Doctors on Overdrive: Fewer Breaks Equal More Burnout

Physicians who take few vacation days each year are more likely to face burnout, as are those who continue working even as little as 30 minutes per day while on break, survey results show.

Cardiologists did slightly better than the average, but the reality is, at least currently, most doctors didn’t manage to take even 3 weeks—15 total workdays over the year—of vacation, Christine A. Sinsky, MD (American Medical Association, Chicago, IL), and colleagues report in JAMA Network Open.

“Burnout among physicians is at an alarmingly high level,” Sinsky told TCTMD in an email, with more than six in 10 physicians, at last count, reporting burnout. “This matters to patients, because errors are higher when physicians are burned out. It also matters to payors, because of higher healthcare costs associated with burnout, and to organizational leaders, because of higher rates of physician turnover with burnout.”

She stressed: “Like other workers, physicians have a human need to periodically truly unplug from work and recharge.”

For Pamela Douglas, MD (Duke Clinical Research Institute, Durham, NC), the question is how to achieve this: individual efforts can only go so far in addressing systemic problems, she said.

“Burnout and well-being are on people’s minds [but] unfortunately much of the focus is on personal resilience”—expecting physicians to set their own limits for work—“and less on the systems, structures, environment, and leadership that allow you to do that guilt free,” she explained.

Laxmi S. Mehta, MD (The Ohio State University, Columbus), also commenting for TCTMD, said that it was “shocking” to see how few physicians managed just 15 days off per year. “I’m not sure if it’s an individual decision, that they feel they can’t, or [if] their organization doesn’t even give them that time. . . . It’s hard to say the exact root cause of it, but it’s very concerning that they’re not taking time off,” she said.

The lack of breaks is especially problematic given the demands of the job, said Mehta. “When we think of physicians, most of us work long hours and weekends. It’s almost like you’re a 24/7 doctor anyhow, just because the cases are in your mind.”

Burnout, which has been on the rise for years in cardiology, reached new heights during the COVID-19 pandemic, leading many healthcare professionals to rethink their work-life balance.

“Just like everything else, if your car doesn’t get a break, it’s going to break down. You can’t run your car forever and you can’t run your body forever,” Mehta urged. “You’ve got to have a physical, mental, and emotional break. We all need that.”

Wide Variations Across Specialties

Between November 2020 and March 2021, Sinsky et al surveyed a sample of US physicians that spanned across specialties represented in the American Medical Association. A total of 3,024 doctors responded.

Among them, 59.6% said that in the past year they took 15 or fewer vacation days and 19.9% took 5 or fewer days. Seventy percent reported that even while on vacation they did patient care-related tasks, and 33.1% cited working at least 30 minutes on a typical vacation day. Around half said they had full coverage of their electronic health record (EHR) inbox during their vacation time.

Vacation-taking habits differed substantially among specialties. Anesthesiologists were the most likely to take a break, with 75.6% reporting they had at least 3 weeks’ vacation each year, whereas only 23.8% of emergency medicine doctors said the same. Urologists, at 55.0%, were the most likely to work at least 30 minutes per day on vacation and emergency medicine specialists the least likely to do so, at 19.5%.

Cardiologists weren’t broken out as a separate category in the study but rather fell under the umbrella of “internal medicine subspecialty.” Within this group, 36.3% took at least 3 weeks’ break each year and 42.0% worked at least 30 minutes per day on vacation. Slightly more than half (54%) had EHR inbox coverage.

The system has a culture that you follow your patients while you’re off. Pamela Douglas

After adjusting for personal and professional factors, several themes emerged as barriers to taking a vacation. Having “quite a bit” of concern about finding someone to cover clinical responsibilities was linked to a lower likelihood of taking more than 3 weeks of time off each year (OR 0.48; 95% CI 0.35-0.65), as did having “very much” concern (OR 0.30; 95% CI 0.21-0.43). Financial concerns also were associated with less likelihood of a 3-week-or-more break, whether they rose to the level of “quite a bit” (OR 0.49; 95%CI, 0.36-0.66) or “very much” (OR 0.38; 95%CI 0.27-0.54). Also influential were 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) and, to a lesser degree, longer hours per week (OR 0.99 per additional hour; 95% CI 0.99-1.00).

Vacations were more likely for married physicians (OR 1.41; 95% CI 1.04-1.92), but age, gender, and having children did not matter.

Full inbox coverage while on vacation independently predicted lower likelihood of working during that time. Female physicians and those working at an academic medical center, with longer hours, age 55 to 64 years, and with a youngest child aged 5 to 12 years were more apt to work while on vacation.

Burnout, based on the Maslach Burnout Inventory, was less likely for physicians taking at least 3 weeks’ vacation (OR 0.66; 95% CI 0.45-0.98) and those with full EHR inbox coverage (OR 0.74; 95% CI 0.63-0.88). On the flip side, physicians who spent at least 30 minutes per day working during vacation saw a higher risk of burnout, ranging from an odds ratio of 1.58 (95% CI 1.22-2.04) for 30-60 minutes up to an odds ratio of 1.92 (95%CI, 1.36-2.73) for more than 90 minutes.

Sinsky said their data are actionable. Possible steps to take include “changes in cultural expectations, with leaders demonstrating that they take vacation and encouraging others to do the same,” she suggested, as well as “practice-level supports such as structuring teams with stable physician-nurse dyads” and “financial structures that do not effectively penalize physicians for taking vacation.”

Future research should look at whether addressing systemic barriers will result in physicians taking more vacation time, Sinsky said.

We have to be supportive of each other and to say, ‘You’re gone, don’t worry. I’m going to take care of it.’ Laxmi S. Mehta

Douglas said that the data showing physicians take few vacations aren’t unexpected and if anything, she was surprised to see how many doctors managed to avoid work entirely while off. “It’s just kind of ‘the routine’—I think most people check email,” she said, adding that it’s getting harder, for everyone, to be totally off the grid in today’s world.

Like Mehta, Douglas noted that it’s impossible to tease out what’s driving the observations. It’s unclear whether physicians have more vacation days available that they’re not taking or if there’s something standing in the way. Moreover, the people most prone to burnout may be the ones least willing to take a break.

In the case of EHR inbox coverage, the problem could be at a system level or an individual level. Is it because that resource isn’t there? Or is it because physicians aren’t willing to let go of that control? Or is there some other reason?

“The fact that you can’t find coverage may be due in some small part to a fear that somebody covering would not know your patients well and your patients would not get the same care that you might provide,” particularly in complex cases, Douglas said. Even there, though, this reluctance could speak to a larger issue, she added. “The system has a culture that you follow your patients while you’re off.”

Another challenge, said Mehta, is that “when you take vacation, the burden is on others. That’s something I fight in my head.”

Douglas pointed out that some medical specialties are better than others at sharing the workload. Surgeons and ob-gyns have done an incredible job in this aspect, “where they’ve figured out the 24/7 need for care and have created a culture where people are on when they’re on and off when they’re off,” she observed, though the urgency of acute cases in cardiology can make this difficult.

Douglas said that team-based care is the way forward: “Feeling more that you’re part of the group and it’s the group’s success that matters.” Another key concept is that “well-being is part of being a good physician,” she noted, adding, “I think there are some lingering pockets that see [the need to talk about that] as weakness.”

Ultimately, Douglas said, given the diversity in compensation models and scheduling, change will most likely come at a practice level.

Mehta said that, as a start, physicians should use the vacation days allotted to them. From the other direction, the institution needs to support this time off and physicians need to foster a climate among their peers where vacations are valued, she advised. “We have to be supportive of each other and to say, ‘You’re gone, don’t worry. I’m going to take care of it.’”