, alleging they were not paid for working through unpaid lunch breaks.

According to a September 2022 article, "Wage theft costs health care workers millions of dollars per year in lost income." Those losses come at a time when physicians' compensation is actually falling. According to the 2023 Physician Compensation Report, between 2021 and 2022, the average compensation for U.S. physicians fell 2.4%. Because of historic inflation rates, doctors' real income fell 9.1%. Those numbers don't tell the real story. Income is falling, but workload is increasing.

These wage pressures are contributing to physician burnout, anxiety, and other adverse mental health outcomes.

Addressing the Issue Will Benefit Providers and Patients Alike

Healthcare workers, of course, are not the only parties who suffer because of wage theft and unsustainable paperwork burdens. Patients suffer too.

While the jobs are vastly different, if you ask a line cook to clock out the moment their shift ends at 12 p.m., and refuse to pay them after but require them to stay to clean up or do prep work for the next chef, that person might be inclined to consciously or unconsciously rush through that uncompensated work. Cleanliness, at the very least, might start to suffer. "Engagement" from the worker can suffer too. Customers might start to rebel when the food does not taste as good or the staff becomes too surly.

Now, let's apply this to patient safety and clinician well-being. Because clinicians took an oath to "do no harm," we will not simply walk out on our patients. But by refusing to compensate doctors for all of their work, are hospitals and staffing agencies unwittingly putting patients in harm's way by encouraging doctors to hasten their work?

Even if that is not the case, I and many others would assert they are putting doctors in harm's way.

The 2023 Physician Burnout and Depression Report found more than half of physicians feel burned out. Burnout is typically higher in lower-paying specialties. Less than half (46%) of plastic surgeons report being burned out, while 59% of pediatricians say they are burned out. Around 45% of orthopedists suffer from burnout, compared to 65% of emergency department doctors.

Burnout may be one reason organizations are seeing a spike in the number of strikes, or why more than 145,000 healthcare practitioners left the industry from 2021 to 2022.

The CDC's recent study on healthcare worker mental health did not examine the impact of wages on rates of burnout, anxiety, and depression. Still, in a briefing about the report, a CDC official noted, "We do know that wages are an important component of satisfaction with the job we have ... Wages are an important predictor overall [of] increased well-being and increased satisfaction with our working lives."

Staffing firms and health systems that do not give their doctors adequate time to complete their documentation or transition care while clocked in are not only potentially harming patients and participating in "wage theft," they also are certainly harming their own employees by creating an unnecessary conundrum.