Trends in the work hours of physicians in the United States

Abstract

Context: Recent trends in hours worked by physicians may affect workforce needs but have not been thoroughly analyzed.

Objectives: To estimate trends in hours worked by US physicians and assess for association with physician fees.

Design, setting, and participants: A retrospective analysis of trends in hours worked among US physicians using nationally representative workforce information from the US Census Bureau Current Population Survey between 1976 and 2008 (N = 116,733). Trends were estimated among all US physicians and by residency status, sex, age, and work setting. Trends in hours were compared with national trends in physician fees, and estimated separately for physicians located in metropolitan areas with high and low fees in 2001.

Main outcome measure: Self-reported hours worked in the week before the survey.

Results: After remaining stable through the early 1990s, mean hours worked per week decreased by 7.2% between 1996 and 2008 among all physicians (from 54.9 hours per week in 1996-1998 to 51.0 hours per week in 2006-2008; 95% confidence interval [CI], 5.3%-9.0%; P < .001). Excluding resident physicians, whose hours decreased by 9.8% (95% CI, 5.8%-13.7%; P < .001) in the last decade due to duty hour limits imposed in 2003, nonresident physician hours decreased by 5.7% (95% CI, 3.8%-7.7%; P < .001). The decrease in hours was largest for nonresident physicians younger than 45 years (7.4%; 95% CI, 4.7%-10.2%; P < .001) and working outside of the hospital (6.4%; 95% CI, 4.1%-8.7%; P < .001), and the decrease was smallest for those aged 45 years or older (3.7%; 95% CI, 1.0%-6.5%; P = .008) and working in the hospital (4.0%; 95% CI, 0.4%-7.6%; P = .03). After adjusting for inflation, mean physician fees decreased nationwide by 25% between 1995 and 2006, coincident with the decrease in physician hours. In 2001, mean physician hours were less than 49 hours per week in metropolitan areas with the lowest physician fees, whereas physician hours remained more than 52 hours per week elsewhere (P < .001 for difference).

Conclusion: A steady decrease in hours worked per week during the last decade was observed for all physicians, which was temporally and geographically associated with lower physician fees.

Figure 1. Mean Self-reported Hours Worked per Week by Physicians Between 1977 and 2007

Current Population Survey data based on hours worked in the previous week. Data represent 3-year moving averages for each year plotted (eg, 1977 represents 1976–1978 and 2007 represents 2006–2008) and are weighted using sampling weights. Error bars indicate 95% confidence intervals.

Figure 2. Mean Self-reported Hours Worked per Week by Resident and Nonresident Physicians Between 1977 and 2007

Current Population Survey data based on hours worked in the previous week. Data represent 3-year moving averages for each year plotted (eg, 1977 represents 1976–1978 and 2007 represents 2006–2008) and are weighted using sampling weights. Error bars indicate 95% confidence intervals. The 2003 data for residents are excluded and are also not used in the 2002 and 2004 moving averages, because duty hour restrictions for residents went into effect on July 1, 2003 (80-hour work week was implemented). The blue portion of the y-axis indicates 49 to 57 self-reported hours worked per week, the range for all physicians (Figure 1).

Figure 3. Inflation-Adjusted Physician Fees Between 1989 and 2006

Fee index is a weighted average of Medicare and private-sector fees compiled from several sources. Medicare fees are based on Medicare trustees’ reports. Private-sector fees are derived from combining the Medicare fees and independent estimates of the ratio of private fees to Medicare fees published by MedPAC for 1999–2006, by Direct Research LLC from 1989–1996, and interpolated for 1997–1998, when that ratio was not available. The proportion of physician services that Medicare comprises comes from the Centers for Medicare & Medicaid Services. The Consumer Price Index for All Urban Consumers was used to convert nominal to real. Medicaid or other services outside of Medicare or private are excluded.

Figure 4. Mean Self-reported Hours Worked per Week by Physicians in Metropolitan Statistical Areas (MSAs) With High and Low Physician Fees in 2001

Current Population Survey (CPS) data based on hours worked in the previous week. Data represent 3-year moving averages for each year plotted (eg, 1989 represents 1988–1990 and 2007 represents 2006–2008) and are weighted using sampling weights. Error bars indicate 95% confidence intervals. Physicians were designated as living in a low-fee (vs high-fee) MSA if the Government Accountability Office fee index from 2001 in their MSA was below the median in our sample. Years before 1989 are excluded because MSA is not consistently identified before 1989 in the CPS data. The blue portion of the y-axis indicates 49 to 57 self-reported hours worked per week, the range for all physicians (Figure 1).