Portal de Periódicos da CAPES

An examination of the vacation behaviors of United States emergency physicians

2024; Wiley; Volume: 32; Issue: 1 Linguagem: Inglês

10.1111/acem.15005

1553-2712

Dave W. Lu, D. Mark Courtney, Christine A. Sinsky, Hanhan Wang, Mickey Trockel, Liselotte N. Dyrbye, Lindsey E. Carlasare, Colin P. West, Tait D. Shanafelt,

Work-Family Balance Challenges

The act of taking vacation is restorative for individuals and advantageous for both employer and employee. Time away from work contributes to personal relationship satisfaction and is linked to improved physical and mental health.1, 2 Vacation time also enhances job performance and satisfaction while mitigating burnout and attrition.3, 4 Despite these benefits, fewer than half of American workers use their entire allocated paid time off.5 A recent study of U.S. physicians across all specialties demonstrated that approximately 60% of physicians reported taking 15 or fewer days (≤3 weeks) of vacation, with 20% taking 5 or fewer days, in the past 12 months.6 Vacation days varied significantly by specialty, with emergency medicine (EM) having the lowest percentage of physicians taking more than 3 weeks of vacation. This study is a secondary analysis of the aforementioned study6 and focuses on the subset of participants who were emergency physicians (EPs). The study's aim was to further characterize the EPs' vacation behaviors and to analyze the association of vacation characteristics with EP demographic and professional factors. A national work–life integration study surveyed a representative sample of physicians across all specialties in the American Medical Association Physician Professional Data between November 20, 2020, and March 23, 2021, using methods that were previously reported.6, 7 The Physician Professional Data is a nearly complete record of all U.S. physicians. Among the 3671 physicians who received the mailed survey along with a $20 incentive check, 1162 (31.7%) completed the survey. Of the 90,000 physicians who received the electronic survey, 6348 (7.1%) completed the survey. A random subset of participants received a mailed or electronic subsurvey about vacation. As previously reported,7 detailed analysis comparing the demographic characteristics of participating physicians with all 897,107 practicing U.S. physicians as well as a secondary survey of non-responders, suggested that participants were representative of U.S. physicians. The Stanford and Mayo Clinic Institutional Review Boards approved this study, which followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines. The vacation subsurvey asked physicians, "Using the definition of vacation that applies to your practice, how many days of vacation did you take in the last 12 months?" 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 other work-related email?" and whether they had full EHR inbox coverage while on vacation. Finally, physicians were asked how much of a barrier to taking vacation 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. 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. Physicians' demographic and professional characteristics and their responses to vacation barriers were summarized using standard descriptive statistics. Associations between vacation response items and demographic and professional factors were examined using Fisher's exact tests. Statistical significance was set at two-tailed p < 0.05 and analyses were conducted using R software (v4.1.2, R Core Team). A total of 3128 physicians were invited to complete the vacation subsurvey, with 3024 (96.7%) completing at least one vacation item. Among these respondents, 175 identified as EPs. Comparable to responding physicians across all specialties, most of the EP respondents were men (63.4% EPs vs. 62% all physicians), were married (86.3% EPs vs 83.7% all physicians), and had children ≤18 years old (54.1% EPs vs. 45.5% all physicians; Table 1). The median number of hours worked per week was 36 (IQR 30–43.5 h) for EPs and 50 (IQR 40–60 h) for all responding physicians. More than half of the EPs worked in a private practice setting (57.5%) and reported that their compensation was not based on productivity (53.1%). Over three-quarters of EPs (76.2%) reported taking 15 or fewer days (≤3 weeks) of vacation in the past 12 months (Table 1) versus 59.6% for all physicians. In the past year, 53 (30.8%) EPs reported ≤5 days of vacation, 78 (45.3%) 6–15 days of vacation, and 41 (23.8%) >15 days of vacation. Vacation days were not associated with EP demographics (age, gender, relationship status, age of youngest child) nor professional factors (hours worked per week, primary practice setting, percent compensation based on productivity). Compared to EPs in private practice, a greater proportion of EPs in academic medical centers reported spending more than 30 min of work on vacation per vacation day (14.1% vs. 39.6%). Most EPs replied "not at all" when asked to what degree the following were considered a barrier to taking vacation: finding someone to cover clinical responsibilities (61.8%), the financial impact of taking vacation (50.9%), and the volume of EHR inbox work to face on return to work (79.1%). EM has traditionally been viewed as one of the specialties with a "controllable lifestyle,"8 with shift-based clinical work considered one of the draws. Our targeted analysis of EPs' vacation characteristics, however, raised more questions than answers about whether expectations of EM as a specialty that is amenable to work–life balance and flexibility are accurate. The primary analysis of U.S. physicians across all specialties previously revealed that EPs were the least likely to take more than 15 vacation days per year.6 Despite EPs working fewer median hours per week compared to other physicians, more than three-quarters of EPs reported taking fewer than 16 days of vacation, with nearly one-third taking less than a week of vacation in the last year. This secondary analysis of EPs showed that vacation days taken did not differ by gender, age, relationship status, hours worked, practice setting, and compensation model. It is unclear why EPs reported taking the least amount of vacation compared to other physicians. Given that EPs work fewer median hours per week, it is possible that the greater amount of time off, along with the benefits that come with time off from work, may make additional vacation unnecessary. While this may be true for some, the fewer hours of clinical work alternatively allow more opportunities for vacation to be taken, and our results suggest that this is not the case for the majority of EPs. The barriers to taking vacation queried in the survey did not explain this discrepancy. We theorize that one of the reasons why EPs reported not taking many vacation days may be the way in which vacation is perceived among EPs. Many EM contracts—in both academic and nonacademic settings—specify an expected number of clinical hours per year and do not include paid time off. What remains unclear is how EPs treat or view the time they have outside of these required hours. For example, clinic-based specialties that operate on a Monday to Friday schedule typically have weekends off; weekends in this situation likely are considered "days off" and not "vacation." For EPs, "days off" are scattered between shifts. If an EP wishes to have a week off, they likely have to work the same number of shifts that month but fitted into the days before and after the week off. In this situation, EPs may differ in whether they consider the non–work week as "days off" versus "vacation." This arrangement also results in EPs having to "pay" for vacation by taking on more burdensome clinical responsibilities in the weeks before or after time off. And since EM shifts cover 24 h of each day, most EPs need non-clinical time to recover from frequent circadian shifts, which may carve into functional time off. We do not know how much of these factors act as barriers to EPs taking vacation. We also do not know if the benefits of "vacation" are also seen with having several consecutive "days off." Regardless of how EPs define vacation, the benefits of taking time away from work should make it a priority for physicians and their employers. There are systems-based interventions that may encourage EPs to take vacation. EM groups may proportionately decrease expected shifts during the month that vacation is taken or allow EPs to bank shifts over months to support extended time off. Compensation models that build in paid time off or that do not rely exclusively on relative value unit–related reimbursement may encourage EPs to take vacation as well. EPs themselves may also consider policing and limiting their own workload to allow vacation time. This may require a change in perspective such that time devoted to vacation is not viewed as "lost compensation" but rather an essential and expected part of the job that promotes career longevity and well-being. Finally, innovative tools that take advantage of artificial intelligence could be used to analyze physician preferences, availabilities, and vacation needs in optimizing complex schedules.9 As previously reported,6 although participants were shown to be representative of U.S. physicians, the response rate to the main survey was low and there is a possibility of response bias. This secondary analysis was also limited by the small sample size of EPs. We do not know how each responding EP defined vacation for themselves. We also do not know if EPs' estimation of work hours or EHR inbox work included nonclinical work, such as email, administrative duties, research, or education. In addition, the study occurred during the first year of the COVID-19 pandemic; travel restrictions and social distancing may have impacted physicians' answers about vacation. Shift work is the norm not just in EM but also in critical care, hospitalist, and other specialties. Future studies on this topic may reveal important physician workforce trends that need to be addressed for purposes of professional satisfaction and career longevity. Future work within EM is also needed to clarify how EPs, compared to other physicians, define vacation and what barriers prevent them from taking time off. Research into this subject, as well as potential solutions, may have important ramifications for how EM is perceived as a desirable specialty by the pipeline of future trainees.10 A better understanding of EPs' vacation use may also inform ongoing efforts to mitigate high levels of EP burnout7 and attrition.11 Dave W. Lu, D. Mark Courtney, Christine A. Sinsky, Liselotte N. Dyrbye, Lindsey E. Carlasare, Colin P. West, Tait D. Shanafelt conceived and designed the study. Liselotte N. Dyrbye, Christine A. Sinsky, and Tait D. Shanafelt supervised the conduct of the study, data collection, and data management. Tait D. Shanafelt and Hanhan Wang provided statistical advice on study design, analyzed, and interpreted the data. Dave W. Lu drafted the manuscript, and all authors contributed substantially to its revision for important intellectual content. Tait D. Shanafelt obtained research funding. Dave W. Lu takes responsibility for the paper as a whole. Funding for this study was provided by the Stanford WellMD Center, Mayo Clinic Department of Medicine Program on Physician Well-being, and the American Medical Association. Consulting for commercial interests, including advisory board work: MTT reported receiving personal fees from Marvin Behavioral Health, Inc., outside the submitted work. Grant money for commercial research: LND reported receiving grants from Med Ed Solutions outside the submitted work. Grant money for investigator-initiated research: LND reported receiving grants from the National Institute of Nursing Research and the National Science Foundation during the conduct of the study. Founder or owner of a start-up company or proprietary interest or stock or ownership in a company with an interest for or against the subject matter: LND, TDS co-invented the Well-Being Index and its derivatives; Mayo Clinic licensed the Well-Being Index and pays them royalties outside the submitted work. Employment: CAS, LEC are employed by the American Medical Association. The opinions expressed in this article are those of the authors and should not be interpreted as American Medical Association policy. The other authors declare no conflicts of interest.