A new study reveals a trend that most of us on the front line of medical education see daily: The number of hours that any given physician works in a week has decreased dramatically over the past decade, along with the fees that he or she collects.1
The retrospective analysis used data from the US Census Bureau Current Population Survey from 1976 through 2008 (n = 116,733). Trends were estimated among all US physicians and by residency status, sex, age, and work setting. As the authors point out, the decrease in work hours was “broad-based,” occurring in different demographic groups and in different settings.1
Among the findings:
- The mean weekly workload remained steady through the early 1990s, but declined 7.2% between 1996 and 2008 among all physicians, from 54.9 hours in 1996–1998 to 51.0 hours in 2006–2008 (95% confidence interval [CI], 5.3%–9.0%; P < .001).
- The hours worked by nonresident physicians decreased by 5.7% (95% CI, 3.8%–7.7%; P < .001), versus 9.8% among residents (95% CI, 5.8%–13.7%; P < .001).
- Overall, among nonresident physicians, those younger than 45 years experienced the biggest decrease in mean work hours (7.4%; 95% CI, 4.7%–10.2%; P < .001). Non-resident physicians who worked outside a hospital setting also saw a significant decrease (6.4%; 95% CI, 4.1%–8.7%; P < .001).
- Overall, nonresident physicians older than 45 years had the smallest decrease in mean work hours (3.7%; 95% CI, 1.0%–6.5%; P < .008). Nonresident physicians who worked in a hospital setting also experienced a slim reduction (4.0%; 95% CI, 0.4%–7.6%; P =.03).
- Mean physician fees declined 25% (after adjustment for inflation) between 1995 and 2006, coincident with diminishing work hours.
- The largest reduction in mean work hours—9.8% among resident physicians—came after the imposition of limits on resident work hours by the American Council of Graduate Medical Education in 2003.1
Which came first—lower reimbursement or fewer hours?
“The observed decrease in physician fees is a potential economic factor behind the decrease in physician hours,” the authors write.1 For example, hours diminished first in metropolitan statistical areas where fees were lowest in 2001.
The General Accounting Office found that these areas also tended to feature greater competition among physicians, as well as greater penetration by managed care, which may have contributed to lower fees. However, these conditions also could have “weakened physician autonomy and reduced job satisfaction, which in turn could have led to fewer hours.”1
Study sheds light on gender shift, generational differences
In this study, Staiger and colleagues documented the reality of the “gender shift” in medicine: Women constituted 20.6% of respondents and worked a mean of 44.4 hours a week in 2006–2008, compared with 51.7 hours for men.1 However, the authors point out, “[a]lthough female physicians work fewer mean hours and represent an increasing proportion of physicians, decreases in hours were observed for both male and female physicians.”1
Although physicians of all ages worked fewer hours than before, the reduction was greatest among physicians younger than 45 years.1
The study also demonstrated that physicians work significantly longer hours than lawyers, engineers, and nurses. The work hours of these other professions have remained relatively stable since 1976.1
How do fewer hours affect the supply of physicians?
Over the past 10 years, much has been written about a projected shortage in the physician workforce and what should be done about it. In response, the Association of American Medical Colleges requested an expansion in medical school capacity, and many medical schools increased class size. In most cases, however, the reason for the increase in class size was financial: a desire for more tuition dollars, one of the few sources of income under the control of a medical school.
In addition, medical school tuition has continued to rise, and the increase in tuition has markedly outpaced the rate of inflation. The result: Medical students graduate with a large financial debt that influences their choice of specialty. Specialties that have high remuneration such as radiology, dermatology, anesthesiology, and orthopedics have become prime choices for graduating medical students.
The system needs to catch up to reality
As Staiger and his coauthors point out, a 5.7% decrease in the mean number of hours worked among approximately 630,000 physicians is equivalent to a loss of 36,000 physicians from the workforce.1 If the current system is sincere about increasing the physician workforce, why haven’t there been 1) a decrease in the length of medical school, 2) control of tuition escalation, and 3) an increase in the number of residency positions? And why has nothing been done to bring some of the lost physicians back in to the workplace by offering part time or flexible positions?