Key Points
Question
Are vacation days taken and working while on vacation associated with physician burnout?
Findings
In this cross-sectional study of 3024 US physicians, 59.6% took 3 weeks of vacation or less per year, and 70.4% worked while on vacation on a typical vacation day; both findings were associated with higher rates of burnout. Full electronic health record inbox coverage was associated with lower rates of working while on vacation and with lower burnout.
Meaning
These findings suggest that support for taking vacation and efforts to reduce physicians’ obligations to perform patient care–related tasks while on vacation, such as providing full electronic health record inbox coverage, should be considered to prevent physician burnout.
This cross-sectional study examines the number of vacation days taken per year and the magnitude of physician work while on vacation and their association with physician burnout and professional fulfillment.
Abstract
Importance
Vacation has been shown to be an important restorative activity in the general population; less is known about physicians’ vacation behaviors and their association with burnout and professional fulfillment.
Objective
To examine the number of vacation days taken per year and the magnitude of physician work while on vacation and their association with physician burnout and professional fulfillment, by individual and organizational characteristics.
Design, Setting, and Participants
This cross-sectional survey of US physicians was conducted between November 20, 2020, and March 23, 2021. Data analysis was performed from March to July 2023.
Main Outcomes and Measures
Burnout was measured using the Maslach Burnout Index, and professional fulfillment was measured using the Stanford Professional Fulfillment Index. Number of vacation days taken in the last year, time spent working on patient care and other professional tasks per typical vacation day (ie, work on vacation), electronic health record (EHR) inbox coverage while on vacation, barriers to taking vacation, and standard demographics were collected.
Results
Among 3024 respondents, 1790 of 3004 (59.6%), took 15 or fewer days of vacation in the last year, with 597 of 3004 (19.9%) taking 5 or fewer days. The majority, 2104 respondents (70.4%), performed patient care–related tasks on vacation, with 988 of 2988 (33.1%) working 30 minutes or more on a typical vacation day. Less than one-half of physicians (1468 of 2991 physicians [49.1%]) reported having full EHR inbox coverage while on vacation. On multivariable analysis adjusting for personal and professional factors, concern about finding someone to cover clinical responsibilities (odds ratio [OR], 0.48 [95% CI, 0.35-0.65] for quite a bit; OR, 0.30 [95% CI, 0.21-0.43] for very much) and financial concerns (OR, 0.49 [95% CI, 0.36-0.66] for quite a bit; OR, 0.38 [95% CI, 0.27-0.54] for very much) were associated with decreased likelihood of taking more than 3 weeks of vacation per year. Taking more than 3 weeks of vacation per year (OR, 0.66 [95% CI, 0.45-0.98] for 16-20 days; OR, 0.59 [95% CI, 0.40-0.86] for >20 days vs none) and having full EHR inbox coverage while on vacation (OR, 0.74; 95% CI, 0.63-0.88) were associated with lower rates of burnout on multivariable analysis, whereas spending 30 minutes or longer per vacation day on patient-related work (OR, 1.58; 95% CI, 1.22-2.04 for 30-60 minutes; OR, 1.97; 95% CI, 1.41-2.77 for 60-90 minutes; OR, 1.92; 95% CI, 1.36-2.73 for >90 minutes) was associated with higher rates of burnout.
Conclusions and Relevance
In this cross-sectional study of 3024 physicians, the number of vacation days taken and performing patient-related work while on vacation were associated with physician burnout. System-level efforts to ensure physicians take adequate vacation and have coverage for clinical responsibilities, including EHR inbox, may reduce physician burnout.
Introduction
Vacation has been shown to be an important restorative activity in the general population. Time away from work provides an opportunity to rest and recharge and is associated with benefits to both employer and employee, including improved job performance, greater productivity, enhanced creativity, greater job satisfaction, enhanced attention to personal relationships, lower absenteeism, less turnover, and lower rates of burnout.1,2,3,4,5,6,7,8 Taking vacation is also associated with improved physical and mental health, including lower risk of cardiovascular mortality, reduced cellular-level markers of stress, and fewer symptoms of depression and anxiety.9,10,11,12,13,14 Despite these benefits, less than one-half (48%) of US workers with paid time off use their full allotted time.15 Fully detaching from work while on vacation is also important and has been shown to improve productivity and reduce emotional exhaustion,1 whereas working during vacation negatively influences health and well-being after vacation.8 Yet, fully detaching from work during time off is not universal. Among workers with a postgraduate degree, 41% report often or extremely often responding to email or other messages outside of their normal work hours.15
Less is known about the vacation behaviors of US physicians and the institutional policies and practices that facilitate or hinder taking vacation. A 2023 survey16 of a convenience sample composed of 9175 physicians in 29 specialties found that 1 in 3 physicians took 2 weeks or less of vacation each year. A 2020 study17 of 490 physicians found that being able to disconnect from work is associated with lower emotional exhaustion and depersonalization, the 2 key dimensions of burnout. Although variation in physician vacation behavior by gender is unknown, female physicians report worse work-life integration,18,19 spending more time on the electronic health record (EHR), including after hours,20,21,22,23,24 and higher and more rapidly rising rates of burnout25 than male colleagues. The present study aims to characterize vacation behavior in a nationally representative sample of US physicians, to identify personal and professional characteristics associated with time spent on patient care–related work while on vacation and the number of vacation days taken, and to analyze the association of vacation characteristics with rates of burnout and professional fulfillment.
Methods
As previously reported,26 between November 20, 2020, and March 23, 2021, we surveyed a representative sample of physicians of all specialties listed in the American Medical Association Physician Professional Data using a methodological approach similar to the 2011,27 2014,28 and 201729 surveys. The Physician Professional Data, previously named the American Medical Association Masterfile, is a nearly complete record of all US physicians. Among the 3671 physicians who received an invitation to participate in the mailed survey, 1162 (31.7%) completed the survey. Of the 90 000 physicians invited to participate in the electronic survey, 6348 (7.1%) completed the survey.26 Participation was voluntary and all responses were anonymous. Informed consent was implied upon completing the survey. A random subset of participants received a subsurvey with items about vacation. As previously reported,26 detailed analysis comparing the demographic characteristics of participating physicians with all 897 107 practicing US physicians, as well as a secondary survey of nonresponders, suggested that participants were representative of US physicians (see the eAppendix in Supplement 1). The Stanford and Mayo Clinic institutional review boards approved this cross-sectional study, which followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.
The vacation subsurvey included items about vacation days taken per year, inbox coverage while on vacation, time spent working on patient care and other professional tasks per typical vacation day (ie, work on vacation [WOV]), and barriers to taking vacation (eAppendix in Supplement 1). Physicians were asked, “Using the definition of vacation that applies to your practice, how many days of vacation did you take in the last 12 months?” Response options were none, 1 to 5 work days (about 1 week), 6 to 10 work days, 11 to 15 work days, 16 to 20 work days, or more than 20 work days. Physicians were asked whether they had full EHR inbox coverage while on vacation, with response options of yes or no. Physicians were also asked, “On a typical vacation day in the last year, how much time did you spend responding to patient-related phone calls, inbox messages in the EHR and on other work-related email?” with response options of none, 1 to 30 minutes, 30 to 60 minutes, 60 to 90 minutes, or more than 90 minutes. Finally, physicians were asked to rate how much of a barrier to taking vacation each of the following dimensions was for them: finding someone to cover clinical responsibilities, financial impact on professional compensation, and the volume of EHR inbox work to be faced on return, with response options for each dimension of not at all, a little bit, somewhat, quite a bit, or very much.
The Maslach Burnout Inventory was used under license with Mind Garden, Inc, to assess the emotional exhaustion and depersonalization dimensions of burnout.30 The professional fulfillment subscale of the Stanford Professional Fulfillment Index was used to measure professional fulfillment with scores normalized on a scale of 0 to 10 (higher scores are more favorable) according to convention.31 Standard demographic information, including age, gender, relationship status, specialty, hours worked per week, and primary practice setting was collected. In addition, physicians were asked what percentage of their compensation was based on productivity, with response options of none, less than 25%, 25% to 50%, 51% to 75%, or greater than 75%.
Statistical Analysis
Data analysis was performed from March to July 2023. Demographic and professional characteristics of physicians and their responses to questions on barriers to taking vacation were summarized using standard descriptive statistics. Associations between vacation items and demographic and professional factors, as well as associations between vacation items and overall burnout, were examined using χ2 tests. Emotional exhaustion, depersonalization, and professional fulfillment scores were compared using t tests and 1-way analysis of variance. Multivariable logistic regression was used to identify variables associated with overall burnout, professional fulfillment, and the 3 vacation items. For all analyses, statistical significance was set at 2-tailed P < .05. All statistical analyses were conducted using R statistical software version 4.1.2 (R Core Team).
Results
Among the 3128 physicians invited to complete the vacation subsurvey, 3024 (96.7%) completed at least 1 vacation item; not all respondents completed all items, so denominators vary by item. Among respondents, 1790 of 3004 (59.6%) took 15 or fewer days (≤3 weeks) of vacation, 1193 of 3004 (39.7%) took 6 to 15 days (1-3 weeks) of vacation, and 597 of 3004 (19.9%) took 5 or fewer days of vacation in the previous 12 months. Less than one-half of physicians (1468 of 2991 physicians [49.1%]) reported full coverage for the EHR inbox while on vacation. On a typical vacation day, 2104 of 2988 physicians (70.4%) reported performing some WOV, with 1116 of 2104 (37.3%) working 1 to 30 minutes, 548 of 2104 (18.3%) working 30 to 60 minutes, 218 of 2104 (7.3%) working 60 to 90 minutes, and 222 of 2104 (7.4%) working more than 90 minutes. Results by demographics, specialty, primary practice setting, and percentage of compensation based on productivity are shown in Table 1.
Table 1. Physician Vacation and Patient-Related Tasks Performed on Vacation Across Demographic and Professional Factors of 3024 US Physicians.
| Variable | Participants, No. (%) | |||||||
|---|---|---|---|---|---|---|---|---|
| All (N = 3024) | Vacation days in last 12 mo | Time spent on patient-related work tasks during vacation, min/da | Full EHR inbox coverage while on vacation | |||||
| ≤5 | 6-15 | >15 | 0 | 1-30 | ≥30 | |||
| All physicians | NA | 597 (19.9) | 1193 (39.7) | 1214 (40.4) | 884 (29.6) | 1116 (37.3) | 988 (33.1) | 1468 (49.1) |
| Gender | ||||||||
| Male | 1873 (62.0) | 354 (19.0) | 728 (39.1) | 780 (41.9) | 583 (31.5) | 713 (38.5) | 555 (30.0) | 900 (48.5) |
| Female | 1145 (37.9) | 243 (21.4) | 461 (40.6) | 432 (38.0) | 299 (26.4) | 402 (35.5) | 430 (38.0) | 566 (50.1) |
| Other or missing | 6b | NA | NA | NA | NA | NA | NA | NA |
| Age, y | ||||||||
| <35 | 121 (4.2) | 30 (25.2) | 48 (40.3) | 41 (34.5) | 52 (43.7) | 39 (32.8) | 28 (23.5) | 65 (54.2) |
| 35-44 | 748 (25.7) | 155 (20.8) | 299 (40.1) | 291 (39.1) | 198 (26.6) | 294 (39.5) | 252 (33.9) | 358 (48.3) |
| 45-54 | 715 (24.6) | 131 (18.4) | 298 (41.9) | 283 (39.7) | 164 (23.2) | 276 (39.0) | 267 (37.8) | 361 (50.8) |
| 55-64 | 790 (27.1) | 145 (18.4) | 335 (42.5) | 308 (39.1) | 215 (27.4) | 285 (36.4) | 284 (36.2) | 373 (47.8) |
| ≥65 | 536 (18.4) | 115 (21.8) | 170 (32.3) | 242 (45.9) | 214 (40.9) | 181 (34.6) | 128 (24.5) | 258 (49.0) |
| Missing | 114b | NA | NA | NA | NA | NA | NA | NA |
| Relationship status | ||||||||
| Single | 318 (10.5) | 93 (29.2) | 125 (39.3) | 100 (31.4) | 105 (33.7) | 104 (33.3) | 103 (33.0) | 146 (46.5) |
| Married | 2525 (83.7) | 471 (18.8) | 994 (39.6) | 1044 (41.6) | 735 (29.4) | 940 (37.6) | 823 (32.9) | 1237 (49.5) |
| Partnered | 142 (4.7) | 28 (19.9) | 57 (40.4) | 56 (39.7) | 34 (24.3) | 60 (42.9) | 46 (32.9) | 65 (46.4) |
| Widowed | 31 (1.0) | 4 (14.3) | 13 (46.4) | 11 (39.3) | 8 (26.7) | 10 (33.3) | 12 (40.0) | 16 (55.2) |
| Missing | 8b | NA | NA | NA | NA | NA | NA | NA |
| Age of youngest child, y | ||||||||
| None | 466 (15.5) | 109 (23.5) | 187 (40.4) | 167 (36.1) | 152 (33.0) | 164 (35.6) | 145 (31.5) | 214 (46.3) |
| <5 | 415 (13.8) | 91 (22.1) | 173 (42.1) | 147 (35.8) | 117 (28.5) | 167 (40.7) | 126 (30.7) | 210 (51.0) |
| 5-12 | 543 (18.1) | 95 (17.6) | 208 (38.4) | 238 (44.0) | 133 (24.7) | 198 (36.7) | 208 (38.6) | 273 (50.8) |
| 13-18 | 407 (13.6) | 84 (20.7) | 171 (42.1) | 151 (37.2) | 105 (26.1) | 143 (35.6) | 154 (38.3) | 200 (49.6) |
| 19-22 | 309 (10.3) | 41 (13.3) | 136 (44.2) | 131 (42.5) | 77 (25.1) | 117 (38.1) | 113 (36.8) | 149 (48.5) |
| >23 | 861 (28.7) | 173 (20.3) | 307 (35.9) | 374 (43.8) | 293 (34.6) | 318 (37.6) | 235 (27.8) | 411 (48.5) |
| Missing | 23b | NA | NA | NA | NA | NA | NA | NA |
| Specialty | ||||||||
| Anesthesiology | 124 (4.1) | 10 (8.1) | 20 (16.3) | 93 (75.6) | 61 (49.2) | 32 (25.8) | 31 (25.0) | 44 (36.1) |
| Dermatology | 63 (2.1) | 9 (14.5) | 23 (37.1) | 30 (48.4) | 8 (12.7) | 32 (50.8) | 23 (36.5) | 29 (46.0) |
| Emergency medicine | 175 (5.8) | 53 (30.8) | 78 (45.3) | 41 (23.8) | 95 (54.6) | 45 (25.9) | 34 (19.5) | 75 (43.6) |
| Family medicine | 224 (7.5) | 47 (21.0) | 100 (44.6) | 77 (34.4) | 55 (24.7) | 77 (34.5) | 91 (40.8) | 114 (51.1) |
| General surgery | 103 (3.4) | 22 (21.6) | 39 (38.2) | 41 (40.2) | 26 (25.7) | 49 (48.5) | 26 (25.7) | 44 (44.0) |
| Surgery subspecialty | 239 (8.0) | 47 (19.8) | 107 (45.1) | 83 (35.0) | 40 (17.2) | 94 (40.5) | 98 (42.2) | 99 (41.8) |
| General internal medicine | 209 (7.0) | 61 (29.6) | 89 (43.2) | 56 (27.2) | 68 (32.7) | 65 (31.2) | 75 (36.1) | 104 (50.2) |
| Internal medicine subspecialty | 301 (10.0) | 65 (21.7) | 126 (42.0) | 109 (36.3) | 60 (20.5) | 110 (37.5) | 123 (42.0) | 161 (54.0) |
| Neurology | 91 (3.0) | 16 (17.6) | 38 (41.8) | 37 (40.7) | 15 (16.7) | 36 (40.0) | 39 (43.3) | 43 (47.8) |
| Neurosurgery | 31 (1.0) | 4 (12.9) | 15 (48.4) | 12 (38.7) | 6 (19.4) | 13 (41.9) | 12 (38.7) | 12 (38.7) |
| Obstetrics and gynecology | 123 (4.1) | 22 (18.0) | 41 (33.6) | 59 (48.4) | 38 (31.1) | 39 (32.0) | 45 (36.9) | 68 (55.7) |
| Ophthalmology | 126 (4.2) | 27 (22.0) | 49 (39.8) | 47 (38.2) | 44 (34.9) | 50 (39.7) | 32 (25.4) | 66 (52.4) |
| Orthopedic surgery | 136 (4.5) | 23 (16.9) | 51 (37.5) | 62 (45.6) | 28 (20.9) | 58 (43.3) | 48 (35.8) | 65 (48.5) |
| Other | 190 (6.3) | 40 (21.2) | 84 (44.4) | 65 (34.4) | 45 (23.9) | 77 (41.0) | 66 (35.1) | 88 (47.3) |
| Otolaryngology | 19 (0.6) | 7 (36.8) | 7 (36.8) | 5 (26.3) | 7 (36.8) | 6 (31.6) | 6 (31.6) | 9 (47.4) |
| Pathology | 80 (2.7) | 8 (10.0) | 27 (33.8) | 45 (56.2) | 27 (34.2) | 33 (41.8) | 19 (24.1) | 38 (48.1) |
| Pediatric subspecialty | 117 (3.9) | 26 (22.4) | 49 (42.2) | 41 (35.3) | 37 (31.9) | 36 (31.0) | 43 (37.1) | 69 (60.0) |
| Pediatrics general | 149 (5.0) | 27 (18.1) | 67 (45.0) | 55 (36.9) | 57 (39.0) | 52 (35.6) | 37 (25.3) | 95 (64.2) |
| Physical medicine and rehabilitation | 67 (2.2) | 14 (20.9) | 31 (46.3) | 22 (32.8) | 21 (31.8) | 29 (43.9) | 16 (24.2) | 32 (47.8) |
| Preventative or occupational medicine | 10 (0.3) | 3 (30.0) | 4 (40.0) | 3 (30.0) | 5 (50.0) | 3 (30.0) | 2 (20.0) | 5 (50.0) |
| Psychiatry | 259 (8.6) | 46 (17.8) | 98 (38.0) | 114 (44.2) | 84 (32.7) | 102 (39.7) | 71 (27.6) | 113 (43.8) |
| Radiation oncology | 33 (1.1) | 4 (12.5) | 8 (25.0) | 20 (62.5) | 5 (16.1) | 15 (48.4) | 11 (35.5) | 20 (62.5) |
| Radiology | 115 (3.8) | 5 (4.3) | 24 (20.9) | 86 (74.8) | 41 (35.7) | 51 (44.3) | 23 (20.0) | 52 (46.4) |
| Urology | 20 (0.7) | 5 (25.0) | 8 (40.0) | 7 (35.0) | 4 (20.0) | 5 (25.0) | 11 (55.0) | 11 (55.0) |
| Missing | 20b | NA | NA | NA | NA | NA | NA | NA |
| Time worked per week, h | ||||||||
| Median (IQR) | 50 (40-60) | NA | NA | NA | NA | NA | NA | NA |
| <40 | 526 (17.5) | 99 (19.0) | 200 (38.4) | 222 (42.6) | 239 (45.9) | 202 (38.8) | 80 (15.4) | 242 (46.4) |
| 40-49 | 720 (24.0) | 138 (19.3) | 256 (35.8) | 321 (44.9) | 248 (34.8) | 284 (39.9) | 180 (25.3) | 380 (53.7) |
| 50-59 | 721 (24.0) | 101 (14.0) | 329 (45.8) | 289 (40.2) | 192 (26.9) | 274 (38.3) | 249 (34.8) | 363 (50.5) |
| 60-69 | 663 (22.1) | 142 (21.6) | 241 (36.6) | 275 (41.8) | 123 (18.9) | 248 (38.0) | 281 (43.1) | 326 (49.8) |
| 70-79 | 174 (5.8) | 44 (25.6) | 78 (45.3) | 50 (29.1) | 30 (17.6) | 53 (31.2) | 87 (51.2) | 74 (43.0) |
| ≥80 | 200 (6.7) | 68 (34.0) | 81 (40.5) | 51 (25.5) | 44 (22.1) | 48 (24.1) | 107 (53.8) | 73 (36.5) |
| Missing | 20b | NA | NA | NA | NA | NA | NA | NA |
| Primary practice setting | ||||||||
| Private practice | 1674 (55.7) | 330 (19.8) | 658 (39.6) | 675 (40.6) | 526 (31.7) | 662 (39.9) | 470 (28.3) | 771 (46.4) |
| Academic medical center | 855 (28.5) | 153 (18.0) | 353 (41.5) | 345 (40.5) | 157 (18.5) | 304 (35.8) | 387 (45.6) | 465 (54.8) |
| Veterans Administration hospital | 78 (2.6) | 17 (21.8) | 35 (44.9) | 26 (33.3) | 35 (45.5) | 18 (23.4) | 24 (31.2) | 46 (59.7) |
| Active military practice | 21 (0.7) | 8 (38.1) | 9 (42.9) | 4 (19.0) | 15 (71.4) | 5 (23.8) | 1 (4.8) | 9 (42.9) |
| Other | 376 (12.5) | 87 (23.4) | 127 (34.1) | 158 (42.5) | 144 (39.6) | 119 (32.7) | 101 (27.7) | 168 (46.0) |
| Missing | 20b | NA | NA | NA | NA | NA | NA | NA |
| Compensation based on productivity, % | ||||||||
| None | 1138 (37.8) | 214 (19.0) | 421 (37.4) | 490 (43.6) | 404 (36.0) | 389 (34.7) | 328 (29.3) | 556 (49.6) |
| <25 | 493 (16.4) | 93 (18.9) | 208 (42.4) | 190 (38.7) | 147 (30.1) | 194 (39.7) | 148 (30.3) | 244 (49.9) |
| 25-50 | 230 (7.6) | 46 (20.0) | 99 (43.0) | 85 (37.0) | 51 (22.5) | 82 (36.1) | 94 (41.4) | 116 (50.9) |
| 51-75 | 193 (6.4) | 45 (23.4) | 72 (37.5) | 75 (39.1) | 36 (18.8) | 78 (40.6) | 78 (40.6) | 99 (51.8) |
| >75 | 955 (31.7) | 194 (20.4) | 386 (40.6) | 371 (39.0) | 239 (25.3) | 369 (39.0) | 337 (35.7) | 445 (46.9) |
| Missing | 15b | NA | NA | NA | NA | NA | NA | NA |
Abbreviations: EHR, electronic health record; NA, not applicable.
Refers to time spent on patient-related telephone calls, electronic health record inbox messages, and other work-related email.
Missing data were not included in calculations of percentages.
Vacation days taken per year varied by specialty. Among specialty disciplines with more than 30 respondents, physicians practicing anesthesiology (93 physicians [75.6%]), radiology (86 physicians [74.8%]), radiation oncology (20 physicians [62.5%]), and pathology (45 physicians [56.2%]) had the highest proportion of physicians taking more than 3 weeks of vacation, whereas family medicine (77 physicians [34.4%]), physical medicine and rehabilitation (22 physicians [32.8%]), general internal medicine (56 physicians [27.2%]), and emergency medicine (41 physicians [23.8%]) had the lowest percentage of physicians taking more than 3 weeks of vacation (Table 1).
Time spent on patient-related tasks while on vacation also varied by specialty. Among specialty disciplines with more than 30 respondents, emergency medicine (34 physicians [19.5%]), radiology (23 physicians [20.0%]), and pathology (19 physicians [24.1%]) had the lowest percentage of physicians performing 30 minutes of WOV on a typical vacation day, whereas urology (11 physicians [55.0%]), neurology (39 physicians [43.3%]), and surgery subspecialties (98 physicians [42.2%]) had the highest percentage of physicians performing 30 minutes or more of WOV on a typical vacation day (Table 1).
More than one-third of physicians indicated that each of the following was a barrier to taking vacation: finding someone to cover clinical responsibilities, the financial impact of taking vacation, and the volume of EHR inbox work to face on return to work (Table 2). On univariable analysis, the number of vacation days taken and WOV varied by gender. A lower proportion of women reported taking more than 3 weeks vacation than men (432 of 1136 women [38.0%] vs 780 of 1862 men [41.9%]). Women were also more likely than men to perform 30 minutes or more of WOV per vacation day (430 of 1131 women [38.0%] vs 555 of 1851 men [30.0%]) (eFigure in Supplement 1). On bivariable analysis, vacation days in the last year, inbox coverage, and WOV were each associated with emotional exhaustion, depersonalization, overall burnout, and professional fulfillment (Table 3 and Figure).
Table 2. Reported Barriers to Taking Vacation.
| Barrier and ratinga | Participants, No. (%) |
|---|---|
| Finding someone to cover my clinical responsibilities | |
| Not at all | 1391 (46.4) |
| A little bit | 558 (18.6) |
| Somewhat | 467 (15.6) |
| Quite a bit | 289 (9.6) |
| Very much | 293 (9.8) |
| Financial impact on my professional compensation | |
| Not at all | 1551 (51.8) |
| A little bit | 452 (15.1) |
| Somewhat | 383 (12.8) |
| Quite a bit | 303 (10.1) |
| Very much | 308 (10.3) |
| The volume of electronic health record inbox work I would face on return | |
| Not at all | 1302 (43.5) |
| A little bit | 587 (19.6) |
| Somewhat | 484 (16.2) |
| Quite a bit | 318 (10.6) |
| Very much | 299 (10.0) |
Participants were asked, “Rate how much of a barrier each of the following is to taking vacation for you.”
Table 3. Bivariable Analysis of Vacation Characteristics and Measures of Burnout and Professional Fulfillment.
| Questions and responses | Emotional exhaustiona | Depersonalizationa | Overall burnoutb | Professional fulfillmentc | ||||
|---|---|---|---|---|---|---|---|---|
| Score, mean (SD) | P value | Score, mean (SD) | P value | Score, mean (SD) | P value | Score, mean (SD) | P value | |
| How many days of vacation (workdays) did you take in the last 12 mo? | ||||||||
| None | 22.63 (15.09) | <.001 | 6.98 (7.03) | <.001 | 93 (45.4) | <.001 | 6.21 (2.59) | <.001 |
| 1-5 | 23.00 (13.09) | 6.41 (6.40) | 166 (43.3) | 6.34 (2.14) | ||||
| 6-10 | 22.14 (12.95) | 6.77 (6.39) | 226 (42.6) | 6.28 (2.22) | ||||
| 11-15 | 21.37 (12.36) | 6.29 (6.10) | 260 (39.8) | 6.59 (1.98) | ||||
| 16-20 | 20.25 (12.76) | 5.77 (5.93) | 189 (35.0) | 6.67 (2.13) | ||||
| >20 | 18.54 (12.53) | 5.35 (5.80) | 210 (31.5) | 6.76 (2.26) | ||||
| Do you have full EHR inbox coverage while on vacation? | ||||||||
| Yes | 19.72 (12.66) | <.001 | 5.82 (5.96) | .007 | 504 (34.5) | <.001 | 6.64 (2.19) | .003 |
| No | 22.22 (13.08) | 6.44 (6.35) | 640 (42.4) | 6.41 (2.17) | ||||
| On a typical vacation day in the last year, how much time (minutes) did you spend responding to patient-related phone calls, inbox messages in the EHR, and on other work-related email? | ||||||||
| None | 18.67 (13.06) | <.001 | 5.72 (5.99) | <.001 | 289 (33.1) | <.001 | 6.60 (2.25) | <.001 |
| 1-30 | 19.91 (12.12) | 5.82 (5.92) | 380 (34.3) | 6.68 (2.02) | ||||
| 30-60 | 23.30 (12.58) | 6.40 (6.15) | 242 (44.6) | 6.27 (2.11) | ||||
| 60-90 | 25.47 (12.97) | 7.47 (6.75) | 116 (53.2) | 6.23 (2.24) | ||||
| >90 | 25.45 (14.25) | 7.51 (7.46) | 113 (51.4) | 6.26 (2.62) | ||||
Abbreviation: EHR, electronic health record.
Assessed using the full-length emotional exhaustion and depersonalization domains of the Maslach Burnout Inventory. Per the standard scoring of the Maslach Burnout Inventory for health care workers, physicians with scores on the emotional exhaustion subscale of 27 or more or on the depersonalization subscale of 10 or more are considered to have a score in that dimension.
Respondents were considered to have symptoms of burnout if they had a high emotional exhaustion and/or high depersonalization scores using the Maslach Burnout Inventory.
The Stanford Professional Fulfillment Index was used to measure professional fulfillment, with scores normalized on a scale of 0 to 10 (higher scores are more favorable).
Figure. Personal and Institutional Vacation Behaviors and Prevalence of Burnout.
Graphs show burnout rates in relation to time performing work-related tasks on a typical vacation day (A), full electronic health record (EHR) inbox coverage during vacation (B), and number of vacation days per year (C).
We next conducted multivariable analysis to identify factors associated with taking more than 3 weeks of vacation per year. After controlling for personal and professional characteristics, relationship status (odds ratio [OR], 1.41 [95% CI, 1.04-1.92] for being married) was associated with taking more than 3 weeks of vacation. Concern about finding someone to cover clinical responsibilities (OR, 0.48 [95% CI, 0.35-0.65] for quite a bit; OR, 0.30 [95% CI, 0.21-0.43] for very much) and financial concerns (OR, 0.49 [95% CI, 0.36-0.66] for quite a bit; OR, 0.38 [95% CI, 0.27-0.54] for very much) were associated with decreased likelihood of taking more than 3 weeks of vacation per year. Hours worked per week (OR, 0.99 [95% CI, 0.99-1.00] for each additional hour) was associated with lower odds of taking more than 3 weeks of vacation. Working in a Veterans Administration hospital (OR, 0.57 [95% CI, 0.33-0.97]) or active military setting (OR, 0.26 [95% CI, 0.07-0.76]) was associated with lower odds of taking more than 3 weeks of vacation compared with private practice. Age, gender, and having children were not associated with taking more than 3 weeks of vacation after adjusting for other personal and professional factors (Table 4).
Table 4. Multivariable Analysis of Factors Associated With the Outcome of Taking More than 15 Vacation Days per Yeara.
| Factor | OR (95% CI) | P value |
|---|---|---|
| Age, y | ||
| <35 | 1 [Reference] | NA |
| 35-44 | 0.89 (0.57-1.41) | .62 |
| 45-54 | 0.86 (0.53-1.40) | .53 |
| 55-64 | 0.82 (0.50-1.38) | .46 |
| ≥65 | 0.96 (0.56-1.67) | .89 |
| Gender | ||
| Male | 1 [Reference] | NA |
| Female | 0.90 (0.74-1.09) | .28 |
| Relationship status | ||
| Single | 1 [Reference] | NA |
| Married | 1.41 (1.04-1.92) | .03 |
| Partnered | 1.41 (0.89-2.24) | .14 |
| Widowed | 1.24 (0.46-3.22) | .67 |
| Age of youngest child, y | ||
| No children | 1 [Reference] | NA |
| <5 | 0.93 (0.66-1.31) | .67 |
| 5-12 | 1.30 (0.94-1.79) | .11 |
| 13-18 | 1.01 (0.71-1.43) | .96 |
| 19-22 | 1.22 (0.83-1.78) | .31 |
| >23 | 1.20 (0.85-1.71) | .30 |
| Compensation based on productivity, % | ||
| None | 1 [Reference] | NA |
| <25 | 0.98 (0.77-1.26) | .89 |
| 25-50 | 0.99 (0.71-1.38) | .97 |
| 51-75 | 0.98 (0.68-1.41) | .91 |
| >75 | 1.03 (0.82-1.28) | .82 |
| Work hours (each additional hour per week) | 0.99 (0.99-1.00) | .005 |
| Practice setting | ||
| Private practice | 1 [Reference] | NA |
| Academic medical center | 0.91 (0.74-1.13) | .40 |
| Veterans Administration hospital | 0.57 (0.33-0.97) | .04 |
| Active military practice | 0.26 (0.07-0.76) | .02 |
| Other | 1.02 (0.78-1.33) | .90 |
| Inbox coverage | ||
| No | 1 [Reference] | NA |
| Yes | 1.07 (0.90-1.26) | .45 |
| Concern regarding finding someone to cover clinical responsibilities | ||
| None or a little bit | 1 [Reference] | NA |
| Moderate | 0.77 (0.61-0.99) | .04 |
| Quite a bit | 0.48 (0.35-0.65) | <.001 |
| Very much | 0.30 (0.21-0.43) | <.001 |
| Financial concerns | ||
| None or a little bit | 1 [Reference] | NA |
| Moderate | 0.71 (0.55-0.93) | .01 |
| Quite a bit | 0.49 (0.36-0.66) | <.001 |
| Very much | 0.38 (0.27-0.54) | <.001 |
| Concern about inbox volume on return | ||
| None or a little bit | 1 [Reference] | NA |
| Moderate | 1.11 (0.88-1.41) | .38 |
| Quite a bit | 0.77 (0.57-1.03) | .08 |
| Very much | 0.96 (0.68-1.34) | .81 |
| Specialty | ||
| Internal medicine subspecialty | 1 [Reference] | |
| Anesthesiology | 5.41 (3.24-9.25) | <.001 |
| Dermatology | 1.93 (1.05-3.57) | .03 |
| Emergency medicine | 0.45 (0.28-0.72) | <.001 |
| Family medicine | 0.93 (0.63-1.39) | .74 |
| General internal medicine | 0.74 (0.48-1.12) | .15 |
| General pediatrics | 0.84 (0.54-1.32) | .45 |
| General surgery | 1.40 (0.84-2.32) | .20 |
| General surgery subspecialty | 1.09 (0.74-1.61) | .65 |
| Neurology | 1.30 (0.76-2.20) | .33 |
| Neurosurgery | 1.00 (0.43-2.21) | .99 |
| Obstetrics and gynecology | 1.83 (1.14-2.94) | .01 |
| Ophthalmology | 1.08 (0.67-1.74) | .75 |
| Orthopedic surgery | 1.41 (0.89-2.24) | .14 |
| Other | 0.95 (0.62-1.45) | .81 |
| Otolaryngology | 0.72 (0.22-2.03) | .56 |
| Pathology | 2.16 (1.25-3.79) | .01 |
| Pediatric subspecialty | 0.78 (0.48-1.27) | .32 |
| Physical medicine and rehabilitation | 1.03 (0.55-1.89) | .93 |
| Preventive medicine or occupational medicine | 0.68 (0.14-2.73) | .60 |
| Psychiatry | 1.28 (0.87-1.89) | .20 |
| Radiation oncology | 2.71 (1.17-6.60) | .02 |
| Radiology | 4.62 (2.74-8.01) | <.001 |
| Urology | 0.88 (0.31-2.32) | .81 |
Abbreviations: NA, not applicable; OR, odds ratio.
Model included the following variables: age category (<35 years old referent), gender (male referent), relationship status (single referent), age of youngest child (no children referent), compensation based on productivity (vs none), hours worked per week (each additional hour), practice setting (private practice referent category), inbox coverage (vs no), concern regarding finding someone to cover clinical responsibilities (vs none or a little bit), financial concerns (vs none or a little bit), concern about inbox volume on return (vs none or a little bit), and specialty (internal medicine subspecialty referent category).
Next, we conducted an exploratory multivariable analysis using the same variables to identify factors associated with WOV. Having full EHR inbox coverage while on vacation, which was available to slightly less than one-half of physicians (Table 1), was independently associated with lower odds of WOV (OR, 0.68 [95% CI, 0.57-0.80]). Female gender (OR, 1.62 [95% CI, 1.33-1.97]), working in an academic medical center (OR, 2.25 [95% CI, 1.83-2.78]), age 55 to 64 years (OR, 1.77 [95% CI, 1.03-3.10]), and age of youngest child 5 to 12 years (OR, 1.51 [95% CI, 1.09-2.10]) were associated with higher odds of WOV. In addition, each additional hour worked per week (OR, 1.03 [95% CI, 1.03-1.04]) was associated with higher odds of WOV (eTable 1 in Supplement 1).
We next conducted a multivariable analysis using the same variables to identify factors associated with burnout. In this analysis, taking more than 3 weeks of vacation per year (OR, 0.66 [95% CI, 0.45-0.98] for 16-20 days; OR, 0.59 [95% CI, 0.40-0.86] for >20 days vs none) and having full EHR inbox coverage while on vacation (OR, 0.74 [95% CI, 0.63-0.88]) were associated with lower risk of burnout, whereas spending 30 minutes or more on WOV on a typical vacation day (OR, 1.58 [95% CI, 1.22-2.04] for 30-60 minutes; OR, 1.97 [95% CI, 1.41-2.77] for 60-90 minutes; OR, 1.92 [95% CI, 1.36-2.73] for >90 minutes) was associated with higher risk of burnout (eTable 2 in Supplement 1). Finally, on multivariable analysis including the same variables to identify factors associated with professional fulfillment, full EHR inbox coverage while on vacation was associated with higher likelihood of professional fulfillment (OR, 1.32 [95% CI, 1.13-1.56]) (eTable 3 in Supplement 1).
Discussion
To our knowledge, this cross-sectional study is the first large study of vacation behaviors among US physicians and the first to evaluate associations of vacation behaviors with burnout. Notably, more than one-half of US physicians (59.6%) take 3 or fewer weeks of vacation per year, with 1 in 5 taking 5 or fewer days. Concerns about finding cross-coverage for clinical responsibilities and concerns about the financial impact of taking vacation (eg, by not meeting productivity targets or continued overhead costs) are associated with taking less than 3 weeks of vacation. The majority of physicians (70.4%) performed WOV on a typical vacation day, with one-third working 30 minutes or more per vacation day. On multivariable analysis controlling for personal and professional factors, women were more likely to perform more than 30 minutes of WOV, consistent with previous reports that women have more after-hours work.21 In multivariable analysis, working in the Veterans Administration or an active military setting was associated with lower odds of taking more than 3 weeks vacation, whereas working in an academic setting was associated with more than twice the odds of WOV.
Taking less vacation and performing WOV was associated with higher mean emotional exhaustion and depersonalization scores and lower professional fulfillment scores. After adjusting for other key factors (age, gender, relationship status, children, specialty, and practice setting), the number of vacation days taken and having full EHR inbox coverage while on vacation were associated with lower odds of burnout, whereas spending 30 minutes or more on WOV on a typical vacation day was associated with higher odds of burnout. Having full EHR inbox coverage while on vacation was also associated with higher odds of professional fulfillment.
Extensive evidence indicates many physicians are experiencing chronic work overload. Physicians work more hours per work week than the general US working population, with the typical full-time physician working 54 hours per week, averaging 10 hours more than other US workers each week.32 Less than 10% of US workers in other fields (9.2%) reported working 55 hours or more per week, compared with 40.7% of physicians.32 Longer work hours per week are associated with higher rates of burnout among physicians, with approximately 2% increase in odds of burnout for each extra hour worked per week.26 In addition, working long hours may impact workers’ physical health: working 55 hours or more week is associated with higher rates of heart disease and stroke.33
Our current data suggest that most physicians are taking 3 or fewer weeks of vacation per year and not fully disconnecting while on vacation. These vacation behaviors are factors likely to exacerbate the effects of chronic work overload associated with long work hours and further heighten the risk of burnout. This chronic work overload is associated with higher rates of burnout and lower professional fulfillment. Occupational burnout among physicians is a serious threat to patient and physician well-being and health system goals and has been associated with higher rates of medical errors,34 longer hospital stays, greater mortality, lower rates of patient satisfaction,35,36 reduction in work hours,37 turnover,35,38 excess health care costs,39,40,41 and physical and mental health issues for physicians.42,43,44
The fact that two-thirds of physicians are obligated to continue to provide clinical care to their patients while on vacation should be considered a marker of poorly designed systems of teamwork, inadequate clinical staffing, and poorly designed cross-coverage systems. Previous research17 suggests that physicians’ ability to disconnect from work is associated with lower burnout but is also associated with lower patient satisfaction. Without system strategies, this situation puts physicians in a double bind. Patient care needs predictably continue even while a physician is on vacation, and it is incumbent on organizations to build systems to provide EHR inbox coverage and deliver team-based care to meet patient needs when a physician is out of office. In this regard, the inability of most physicians to completely disengage from patient care while on vacation should be considered a system failure—one with consequences for both the patient and the physician.
Suboptimal vacation behaviors, such as fewer days of vacation taken and more time spent providing patient care while on vacation, may also be harmful to physicians’ personal relationships. Relationships require time together to be nurtured and strengthened; vacation has been shown to enhance personal relationships in the general population.8 Among physician spouses, time spent awake together with their physician partner is the primary factor associated with relationship satisfaction.45 A lack of attention to one’s personal relationships may be harmful to both patient care (more patient complaints) and physicians (more occupational distress and burnout).46
Given the high prevalence of burnout among physicians, efforts to mitigate this reduced time for recovery and restoration are warranted. According to surveys by the American Medical Association47 and the Physicians Advocacy Institute,48 the majority of physicians are employed, a trend that is expected to continue. For example, Merritt Hawkins reported in 2022 that more than 90% of physicians accepting new positions will practice as employees and not as independent practice owners or partners.49 Our results suggest that ensuring physicians take at least 3 weeks of vacation per year and providing coverage for clinical work, including full EHR inbox coverage while physicians are on vacation, may be tangible and pragmatic organizational actions to mitigate burnout risk. Overt efforts to track, normalize, and model taking vacation would likely be helpful. For example, organizations could track the percentage of allotted vacation days taken and amount of patient care work done while on vacation in organizational dashboards as leading indicators of systemic stress and occupational burnout. In addition, our data suggest that routinely providing full clinical and EHR inbox coverage for physicians while on vacation and reducing the financial incentives that encourage physicians to forgo vacation (eg, overreliance on relative value unit–related incentive-based compensation) may increase uptake of vacation time and fully disconnecting from work while on vacation.
Limitations
Our study is subject to limitations. Although we studied a large sample of US physicians, and the results of a secondary survey suggested participants were representative of US physicians, the participation rate was low and response bias remains a concern. It is unknown whether physicians who take fewer days of vacation or who spend more time on WOV are more or less likely to participate in a survey assessing these dimensions. This is a cross-sectional study, so causation cannot be determined. We asked about the number of vacation days per year and do not know whether some respondents, particularly those who are self-employed, included within this estimate paid time off for other purposes, such as illness, family medical leave, or attending professional meetings. Academic physicians vary widely in day-to-day activities and may have personal preferences for flexibility in scheduling multiple work responsibilities that cannot be accounted for in our analyses. The overall sample size for some specialties was modest, which limits precision when comparing vacation behaviors across specialties.
Conclusions
In this cross-sectional study of 3024 physicians, vacation behaviors were associated with physician well-being. Specifically, the number of vacation days taken per year and time spent performing patient-care work tasks while on vacation were associated with physician burnout. Where not currently in place, institutional efforts to provide operational support and clinical coverage, including full EHR inbox coverage, when physicians are on vacation should be pursued. Normalizing the expectation that physicians take time off and fully disconnect from clinical work while away may also be beneficial at both the organizational and professional level. Such efforts may be critical and tangible system-based approaches to mitigate the high rates of occupational burnout among physicians.
eAppendix. Supplemental Methods
eTable 1. Multivariable Analysis of Factors Associated with Performing Patient-Related Care on Vacationa
eTable 2. Multivariable Analysis of Factors Associated With Burnouta
eTable 3. Multivariable Analysis of Factors Associated With Professional Fulfillmenta
eFigure. Patient-Related Tasks (≥ 30 min) on a Typical Vacation Day by Gender
eReferences
Data Sharing Statement
References
- 1.Fritz C, Yankelevich M, Zarubin A, Barger P. Happy, healthy, and productive: the role of detachment from work during nonwork time. J Appl Psychol. 2010;95(5):977-983. doi: 10.1037/a0019462 [DOI] [PubMed] [Google Scholar]
- 2.de Bloom J, Geurts SA, Sonnentag S, Taris T, de Weerth C, Kompier MA. How does a vacation from work affect employee health and well-being? Psychol Health. 2011;26(12):1606-1622. doi: 10.1080/08870446.2010.546860 [DOI] [PubMed] [Google Scholar]
- 3.de Bloom J, Ritter S, Kühnel J, Reinders J, Geurts S. Vacation from work: a ‘ticket to creativity’?: the effects of recreational travel on cognitive flexibility and originality. Tour Manage. 2014;44:164-171. doi: 10.1016/j.tourman.2014.03.013 [DOI] [Google Scholar]
- 4.Syrek CJ, de Bloom J, Lehr D. Well recovered and more creative? a longitudinal study on the relationship between vacation and creativity. Front Psychol. 2021;12:784844. doi: 10.3389/fpsyg.2021.784844 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Westman M, Etzion D. The impact of vacation and job stress on burnout and absenteeism. Psychol Health. 2001;16(5):595-606. doi: 10.1080/08870440108405529 [DOI] [PubMed] [Google Scholar]
- 6.Sonnentag S. Recovery, work engagement, and proactive behavior: a new look at the interface between nonwork and work. J Appl Psychol. 2003;88(3):518-528. doi: 10.1037/0021-9010.88.3.518 [DOI] [PubMed] [Google Scholar]
- 7.Kühnel J, Sonnentag S. How long do you benefit from vacation? a closer look at the fade-out of vacation effects. J Organ Behav. 2011;32:125-143. doi: 10.1002/job.699 [DOI] [Google Scholar]
- 8.de Bloom J, Geurts SA, Kompier MA. Effects of short vacations, vacation activities and experiences on employee health and well-being. Stress Health. 2012;28(4):305-318. doi: 10.1002/smi.1434 [DOI] [PubMed] [Google Scholar]
- 9.Gump BB, Matthews KA. Are vacations good for your health? the 9-year mortality experience after the multiple risk factor intervention trial. Psychosom Med. 2000;62(5):608-612. doi: 10.1097/00006842-200009000-00003 [DOI] [PubMed] [Google Scholar]
- 10.Epel ES, Puterman E, Lin J, et al. Meditation and vacation effects have an impact on disease-associated molecular phenotypes. Transl Psychiatry. 2016;6(8):e880-e880. doi: 10.1038/tp.2016.164 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Joudrey AD, Wallace JE. Leisure as a coping resource: a test of the job demand-control-support model. Hum Relat. 2009;62:195-217. doi: 10.1177/0018726708100357 [DOI] [Google Scholar]
- 12.de Bloom J, Kompier M, Geurts S, de Weerth C, Taris T, Sonnentag S. Do we recover from vacation? meta-analysis of vacation effects on health and well-being. J Occup Health. 2009;51(1):13-25. doi: 10.1539/joh.K8004 [DOI] [PubMed] [Google Scholar]
- 13.Fritz C, Sonnentag S. Recovery, well-being, and performance-related outcomes: the role of workload and vacation experiences. J Appl Psychol. 2006;91(4):936-945. doi: 10.1037/0021-9010.91.4.936 [DOI] [PubMed] [Google Scholar]
- 14.Gilbert D, Abdullah J. Holidaytaking and the sense of well-being. Ann Tour Res. 2004;31(1):103-121. doi: 10.1016/j.annals.2003.06.001 [DOI] [Google Scholar]
- 15.Horowitz JM, Parker K. How Americans view their jobs. Pew Research Center. March 30, 2023. Accessed May 22, 2023. https://www.pewresearch.org/social-trends/2023/03/30/how-americans-view-their-jobs/
- 16.McKenna J. Physician lifestyle and happiness report 2023. Medscape. Accessed July 14, 2023. https://www.medscape.com/sites/public/lifestyle/2023
- 17.Howell TG, Mylod DE, Lee TH, Shanafelt T, Prissel P. Physician burnout, resilience, and patient experience in a community practice: correlations and the central role of activation. J Patient Exp. 2020;7(6):1491-1500. doi: 10.1177/2374373519888343 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Tawfik DS, Shanafelt TD, Dyrbye LN, et al. Personal and professional factors associated with work-life integration among US physicians. JAMA Netw Open. 2021;4(5):e2111575. doi: 10.1001/jamanetworkopen.2021.11575 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Marshall AL, Dyrbye LN, Shanafelt TD, et al. Disparities in burnout and satisfaction with work-life integration in U.S. physicians by gender and practice setting. Acad Med. 2020;95(9):1435-1443. doi: 10.1097/ACM.0000000000003521 [DOI] [PubMed] [Google Scholar]
- 20.Rotenstein LS, Fong AS, Jeffery MM, et al. Gender differences in time spent on documentation and the electronic health record in a large ambulatory network. JAMA Netw Open. 2022;5(3):e223935. doi: 10.1001/jamanetworkopen.2022.3935 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Rittenberg E, Liebman JB, Rexrode KM. Primary care physician gender and electronic health record workload. J Gen Intern Med. 2022;37(13):3295-3301. doi: 10.1007/s11606-021-07298-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Rule A, Shafer CM, Micek MA, Baltus JJ, Sinsky CA, Arndt BG. Gender differences in primary care physicians’ electronic health record use over time: an observational study. J Gen Intern Med. 2023;38(6):1570-1572. doi: 10.1007/s11606-022-07837-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Gupta KMS, Sarkar U, Mourad M, Adler-Milstein J. Differences in ambulatory EHR use patterns for male vs female physicians. NEJM Catal. 2019;5(6):2019. doi: 10.1056/CAT.19.0690 [DOI] [Google Scholar]
- 24.Tait SD, Oshima SM, Ren Y, et al. Electronic health record use by sex among physicians in an academic health care system. JAMA Intern Med. 2021;181(2):288-290. doi: 10.1001/jamainternmed.2020.5036 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Shanafelt TD, West CP, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic. Mayo Clin Proc. 2022;97(12):2248-2258. doi: 10.1016/j.mayocp.2022.09.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2020. Mayo Clin Proc. 2022;97(3):491-506. doi: 10.1016/j.mayocp.2021.11.021 [DOI] [PubMed] [Google Scholar]
- 27.Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-1385. doi: 10.1001/archinternmed.2012.3199 [DOI] [PubMed] [Google Scholar]
- 28.Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613. doi: 10.1016/j.mayocp.2015.08.023 [DOI] [PubMed] [Google Scholar]
- 29.Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clin Proc. 2019;94(9):1681-1694. doi: 10.1016/j.mayocp.2018.10.023 [DOI] [PubMed] [Google Scholar]
- 30.Maslach CJS, Leiter M. Maslach Burnout Inventory Manual. 3rd ed. Consulting Psychologists Press; 1996. [Google Scholar]
- 31.Trockel M, Bohman B, Lesure E, et al. A brief instrument to assess both burnout and professional fulfillment in physicians: reliability and validity, including correlation with self-reported medical errors, in a sample of resident and practicing physicians. Acad Psychiatry. 2018;42(1):11-24. doi: 10.1007/s40596-017-0849-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Shanafelt TD, West CP, Sinsky CA, et al. At-risk work hours among U.S. physicians and other U.S. workers. Am J Prev Med. 2023;65(4):568-578. doi: 10.1016/j.amepre.2023.03.020 [DOI] [PubMed] [Google Scholar]
- 33.Li J, Pega F, Ujita Y, et al. The effect of exposure to long working hours on ischaemic heart disease: a systematic review and meta-analysis from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury. Environ Int. 2020;142:105739. doi: 10.1016/j.envint.2020.105739 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. doi: 10.1097/SLA.0b013e3181bfdab3 [DOI] [PubMed] [Google Scholar]
- 35.Windover AK, Martinez K, Mercer MB, Neuendorf K, Boissy A, Rothberg MB. Correlates and outcomes of physician burnout within a large academic medical center. JAMA Intern Med. 2018;178(6):856-858. doi: 10.1001/jamainternmed.2018.0019 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Welle D, Trockel MT, Hamidi MS, et al. Association of occupational distress and sleep-related impairment in physicians with unsolicited patient complaints. Mayo Clin Proc. 2020;95(4):719-726. doi: 10.1016/j.mayocp.2019.09.025 [DOI] [PubMed] [Google Scholar]
- 37.Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc. 2016;91(4):422-431. doi: 10.1016/j.mayocp.2016.02.001 [DOI] [PubMed] [Google Scholar]
- 38.Hamidi MS, Bohman B, Sandborg C, et al. Estimating institutional physician turnover attributable to self-reported burnout and associated financial burden: a case study. BMC Health Serv Res. 2018;18(1):851. doi: 10.1186/s12913-018-3663-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177(12):1826-1832. doi: 10.1001/jamainternmed.2017.4340 [DOI] [PubMed] [Google Scholar]
- 40.Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States: cost of physician burnout. Ann Intern Med. 2019;170(11):784-790. doi: 10.7326/M18-1422 [DOI] [PubMed] [Google Scholar]
- 41.Sinsky CA, Shanafelt TD, Dyrbye LN, Sabety AH, Carlasare LE, West CP. Health care expenditures attributable to primary care physician overall and burnout-related turnover: a cross-sectional analysis. Mayo Clin Proc. 2022;97(4):693-702. doi: 10.1016/j.mayocp.2021.09.013 [DOI] [PubMed] [Google Scholar]
- 42.Weaver MD, Robbins R, Quan SF, et al. Association of sleep disorders with physician burnout. JAMA Netw Open. 2020;3(10):e2023256. doi: 10.1001/jamanetworkopen.2020.23256 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Trockel MT, Menon NK, Rowe SG, et al. Assessment of physician sleep and wellness, burnout, and clinically significant medical errors. JAMA Netw Open. 2020;3(12):e2028111. doi: 10.1001/jamanetworkopen.2020.28111 [DOI] [PubMed] [Google Scholar]
- 44.Toker S, Melamed S, Berliner S, Zeltser D, Shapira I. Burnout and risk of coronary heart disease: a prospective study of 8838 employees. Psychosom Med. 2012;74(8):840-847. doi: 10.1097/PSY.0b013e31826c3174 [DOI] [PubMed] [Google Scholar]
- 45.Shanafelt TD, Boone SL, Dyrbye LN, et al. The medical marriage: a national survey of the spouses/partners of US physicians. Mayo Clin Proc. 2013;88(3):216-225. doi: 10.1016/j.mayocp.2012.11.021 [DOI] [PubMed] [Google Scholar]
- 46.Trockel J, Bohman B, Wang H, Cooper W, Welle D, Shanafelt TD. Assessment of the relationship between an adverse impact of work on physicians’ personal relationships and unsolicited patient complaints. Mayo Clin Proc. 2022;97(9):1680-1691. doi: 10.1016/j.mayocp.2022.03.005 [DOI] [PubMed] [Google Scholar]
- 47.Kane CK. Recent changes in physician practice arrangements: private practice dropped to less than 50 percent of physicians in 2020. 2021. Accessed May 14, 2023. https://www.ama-assn.org/system/files/2021-05/2020-prp-physician-practice-arrangements.pdf
- 48.Physicians Advocacy Institute . COVID-19’s impact on acquisitions of physician practices and physician employment 2019-2021. Avalere Health. June 2021. Accessed May 22, 2023. https://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/Revised-6-8-21_PAI-Physician-Employment-Study-2021-FINAL.pdf?ver=K6dyoekRSC_c59U8QD1V-A%3D%3D
- 49.Miller P. A growing number of physicians are employed. AMN Healthcare. May 6, 2022. Accessed May 22, 2023. https://www.amnhealthcare.com/blog/physician/perm/a-growing-number-of-physicians-are-employed/
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eAppendix. Supplemental Methods
eTable 1. Multivariable Analysis of Factors Associated with Performing Patient-Related Care on Vacationa
eTable 2. Multivariable Analysis of Factors Associated With Burnouta
eTable 3. Multivariable Analysis of Factors Associated With Professional Fulfillmenta
eFigure. Patient-Related Tasks (≥ 30 min) on a Typical Vacation Day by Gender
eReferences
Data Sharing Statement