All busy professionals understand that time pressure creates stress, and that stress leads to mistakes. For physicians in particular, those mistakes can be truly costly. Yet physicians often make poor — and avoidable — decisions about marginal time and marginal cost by undervaluing their time. Fortunately, simple strategies and a shift in thinking about spending money to create more time can improve well-being and professional performance.
While the concept is related to spending money to buy more help, it is more nuanced: the key is that marginal (extra) free time has more value both in reducing stress and increasing happiness and therefore is worth spending more money to find. Understanding this concept is key to mentoring junior faculty, managing physicians and designing programs to support their career goals.
I first began thinking about the value of marginal time when I was advising junior faculty about child care options. My advice was fairly simple: spend more money to build in more child care time than you think you need. For example, if you leave for work at 7:30 a.m., have your care provider come at 7:00 a.m. — not at 7:15 a.m., or 7:30 a.m. Something always happens in the morning when you are trying to get kids out the door. Someone throws up; permission slips need to be signed; you need to find $2 for the bake sale. And you want some time to huddle with that care provider to plan the day too. If by chance, you end up with 15 minutes of stress-free downtime to have a cup of coffee or talk with your kids, it's a win all around. But if you don't have the marginal time built in, everyone will be in a rush and that's when mistakes — and stress — happen. The mistakes range from irrelevant to potentially important, and include forgetting the homework or not getting the car seat buckled right. But even if they aren't important, they leave everyone in a bad mood.
More recently, I have expanded this concept into a series of interactive questions, designed to get my audiences thinking about money-time trade-offs, and reducing physician burnout. As I have delivered this exercise to multiple audiences, some interesting themes emerge. Loss aversion — the disproportionate fear of losing something compared to the value of gaining something — appears to play a role in how people think about these trade-offs, and most people don't make rational decisions where loss is involved.
Time vs. money
Put yourself in the following situations. How much are you willing to spend?
1. You are at the airport. Your flight leaves in three hours, but for a change fee, you can get on an earlier flight now, and catch up on some work you need to do at the office. What is the most you would pay to switch? $5 $25 $75 $125 $250
2. You are at the airport. Your flight is in three hours, but for a change fee you can get on an earlier flight now. You’ve been gone for a week and if you take the flight now you’ll be able to get home to see the kids before they go to bed. What is the most you would pay to switch?
3. Your commute home usually takes 20 minutes. But about once a week, and you can’t predict when, it takes 45 minutes. Sometimes that delay makes you stressed because you need to pick up your kids from their sports activities. What is the most you would pay per week to make it a predictable 20-minute commute every day?
4. Your mother-in-law calls. She’s fine but if you are the one who answers the phone, it’s almost always a 45-minute chat during which the state of the living room upholstery comes up. What is the most you would pay to have your spouse answer the phone every time?
5. You are applying for a passport and the form asks you to fill in every country you have visited and every place you have lived in the past 20 years. Your trusted assistant is out sick and it will probably take you at least an hour and a half to fill out the annoying form. How much would you pay to have someone else go through your files and fill in the information for you?
6. You really like your book club that meets monthly; it's a bunch of friends and the conversation is always interesting and satisfying. The group decides to move to a venue where you will have to pay for the space. What is the most you are willing to pay per two-hour session to continue to participate?
Time vs. money: The answers — and what they mean
Rational choices around marginal time and marginal money aren't intuitive and explain to some extent why some physicians and their organizations can be slow to realize their own level of burnout symptoms and how to address them. Whether I give this quiz to physicians or leadership groups, responses have been consistent. In almost no case have participants been willing to spend what is likely a rational amount of money for the value of their time; however, as we review the responses to each question from the quiz, some important observations become clear about what people value the most:
1. Most of the time, people say they are willing to pay around $50-$75 for a flight change that gives them a few hours to finish office work, which is, incidentally, less than what most airlines charge (at least pre-COVID) to change a flight. Even $100 is probably too low when compared to the value of a physician's time, especially since getting home in a timely way on a plane that is in front of you is more certain than one that hasn't even arrived yet to pick you up.
The clinical analogue to this scenario is the scribe. Many places suggest that physicians should either pay for the expense of a scribe or increase productivity to cover the expense. At roughly $20-$25 an hour, if a scribe allows a physician to complete ambulatory session notes one hour earlier, he or she should probably do it. Yet when faced with this trade off, in my experience, many physicians decline. Loss aversion, the concept that the negative impact of loss of money outweighs the pleasure of gain for the same amount of money, probably plays an important role in this choice.
2. For most people, a flight switch to see their kids before bed is worth a lot, and certainly worth more than scenario one. (Although some have joked that they were in no rush to get home!) A year ago, I was at the airport and faced this scenario with a two-hour gain and the chance to have dinner with my family. The attendant looked at me when I asked if I could switch and, shaking his head woefully, said, "it will be a $75 change fee." I grinned with delight and to his surprise handed him a credit card. I guess most people price this time differently.
The clinical scenario is similar to the first one with the scribe, but the perceived value of the time is higher because of the chance to spend it with your family.
3. The scenario that uniformly generates the highest willingness to pay is the chance to have a predictable commute, and people usually price it in the $125-$250 range. This prioritization highlights how stressful the unpredictability of clinical practice can be. Physicians are giving of their time but they also need boundaries that protect them. If you need to pick up your child at daycare before it closes, the prospect of seeing the urgent additional patient, who also really needs you, becomes very stressful. I'd also note that while physicians used to be able to sign out their beeper to someone covering, the ubiquity of email and texting has melted these boundaries. I've received urgent clinical emails multiple times while on vacation. What if I didn't see or answer them? The expectation of being always available, even when you shouldn't be, adds to the stress.
4. The question about how much you would value having someone else take care of time-consuming interactions for you, described in this scenario as taking your mother-in-law's calls, illustrates the meaning of "marginal value." Depending on how often you end up on the phone with your mother-in-law hearing about Helen's gout and Geraldine's dog's incontinence, or whether your mother-in-law is usually calling to offer to help with the kids because she made a massage appointment for you, will result in a very different value to having someone else answer the call.
In the clinical corollary, some patients, as would be expected, have difficulty telling their experience and synthesizing their history into a brief narrative. Another similarity is the call from the patient whose clinical status is unpredictable but who is emotionally tiring to manage. Having a trusted intermediary, such as a nurse or advance practice provider who can help manage the emotional aspects of the patient's needs and condense elucidate relevant clinical information can expedite the conversation in a more productive way — and in some cases might solve the problem altogether.
5. Most people taking my survey are willing to pay a moderate amount of money to help get a highly technical time-consuming task, like applying for a passport, situated. In the era of EHRs, this scenario highlights the level of data entry that physicians currently are responsible for managing. Part of the hesitation is likely that there are some things that only the treating physician can reliably know or interpret. However, scribes, voice dictation and automation are all areas that can reduce the burden of this kind of data management — even if the physician needs to review the record after it has been entered.
6. Generally, participants aren't willing to spend much to ensure they experience their book club, usually maxing out around $25. But that trade off may also be a significant mistake. Multiple studies have shown that time with colleagues, continuing medical education activities and learning more material are highly protective against burnout. Physicians and their organizations might want to invest more in their well-being, which in this case doesn't cost very much.
Conscious use of marginal time to combat physician burnout
Simply engaging in the above exercise begins a conversation about avoidable stress and changing our thinking around the value of our time and, more importantly, the value of certain kinds of time. Once we are aware of our choices — some that we were making without even realizing it — we can change the choices we make. It's great if your organization recognizes this also, but even if it doesn't it's well worth being thoughtful about the choices you control as well. Spend the money to have your nanny arrive a half hour earlier — if all is calm, you can still spend that half hour with your children, which will be money very well spent. Pay for the scribe (or the household help, dry cleaning delivery service, etc.). Finding the areas where we can control stress — and properly valuing our time in deciding to pay to create more of it — are essential skills that make us more productive, happier, more effective and better physicians — not to mention better parents, spouses and friends.