Key Points
Question
How has the prevalence of physicians intending to reduce their clinical hours (ITR) or intending to leave their current organization (ITL) changed since the COVID-19 pandemic?
Findings
In this serial cross-sectional multisite study of 37 112 physicians surveyed from 2022 to 2024, the point prevalence of ITR decreased from 25.6% in 2022 to 22.5% in 2024, while the prevalence of ITL decreased from 19.9% in 2022 to 15.1% in 2024. A desire for increased workflow efficiency, improved staffing, and enhanced compensation were the most prevalent factors that would make respondents reconsider ITR or ITL.
Meaning
This study suggests that, while the prevalence of ITR and ITL have decreased since the pandemic, more than one-fifth of physicians continued to report ITR and nearly 1 in 6 reported ITL, representing mixed progress on enhancing retention of physicians and their clinical effort.
Abstract
Importance
The COVID-19 pandemic was associated with a substantial prevalence of physicians intending to reduce their clinical hours (ITR) or intending to leave their current organization (ITL). It is unclear how work intentions have changed since that time.
Objective
To characterize how the prevalence of ITR and ITL changed among physicians since the COVID-19 pandemic, factors associated with ITR and ITL, and factors associated with physicians’ decision to remain at their current clinical workload or their current organization.
Design, Setting, and Participants
This serial cross-sectional study was conducted from January 7, 2022, to November 3, 2024, among 160 organizations across the US with 100 or more physicians across specialties. Physicians responded to the American Medical Association's Organizational Biopsy study in 2022, 2023, or 2024.
Main Outcomes and Measures
Main outcomes were ITR within the next 12 months and ITL within the next 24 months.
Results
The sample consisted of 37 112 physicians (7176 physicians in 2022, 12 248 in 2023, and 17 688 in 2024; median organizational response rate of 41.5% [IQR, 29%-60%]; 18 626 of 35 202 male physicians [52.9%]) from 160 organizations, including 81.4% physicians (25 381 of 31 182) who identified as practicing clinically full-time. The overall point prevalence of ITR decreased from 25.6% (1489 of 5815) in 2022 to 22.5% (3266 of 14 540) in 2024 (P = .002), while the prevalence of ITL decreased from 19.9% (1345 of 6760) in 2022 to 15.1% (2414 of 15 935) in 2024 (P = .002). Decreases in ITR and ITL were seen across multiple physician groups. In multivariable-adjusted models, female physicians had higher odds of ITR than male physicians (odds ratio [OR], 1.11; 95% CI, 1.04-1.20), but lower odds of ITL (OR, 0.93; 95% CI, 0.87-0.99). Part-time physicians had 1.18 (95% CI, 1.09-1.29) times the odds of ITR and 1.35 (95% CI, 1.25-1.45) times the odds of ITL compared with full-time physicians. The most prevalent factors that would make respondents reconsider ITR or ITL—including a desire for increased workflow efficiency, improved staffing, and enhanced compensation—were common across the 2 outcomes.
Conclusions and Relevance
This serial, cross-sectional, multisite study of US physicians suggests that while the prevalence of ITR and ITL have decreased since the COVID-19 pandemic, more than one-fifth of physicians continued to report ITR and nearly 1 in 6 reported ITL. In aggregate, compared with historical data, current rates represent mixed progress with favorable overall trends in ITL but unfavorable trends in ITR. Common factors, including greater workflow efficiency and consistent staffing, were reported as potentially mitigating both ITR and ITL. These findings can help leaders prioritize and target interventions to sustain the effort of the physician workforce.
This cross-sectional study uses survey data to characterize how the prevalence of physicians intending to reduce clinical hours and intending to leave their current organization has changed since the COVID-19 pandemic, as well as factors associated with these decisions.
Introduction
In addition to its effects across the health care system,1 the COVID-19 pandemic placed particular strain on physicians. As of 2021, 2 in 5 physicians reported an intent to reduce their clinical work hours (ITR), representing significant increases from 2014 and 2011.2 In addition, about one-fourth indicated it was likely or definite that they intended to leave their current practice (ITL) in the next 24 months, with a stable prevalence between 2014 and 2021.2 These work intentions, associated with stressful working conditions3 and perceptions of personal risk,4,5 signaled a concerning trend for the physician workforce, which had already been grappling with increased rates of clinical attrition6 and reductions in clinical work effort.
Given the time that has elapsed since the pandemic, it is unclear how trends in work intentions have changed. Although the acute stresses of the COVID-19 pandemic may have cleared, physicians are still facing persistent downstream effects, such as incomplete staffing and the operational consequences of financial stresses faced by health care organizations. In addition, we have an incomplete understanding of which physician groups may be more likely to reduce their work hours or leave the postpandemic workplace, limiting the ability of health care and well-being leaders to target interventions based on prior knowledge of factors associated with physician work intentions.1,7,8 Finally, given a known physician shortage9 and threats to patient access, there is an opportunity to characterize what changes would limit physician ITL or ITR.
In this context, we sought to answer 3 main questions in this multisite, serial, cross-sectional study: (1) How has the prevalence of ITR and ITL changed among physicians since the COVID-19 pandemic, and have these trends differed by physician subgroup? (2) What factors are associated with differential likelihood of physician ITR or ITL since the COVID-19 pandemic? and (3) What factors are associated with physicians’ decision to remain at their current clinical workload or their current organization?
Methods
Survey Instrument and Participants
The American Medical Association’s (AMA’s) Organizational Biopsy is a survey tool that, as previously described,8,10,11 supports organizations in measuring and taking action to improve the well-being of their workforce. It is available to organizations with 100 or more physicians. Each organization distributes the survey to some or all physicians via a custom link. Respondents are presented with data sharing agreement information ahead of completing the survey. To preserve anonymity and limit any potential identification of respondents, no internet protocol address information is collected from respondents and all data results with fewer than 6 responses are suppressed. Organizations can choose which questions to ask their physicians from a master question bank. The survey has 40 core items, including items querying respondents about demographic and professional characteristics. It also asks questions about respondents’ ITR, ITL, and factors associated with these work intentions. The present analysis was limited to data from physicians who responded to the survey in 2022, 2023, or 2024. The study was deemed to be not human participants research by the University of Illinois Chicago institutional review board. Participant consent was implied by completion of the survey. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines for cross-sectional studies.
Demographic and Professional Questions
Participants were queried about their years in clinical practice after training, their gender identity (male; female; nonbinary, genderqueer, or transgender; or prefer not to answer), their race and ethnicity (American Indian or Alaska Native; Asian; Asian or Pacific Islander; Black or African American; Latinx, Latino, Latina, or Hispanic; Middle Eastern or North African; Native Hawaiian or Pacific Islander; White; some other race or ethnicity; or more than 1 race or ethnicity), clinical full-time equivalent (FTE; full-time or part-time; self-defined), clinical setting (outpatient only, both inpatient and outpatient, inpatient only, or other), and specialty, which we subsequently categorized into primary care specialties (ie, general internal medicine, family medicine, general pediatrics), nonprimary care medical specialties, hospital-based specialties, obstetrics and gynecology, psychiatry, and surgical specialties according to the classification used in the Centers for Medicare & Medicaid Service’s Data on Provider Practice and Specialty.12 Data on race and ethnicity were included in the study because they are standard demographic characteristics that are collected in physician surveys.
Work Intentions
Physician career intentions were assessed with 2 previously described items assessing ITR and ITL.2,5,13,14,15 The ITR item queried participants on “What is the likelihood that you will reduce the number of hours you devote to clinical care over the next 12 months?” The ITL item queried participants on “What is the likelihood that you will leave your current organization within 2 years?” Response options for both items were: none, slight, moderate, likely, or definitely. We considered responses of likely or definitely as a positive response. Those who answered definitely or likely to the ITR item were also asked “What would keep you in your role with at least the current amount of clinical percent FTE?” and asked to choose all that apply from a menu of options developed based on prior free text responses to these questions and the hypotheses and experiences of AMA physician advisors. Those who answered definitely or likely to the ITL item were also asked “What would make you reconsider and stay in your current organization?” and asked to choose all that apply from a menu of options.
Statistical Analysis
We first descriptively analyzed physicians’ answers to demographic and professional questions across study years and for each study year individually. We compared demographic and professional characteristics across study years using χ2 tests and used the Benjamini-Hochberg method to adjust for multiple comparisons.
We then characterized the distribution of physician responses to the ITR and ITL questions using numbers and percentages based on preestablished cut-points as described above. Responses were again calculated across study years and for each study year individually. We compared the point prevalence of ITR and ITL over the study period within each group of demographic and professional characteristics using χ2 tests. We again used the Benjamini-Hochberg method to adjust for multiple comparisons.
To identify the factors associated with ITL and ITR across study years, we fit 2 generalized linear mixed-effects model with a logit link and organization-level random effects, estimated by maximum likelihood using the Laplace approximation. Longitudinal measurements across 3 time periods were modeled using a compound symmetry covariance structure, yielding cluster-specific effect estimates that account for both within-organization and within-individual correlation. Models adjusted for study year, respondents’ gender, part-time vs full-time status, clinical setting, specialty category, race and ethnicity, and years in practice after training.
Finally, we quantified the period prevalence (2022-2024) of affirmative responses to each potential factor that would keep the respondent in their role at their current amount of clinical percentage FTE and each potential factor that would keep the respondent in their current organization. We adjusted for multiple comparisons using the Benjamini-Hochberg false discovery rate. Analyses were conducted in SAS, version 9.4 (SAS Institute Inc), with 2-sided α = .05 deemed statistically significant.
Results
Sample Characteristics
The sample consisted of 37 112 physicians (7176 physicians in 2022, 12 248 physicians in 2023, and 17 688 physicians in 2024), including 18 626 of 35 202 male physicians (52.9%) and 15 049 of 35 202 female physicians (42.8%); 44 of 34 433 (0.1%) were American Indian or Alaska Native, 4179 of 34 433 (12.1%) were Asian, 273 of 34 433 (0.8%) were Asian or Pacific Islander, 1062 of 34 433 (3.1%) were Black or African American, 1150 of 34 433 (3.3%) were Latinx, Latino, Latina, or Hispanic, 568 of 34 433 (1.6%) were Middle Eastern or North African, 46 (0.1%) were Native Hawaiian or Pacific Islander, 1053 of 34 433 (3.1%) were more than 1 race or ethnicity, 353 of 34 433 (1.0%) were other race or ethnicity, and 3428 of 34 433 (10.0%) preferred not to answer (Table 1). A total of 25 381 of 31 182 physicians (81.4%) identified as practicing clinically full-time. These physicians were derived from a total of 160 organizations, with a median response rate of 41.5% (IQR, 29%-60%). They were distributed across specialties, including 35.3% primary care physicians (11 957 of 33 830), 25.8% hospital-based physicians (8724 of 33 830), 17.4% medical specialists (5888 of 33 830), 13.2% surgical specialists (4450 of 33 830), 5.9% obstetrics and gynecology physicians (1980 of 33 830), and 2.5% psychiatric physicians (831 of 33 830). A total of 41.0% of respondents (13 317 of 32 486) practiced in both the inpatient and outpatient settings, 37.1% (12 048 of 32 486) in the outpatient setting only, and 18.0% (5846 of 32 486) in the inpatient setting only. About one-third of respondents (35.6% [12 666 of 35 580]) had been in practice for 20 years or more. Although participant characteristics remained largely consistent over the study period, the proportion of respondents who worked full-time decreased from 85.1% (5307 of 6235) in 2022 to 78.0% (11 133 of 14 275) in 2024 (P < .001), while the proportion of respondents who worked part-time increased from 14.9% (928 of 6 235) in 2022 to 22.0% (3142 of 14 275) in 2024 (P < .001).
Table 1. Demographic Characteristics of Physician Sample, Overall and by Study Year.
| Characteristic | Physicians, No. (%) | P value for difference across years | |||
|---|---|---|---|---|---|
| 2022-2024 (N = 37 112) | 2022 (n = 7176) | 2023 (n = 12 248) | 2024 (n = 17 688) | ||
| Gender identity | |||||
| Male | 18 626 (52.9) | 3460 (52.1) | 6169 (52.7) | 8997 (53.4) | .62 |
| Female | 15 049 (42.8) | 2682 (40.4) | 5104 (43.6) | 7263 (43.1) | .62 |
| Nonbinary, genderqueer, or transgender | 71 (0.2) | 22 (0.3) | 24 (0.2) | 25 (0.1) | .91 |
| Prefer not to answer | 1430 (4.1) | 471 (7.1) | 400 (3.4) | 559 (3.3) | .05 |
| >1 Gender identity | 26 (0.1) | 0 | 11 (0.1) | 15 (0.1) | .07 |
| Missing | 1910 | 541 | 540 | 829 | NA |
| By your own definition, are you clinically full-time or part-time? | |||||
| Full time | 25 381 (81.4) | 5307 (85.1) | 8941 (83.8) | 11 133 (78.0) | <.001 |
| Part time | 5801 (18.6) | 928 (14.9) | 1731 (16.2) | 3142 (22.0) | <.001 |
| Missing | 5930 | 941 | 1576 | 3413 | NA |
| Specialty | |||||
| Primary care | 11 957 (35.3) | 2112 (33.9) | 3966 (35.2) | 5879 (36.0) | .41 |
| Hospital based | 8724 (25.8) | 1707 (27.4) | 2767 (24.6) | 4250 (26.0) | .24 |
| Medical specialty | 5888 (17.4) | 1047 (16.8) | 2189 (19.4) | 2652 (16.2) | .23 |
| Surgery specialty | 4450 (13.2) | 803 (12.9) | 1417 (12.6) | 2230 (13.6) | .91 |
| Obstetrics and gynecology | 1980 (5.9) | 398 (6.4) | 649 (5.8) | 933 (5.7) | .69 |
| Psychiatry | 831 (2.5) | 161 (2.6) | 268 (2.4) | 402 (2.5) | .91 |
| Missing | 3282 | 948 | 992 | 1342 | NA |
| Clinical setting | |||||
| Both inpatient and outpatient | 13 317 (41.0) | 2406 (40.2) | 4362 (42.4) | 6549 (40.4) | .66 |
| Outpatient only | 12 048 (37.1) | 2258 (37.7) | 3824 (37.2) | 5966 (36.8) | .91 |
| Inpatient only (ie, hospitalist) | 5846 (18.0) | 1092 (18.2) | 1684 (16.4) | 3070 (18.9) | .41 |
| Other | 1275 (3.9) | 231 (3.9) | 420 (4.1) | 624 (3.8) | .91 |
| Missing | 4626 | 1189 | 1958 | 1479 | NA |
| Race and ethnicity | |||||
| American Indian or Alaska Native | 44 (0.1) | 10 (0.1) | 13 (0.1) | 21 (0.1) | .77 |
| Asian | 4179 (12.1) | 488 (7.20 | 1440 (12.7) | 2251 (13.8) | .00 |
| Asian or Pacific Islander | 273 (0.8) | 273 (4.0) | 0 | 0 | NA |
| Black or African American | 1062 (3.1) | 157 (2.3) | 403 (3.5) | 502 (3.1) | .07 |
| Latinx, Latino, Latina, or Hispanic | 1150 (3.3) | 189 (2.8) | 465 (4.1) | 496 (3.0) | .02 |
| Middle Eastern or North African | 568 (1.6) | 42 (0.6) | 212 (1.9) | 314 (1.9) | .00 |
| Native Hawaiian or Pacific Islander | 46 (0.1) | 7 (0.1) | 13 (0.1) | 26 (0.2) | .41 |
| White | 22 277 (64.7) | 4454 (65.8) | 7278 (64.1) | 10 545 (64.7) | .91 |
| >1 Race or ethnicity | 1053 (3.1) | 237 (3.5) | 336 (3.0) | 480 (2.9) | .62 |
| Other race or ethnicitya | 353 (1.0) | 95 (1.4) | 106 (0.9) | 152 (0.9) | .23 |
| Prefer not to answer | 3428 (10.0) | 813 (12.0) | 1095 (9.6) | 1520 (9.3) | .05 |
| Missing | 2679 | 411 | 887 | 1381 | NA |
| Years in practice post training | |||||
| 1-5 | 6718 (18.9) | 1253 (19.2) | 2333 (19.1) | 3132 (18.6) | .91 |
| 6-10 | 6122 (17.2) | 1165 (17.9) | 2092 (17.1) | 2865 (17.0) | .91 |
| 11-15 | 5793 (16.3) | 1056 (16.2) | 2064 (16.9) | 2673 (15.9) | .91 |
| 16-20 | 4247 (11.9) | 739 (11.3) | 1484 (12.1) | 2024 (12.0) | .91 |
| >20 | 12 666 (35.6) | 2274 (34.9) | 4268 (34.9) | 6124 (36.4) | .62 |
| NA | 34 (0.1) | 34 (0.5) | 0 | 0 | NA |
| Missing | 1532 | 655 | 7 | 870 | NA |
Abbreviation: NA, not applicable.
The other race or ethnicity field was a free-text field where respondents could write in their race or ethnicity.
Unadjusted Prevalence of ITR
As shown in Table 2, the overall point prevalence of ITR decreased from 25.6% (1489 of 5815) in 2022 to 22.5% (3266 of 14 540) in 2024 (P = .002). The prevalence of ITR decreased from 24.9% (691 of 2772) in 2022 to 22.1% (1647 of 7438) in 2024 (P = .03) among male physicians and 25.2% (547 of 2168) in 2022 to 22.4% (1356 of 6066) in 2024 (P = .047) among female physicians. For full-time physicians, the point prevalence of ITR decreased from 24.8% (1142 of 4603) in 2022 to 21.9% (2045 of 9327) in 2024 (P = .02). The point prevalence of ITR decreased among primary care specialists (from 25.3% [430 of 1697] in 2022 to 21.7% [1005 of 4624] in 2024; P = .03), medical specialists (from 25.4% [225 of 886] in 2022 to 19.4% [443 of 2278] in 2024; P = .02), and surgical specialists (from 25.0% [174 of 697] in 2022 to 20.8% [380 of 1829] in 2024; P = .047), but not among other specialties. When considering trends by racial and ethnic group, the prevalence of ITR decreased significantly only among White respondents (from 25.2% [918 of 3640] in 2022 to 22.2% [1986 of 8932] in 2024; P = .02). Temporal trends in the point prevalence of ITR varied by clinical setting, with significant decreases seen among those who practiced in both inpatient and outpatient settings (from 24.3% [495 of 2037] in 2022 to 21.4% [1131 of 5285] in 2024; P = .047) and those who practiced in outpatient settings only (from 27.1% [524 of 1936] in 2022 to 21.9% [1074 of 4910] in 2024; P = .02). Finally, the point prevalence of ITR varied by years in practice, with significant decreases seen among those with 1 to 5 years in practice, 6 to 10 years in practice, or 16 to 20 years in practice.
Table 2. Temporal Trends in Unadjusted Prevalence of Intent to Reduce Clinical Hours and Intent to Leave Current Organization, Overall and by Demographic Subgroup.
| Characteristic | Intent to reduce clinical hours, % (No./total No.) | P value | Intent to leave current organization, % (No./total No.) | P value | ||||
|---|---|---|---|---|---|---|---|---|
| 2022 | 2023 | 2024 | 2022 | 2023 | 2024 | |||
| All physicians | 25.6 (1489/5815) | 24.5 (2058/8385) | 22.5 (3266/14 540) | .002 | 19.9 (1345/6760) | 17.1 (1836/10 706) | 15.1 (2414/15 935) | .002 |
| Gender | ||||||||
| Male | 24.9 (691/2772) | 24.4 (1035/4238) | 22.1 (1647/7438) | .03 | 20.4 (655/3218) | 17.2 (953/5534) | 15.8 (1289/8139) | .002 |
| Female | 25.2 (547/2168) | 24.0 (867/3611) | 22.4 (1356/6066) | .047 | 17.8 (454/2551) | 15.8 (714/4508) | 13.1 (869/6658) | .002 |
| Prefer not to answer | 36.9 (138/374) | 32.9 (80/243) | 31.1 (141/453) | .22 | 30.0 (135/450) | 30.8 (113/367) | 30.6 (158/516) | .84 |
| Nonbinary, genderqueer, or transgender | 33.3 (7/21) | 31.6 (6/19) | 23.8 (5/21) | .41 | 31.8 (7/22) | 39.1 (9/23) | 33.3 (8/24) | .51 |
| >1 Gender identity | NA | 18.2 (2/11) | 21.4 (3/14) | NA | NA | 0 | 20.0 (3/15) | NA |
| Race and ethnicity | ||||||||
| American Indian or Alaska Native | 33.3 (2/6) | 42.9 (3/7) | 53.3 (8/15) | .39 | 10.0 (1/10) | 45.5 (5/11) | 26.3 (5/19) | .33 |
| Asian | 21.5 (87/405) | 24.4 (257/1055) | 19.9 (387/1947) | .33 | 15.8 (66/418) | 14.8 (183/1238) | 12.7 (267/2098) | .03 |
| Asian or Pacific Islander | 19.5 (38/195) | NA | NA | NA | 13.9 (38/273) | NA | NA | NA |
| Black or African American | 21.1 (27/128) | 20.9 (55/263) | 22.4 (100/446) | .80 | 20.0 (29/145) | 17.5 (65/371) | 16.0 (76/475) | .28 |
| Latinx, Latino, Latina, or Hispanic | 22.4 (28/125) | 23.9 (63/264) | 23.0 (95/413) | .79 | 16.7 (31/186) | 16.4 (71/433) | 13.3 (61/460) | .14 |
| Middle Eastern or North African | 20.5 (8/39) | 22.4 (32/143) | 18.9 (48/254) | .59 | 26.3 (10/38) | 16.8 (31/185) | 15.9 (43/271) | .03 |
| Native Hawaiian or Pacific Islander | 33.3 (2/6) | 25.0 (3/12) | 13.6 (3/22) | .12 | 14.3 (1/7) | 9.1 (1/11) | 20.8 (5/24) | .41 |
| White | 25.2 (918/3640) | 23.9 (1213/5076) | 22.2 (1986/8932) | .02 | 19.5 (824/4216) | 16.3 (1052/6472) | 14.4 (1436/9967) | .002 |
| >1 Race or ethnicity | 21.8 (48/220) | 23.0 (51/222) | 19.3 (79/409) | .38 | 15.7 (36/229) | 14.7 (44/299) | 14.5 (66/456) | .65 |
| Other race or ethnicity | 23.0 (17/74) | 18.4 (14/76) | 18.6 (24/129) | .36 | 19.1 (17/89) | 17.2 (16/93) | 12.1 (17/141) | .07 |
| Prefer not to answer | 35.3 (226/641) | 32.0 (226/707) | 30.4 (381/1255) | .19 | 29.1 (220/757) | 26.7 (262/982) | 24.3 (346/1424) | .06 |
| Years in practice post training | ||||||||
| 1-5 | 23.7 (227/958) | 20.4 (327/1601) | 18.5 (470/2542) | .002 | 18.9 (221/1168) | 16.7 (330/1980) | 13.0 (365/2799) | .002 |
| 6-10 | 25.1 (236/942) | 24.0 (339/1414) | 20.8 (483/2318) | .03 | 16.2 (180/1114) | 15.4 (279/1812) | 12.9 (330/2558) | .04 |
| 11-15 | 22.1 (191/866) | 24.3 (352/1450) | 20.1 (442/2203) | .36 | 15.1 (152/1009) | 13.9 (256/1841) | 10.5 (252/2405) | .02 |
| 16-20 | 23.1 (138/597) | 19.1 (193/1010) | 18.7 (311/1664) | .02 | 18.8 (129/686) | 12.2 (159/1306) | 10.7 (195/1818) | .002 |
| >20 | 29.5 (524/1777) | 29.1 (845/2903) | 27.1 (1340/4943) | .39 | 25.4 (532/2094) | 21.6 (812/3760) | 20.1 (1101/5485) | .03 |
| NA | 30.0 (6/20) | NA | NA | NA | 35.3 (12/34) | NA | NA | NA |
| Clinical FTE | ||||||||
| Full time | 24.8 (1142/4603) | 23.5 (1506/6397) | 21.9 (2045/9327) | .02 | 18.5 (955/5157) | 16.2 (1277/7891) | 13.8 (1414/10 265) | .002 |
| Part time | 30.3 (243/802) | 29.5 (343/1162) | 26.1 (683/2616) | .09 | 25.5 (235/922) | 21.6 (318/1470) | 18.8 (548/2916) | .002 |
| Specialty | ||||||||
| Primary care | 25.3 (430/1697) | 23.1 (565/2447) | 21.7 (1005/4624) | .03 | 20.3 (410/2024) | 18.7 (609/3260) | 13.9 (714/5134) | .002 |
| Hospital based | 28.0 (402/1434) | 26.0 (532/2048) | 25.3 (915/3620) | .19 | 19.6 (333/1696) | 16.2 (413/2543) | 15.2 (592/3890) | .002 |
| Medical specialty | 25.4 (225/886) | 23.8 (363/1525) | 19.4 (443/2278) | .02 | 20.9 (214/1025) | 15.4 (307/1992) | 14.5 (362/2489) | .002 |
| Surgery specialty | 25.0 (174/697) | 24.4 (230/942) | 20.8 (380/1829) | .047 | 22.2 (175/788) | 17.5 (216/1236) | 16.5 (330/2006) | .002 |
| Obstetrics and gynecology | 25.1 (86/342) | 26.0 (109/420) | 23.4 (175/749) | .48 | 16.1 (61/378) | 14.8 (87/586) | 15.0 (131/873) | .62 |
| Psychiatry | 23.6 (33/140) | 28.6 (57/199) | 21.2 (70/330) | .19 | 26.1 (42/161) | 21.4 (50/234) | 16.5 (63/382) | .02 |
| Clinical setting | ||||||||
| Both inpatient and outpatient | 24.3 (495/2037) | 24.6 (776/3153) | 21.4 (1131/5285) | .047 | 19.9 (464/2326) | 17.9 (720/4019) | 15.1 (874/5793) | .002 |
| Outpatient only | 27.1 (524/1936) | 24.3 (691/2841) | 21.9 (1074/4910) | .02 | 18.8 (409/2179) | 17.0 (600/3529) | 14.5 (806/5553) | .002 |
| Inpatient only (ie, hospitalist) | 26.2 (259/987) | 24.8 (328/1325) | 25.5 (661/2592) | .67 | 21.5 (232/1081) | 16.7 (258/1547) | 15.3 (416/2719) | .002 |
| Other | 27.9 (58/208) | 21.9 (70/320) | 23.9 (127/532) | .25 | 20.4 (46/226) | 14.9 (59/397) | 12.2 (70/572) | <.001 |
Abbreviations: FTE, full-time equivalent; NA, not applicable.
Unadjusted Prevalence of ITL
The overall point prevalence of ITL also decreased from 19.9% (1345 of 6760) in 2022 to 15.1% (2414 of 15 935) in 2024 (P = .002) (Table 2). It decreased from 20.4% (655 of 3218) in 2022 to 15.8% (1289 of 8139) in 2024 among male physicians (P = .002), and from 17.8% (454 of 2551) in 2022 to 13.1% (869 of 6658) in 2024 among female physicians (P = .002). The point prevalence of ITL decreased among both part-time and full-time physicians (part-time physicians: from 25.5% [235 of 922] in 2022 to 18.8% [548 of 2916] in 2024; P = .002; and full-time physicians: from 18.5% [955 of 5157] in 2022 to 13.8% [1414 of 10 265] in 2024; P = .002). It decreased across all specialties except for obstetrics and gynecology, across all clinical settings, and among all groups of years in practice. Temporal trends in the point prevalence of ITL varied by racial and ethnic group, as shown in Table 2.
Factors Associated With ITR and ITL in Multivariable Analyses
In multivariable adjusted models (Table 3), female physicians had higher odds of ITR than male physicians (odds ratio [OR], 1.11; 95% CI, 1.04-1.20). Compared with physicians in practice for 1 to 5 years after training, those in practice for 20 years or more had 1.55 (95% CI, 1.40-1.71) greater odds of ITR. Part-time physicians had 1.18 (95% CI, 1.09-1.29) times the odds of ITR than full-time physicians and hospital-based physicians had 1.22 (95% CI, 1.10-1.36) times the odds of ITR than primary care physicians. Odds of ITR did not vary by clinical practice site (ie, inpatient only, outpatient only, or both).
Table 3. Factors Associated With Intent to Reduce Clinical Hours and Intent to Leave Current Organization in Multivariable Adjusted Models.
| Characteristic | Intent to reduce clinical hours | Intent to leave current organization | ||
|---|---|---|---|---|
| OR (95% CI) | P value | OR (95% CI) | P value | |
| Year | ||||
| 2022 | 1 [Reference] | NA | 1 [Reference] | NA |
| 2023 | 0.89 (0.78-1.00) | .06 | 0.95 (0.86-1.06) | .37 |
| 2024 | 0.81 (0.71-0.93) | .002 | 0.79 (0.71-0.89) | <.001 |
| Gender | ||||
| Male | 1 [Reference] | NA | 1 [Reference] | NA |
| Female | 1.11 (1.04-1.20) | .003 | 0.93 (0.87-0.99) | .02 |
| Prefer not to answer | 1.26 (1.05-1.50) | .01 | 1.61 (1.38-1.88) | <.001 |
| >1 Gender identity | 0.75 (0.25-2.23) | .60 | 1.85 (0.79-4.35) | .16 |
| Nonbinary genderqueer, or transgender | 1.61 (0.83-3.10) | .16 | 3.01 (1.66-5.46) | <.001 |
| Race and ethnicity | ||||
| American Indian or Alaska Native | 1.55 (0.64-3.72) | .33 | 1.74 (0.86-3.53) | .12 |
| Asian | 0.92 (0.83-1.02) | .12 | 0.86 (0.78-0.94) | <.001 |
| Asian or Pacific Islander | 0.69 (0.44-1.10) | .12 | 0.74 (0.52-1.07) | .11 |
| Black or African American | 0.97 (0.80-1.17) | .72 | 0.88 (0.75-1.04) | .13 |
| Latinx, Latino, Latina, or Hispanic | 1.10 (0.91-1.34) | .31 | 1.04 (0.88-1.22) | .66 |
| Middle Eastern or North African | 0.80 (0.59-1.07) | .12 | 0.95 (0.75-1.20) | .67 |
| Native Hawaiian or Pacific Islander | 1.15 (0.50-2.60) | .75 | 0.63 (0.27-1.50) | .30 |
| White | 1 [Reference] | NA | 1 [Reference] | NA |
| >1 Race or ethnicity | 0.86 (0.70-1.05) | .15 | 0.88 (0.74-1.04) | .12 |
| Other race or ethnicity | 0.84 (0.60-1.20) | .34 | 0.90 (0.67-1.20) | .47 |
| Prefer not to answer | 1.55 (1.37-1.75) | <.001 | 1.60 (1.44-1.78) | <.001 |
| Years in practice post training | ||||
| 1-5 | 1 [Reference] | NA | 1 [Reference] | NA |
| 6-10 | 1.12 (1.00-1.26) | .05 | 1.09 (0.99-1.19) | .08 |
| 11-15 | 1.07 (0.95-1.20) | .24 | 0.94 (0.85-1.04) | .21 |
| 16-20 | 0.96 (0.85-1.10) | .57 | 0.88 (0.79-0.98) | .02 |
| >20 | 1.55 (1.40-1.71) | <.001 | 1.41 (1.29-1.53) | <.001 |
| NA | 0.83 (0.22-3.04) | .77 | 1.30 (0.59-2.85) | .52 |
| Clinical FTE | ||||
| Part time | 1.18 (1.09-1.29) | <.001 | 1.35 (1.25-1.45) | <.001 |
| Full time | 1 [Reference] | NA | 1 [Reference] | NA |
| Specialty | ||||
| Hospital based | 1.22 (1.10-1.36) | <.01 | 1.01 (0.92-1.10) | .85 |
| Medical specialty | 0.99 (0.89-1.10) | .79 | 1.00 (0.91-1.09) | .96 |
| Surgery specialty | 0.97 (0.86-1.10) | .64 | 1.09 (0.98-1.20) | .10 |
| Obstetrics and gynecology | 1.06 (0.91-1.24) | .48 | 0.92 (0.80-1.05) | .19 |
| Psychiatry | 1.11 (0.89-1.39) | .34 | 1.27 (1.06-1.53) | <.001 |
| Primary care | 1 [Reference] | NA | 1 [Reference] | NA |
| Clinical setting | ||||
| Inpatient only | 1 [Reference] | NA | 1 [Reference] | NA |
| Outpatient only | 0.97 (0.87-1.08) | .59 | 0.84 (0.76-0.92) | <.01 |
| Both inpatient and outpatient | 1.00 (0.90-1.11) | .95 | 0.97 (0.89-1.07) | .57 |
| Other | 0.95 (0.79-1.13) | .56 | 0.77 (0.66-0.90) | <.001 |
Abbreviations: FTE, full-time equivalent; NA, not applicable.
Female physicians had lower odds of ITL than male physicians (OR, 0.93; 95% CI, 0.87-0.99) in multivariable adjusted models (Table 3). Compared with those in practice for 1 to 5 years, physicians in practice for 20 years or more had 1.41 (95% CI, 1.29-1.53) times the odds of ITL, while those in practice 16 to 20 years had 0.88 (95% CI, 0.79-0.98) times the odds of ITL. Part-time physicians had 1.35 (95% CI, 1.25-1.45) times the odds of ITL compared with full-time physicians. Psychiatric physicians had 1.27 (95% CI, 1.06-1.53) times the odds of ITL compared with primary care physicians. Compared with physicians in an inpatient-only setting, those in an outpatient-only setting had significantly lower odds of ITL (OR, 0.84; 95% CI, 0.76-0.92).
Factors Associated With Maintenance of Clinical FTE
As shown in Table 4, across study years, the most commonly cited factors that would keep physicians who indicated a moderate or likely ITR at their current clinical FTE were enhanced workflow efficiency (54.5% [2611 of 4790]), higher compensation (52.7% [2526 of 4790]), less EHR work outside of office hours (52.6% [2518 of 4790]), less documentation or work outside of work (52.5% [2516 of 4790]), and consistent staffing (49.9% [2391 of 4790]).
Table 4. Prevalence of Factors That Would Keep Physicians at Their Current FTE and at Their Current Organization, Across Study Years.
| Characteristic | Physicians, No. (%) | |
|---|---|---|
| Keep physicians at current FTE (n = 4790) | Keep physicians at their current organization (n = 3438) | |
| Total | ||
| Enhanced workflow efficiency | 2611 (54.5) | 1492 (43.4) |
| Higher compensation (ie, higher pay) | 2526 (52.7) | 1851 (53.8) |
| Fewer EHR hassles (ie, less EHR work outside of office hours) | 2518 (52.6) | 1400 (40.7) |
| Less documentation and less work outside of work | 2516 (52.5) | 1393 (40.5) |
| Consistent staffing | 2391 (49.9) | 1535 (44.6) |
| Better ability to help patients (fewer roadblocks) | 1780 (37.2) | 1243 (36.2) |
| Support for non–“top of license” activities | 1493 (31.2) | 862 (25.1) |
| Greater alignment of personal values with organizational values | 1330 (27.8) | 1242 (36.1) |
| Greater sense of being part of a team | 1179 (24.6) | 1098 (31.9) |
| Greater opportunities for leadership | 753 (15.7) | 559 (16.3) |
| Other | 738 (15.4) | 798 (23.2) |
| Greater opportunities to teach | 600 (12.5) | 426 (12.4) |
| Greater opportunities for research | 381 (8.0) | 282 (8.2) |
Abbreviations: EHR, electronic health record; FTE, full-time equivalent.
Factors That Would Keep Physicians at Their Organization
As described in Table 4, across study years, the most commonly cited factors that would keep physicians who indicated a moderate or likely ITL at their organization included higher compensation (53.8% [1851 of 3438]), consistent staffing (44.6% [1535 of 3438]), and enhanced workflow efficiency (43.4% [1492 of 3438]).
Discussion
In this multisite, serial cross-sectional study of more than 37 000 physicians, a substantial yet decreasing point prevalence of ITR and ITL was observed among US physicians. Overall, the prevalence of ITR decreased from 25.6% in 2022 to 22.5% in 2024. Meanwhile, the point prevalence of ITL decreased from 19.9% in 2022 to 15.1% in 2024. Specific groups of physicians were more likely to report ITR and ITL, and common factors, including greater workflow efficiency and consistent staffing, were reported as factors that could potentially mitigate ITR and ITL.
Although the decreasing point prevalence of ITR and ITL are encouraging, they nonetheless remain ongoing threats to the physician workforce. Among physicians indicating moderate or likely ITR or ITL, common factors associated with physicians staying at their level of current clinical effort or at their current institution include enhanced workflow efficiency, increased compensation, and more consistent staffing. Other interventions, such as less documentation and work outside of work, less EHR work outside of office hours, and greater individual organization values alignment, were also highly rated by many physicians. These findings provide potentially actionable evidence for health care leaders seeking to tangibly improve the experiences of practicing physicians through targeted interventions.
Our findings of decreased ITR and ITL across the study period are consistent with evidence of decreased physician burnout in the years since the COVID-19 pandemic.2,14 Burnout and problems with work-life integration have consistently been found to be associated with ITL and ITR.2,13,15 The prevalence of ITR we identified at the end of our study period (22.5%) in our sample of physicians from large health systems is lower than the 40% reported in a national study of US physicians in 20212 but still higher than the 19.8% identified among US physicians nationwide in 2014.2 Meanwhile, the prevalence of ITL (15.1% in 2024) in our sample is less than both that reported in national studies of US physicians in both 2021 and 2014.2 Even with the decreases in point prevalence of ITL and ITR identified, and relative improvements in ITL compared with prepandemic studies, more than one-fifth of physicians intended to reduce their clinical hours and nearly 1 in 6 intended to leave their organization. In light of evidence regarding increasing clinical attrition,16 a projected shortage of 86 000 physicians by 2036,9 and the known substantial costs of replacing a physician who leaves the organization,17 the ITR and ITL values derived from our study continue to raise concern regarding the adequacy of the US physician workforce to meet demands for clinical care. These findings suggest a sustained need for organizations to attend to known factors associated with ITR and ITL, including an imbalance between job demands and resources, burnout, incomplete staffing,7 poor control over the work environment,8 childcare stress,18 work climate,19,20 moral injury,21 and work overload,1 among many contributors.
In multivariable analyses, several physician and practice characteristics were associated with increased odds of ITR and ITL in our analyses. Female physicians, those in practice for 20 years or more, part-time physicians, and hospital-based physicians (vs primary care physicians) were more likely to report ITR. Those in practice for 20 years or more and practicing part-time were more likely to report ITL, while female physicians were less likely to report ITL. These findings suggest the potential value of targeting interventions aimed at improving experiences of work for specific groups with higher odds of ITR and ITL. There is evidence that part-time physicians spend more time per patient than full-time physicians,22,23 potentially leading to greater workload relative to compensated time, thus contributing to burnout, and subsequently, ITR and ITL. Particularly given that female physicians are known to have higher rates of EHR time expenditure24 than male counterparts and experience different patient expectations,25,26 it is notable that female physicians were more likely to express ITR, while being less likely to express ITL. It is possible that female physicians feel the need to cut back on their relatively greater workload for it to feel sustainable, but this likely happens at the expense of revenue generated, as previously demonstrated.27 Finally, while it could perhaps be expected that physicians with 20 years or more in practice would be more likely to reduce clinical hours or plan to leave the job, it is important to ensure they are doing so in line with preexisting plans rather than due to burnout28 or frustration with day-to-day work.
Our study uniquely characterizes factors that would prevent physicians from reducing their hours devoted to clinical care and from leaving their current organization. The most prevalent factors—including a desire for increased workflow efficiency, improved staffing, and enhanced compensation—were common across the outcomes of ITR and ITL. Addressing each of these factors, for example, through EHR redesign, addressing common workflow points that frustrate physicians, provision of ambient documentation support, enhanced teams to facilitate enhanced clinical workflows, investments in the work lives of nonphysicians to enhance team stability, and enhancing either salary or other aspects of compensation, will require substantial investments on the part of health care leaders. However, these investments may be warranted given evidence that it costs $500 000 to $1 million to replace a physician who leaves an organization,17 and there are additional costs due to lack of available care when physicians reduce their clinical effort.29
Strengths and Limitations
This study has some strengths, including the large sample size of the study, comprising more than 37 000 physicians representing 160 organizations. The serial, cross-sectional nature of the analysis enabled us to identify trends over time and identify physician characteristics associated with these trends.
This study also has some limitations, including that, given its cross-sectional nature, we could only identify associations and cannot interpret causation or the potential direction of effect from our findings. Although we were able to identify changes in point prevalence, the data were not longitudinal at the level of individual physicians. We also evaluated physicians’ self-report of ITR and ITL rather than actual departures or changes in work effort. Nonetheless, while not all physicians who indicated ITR or ITL follow through on stated intentions, self-report of ITL has been found to be a strong proxy measure of actual departure.30,31 Future studies should evaluate reasons for following through among those who describe ITL and ultimately do leave their organization, as well as reasons for staying among those who do not leave after expressing ITL. Although we collected multiple demographic characteristics of our physicians, including number of years in practice, we do not know about physicians’ ages, which may not directly correlate with their years in practice.
In addition, while our survey asked about factors associated with effort reduction or leaving the organization, more granular information would be valuable to creating interventions to mitigate these stated intentions. For example, future studies should evaluate how factors associated with work intentions change upon introduction of interventions aimed at improving workplace efficiency or reducing EHR burden, such as introduction of team-based care protocols or ambient documentation support. In addition, further qualitative exploration would be valuable to characterize physician desires around compensation, including perceived tradeoffs between desired compensation and workload, the form that respondents desired for their compensation (ie, salary, incentive compensation, benefits), and particular groups (eg, specialty groups, physicians practicing in certain geographic regions) for whom increased compensation may be most important. Our median response rate of 41.5%, while high for large-scale physician surveys, still raises questions regarding response bias (although prior studies have not identified significant differences in well-being measures among responders vs nonresponders32,33,34). Finally, organizations could choose whether to deploy the survey to all physicians or to certain departments or subcomponents of the organization.
Conclusions
In this cross-sectional, multisite study of US physicians, we found a decreasing but still substantial point prevalence of ITR and ITL among the physician workforce in the years since the peak of the COVID-19 pandemic. Specific groups were more likely to report ITR and ITL and common factors, including enhanced workflow efficiency, the need for consistent staffing, and increased compensation, were identified as potentially mitigating these intentions. Future studies should evaluate interventions intended to reduce ITR and ITL, and to correlate work intentions with actual changes in clinical effort or job changes at scale.
Data Sharing Statement
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Sharing Statement
