Why physicians are working fewer hours

Originally published in MedPage Today

by Michael Smith, MedPage Today North American Correspondent

Physicians are working fewer hours than they once did, the result of a decade-long decline that coincided with lower fees for their services, a study showed.

After two decades of stable hours, a steady decrease began in 1997, according to Douglas Staiger, PhD, of Dartmouth College, and colleagues.

The decline coincided with a marked drop in physician fees, as measured by an inflation-adjusted fee index, Staiger and colleagues reported in the Feb. 24 issue of the Journal of the American Medical Association.

For nonresident physicians, the decline is equivalent to the loss of 36,000 doctors working at the previous hour levels, the researchers said. The finding may have implications for health reform, they added.

To calculate work hours, Staiger and colleagues used data from 1977 through 2007 from the Current Population Survey, which is administered monthly by the U.S. Census Bureau to a nationally representative sample of more than 100,000 people.

They found that from 1977 through 1996, work rates for all doctors were relatively stable at 55 hours a week, on average. But from 1996 through 2007, average hours fell 7.2%, reaching a low of 51 hours by the end of 2007. The drop was significant at P<0.001.

Among other findings:

* Resident physicians saw their hours fall sharply due to duty hour limits imposed in 2003. The decline was 9.8% and was also significant at P<0.001.
* At the same time, average work hours for nonresident doctors fell by 5.7%, again significant at P<0.001.
* Among nonresident physicians, the decrease was largest for those who were younger than 45 (at 7.4%) and working outside the hospital (at 6.4%). Both drops were significant at P<0.001.
* The decrease was smallest for those 45 years or older (at 3.7%) and working in the hospital (at 4.0%). The declines were significant at P=0.008 and P=0.03, respectively.

Between 1995 and 2006, Staiger and colleagues found, average physician fees nationwide fell by 25%.

They also found that in 2001 (the only year for which the comparison was available), doctors in metropolitan areas with the lowest physician fees worked less than 49 hours a week on average, while those elsewhere worked more than 52 hours a week. The difference was significant at P<0.001.

The change “likely reflects a combination of economic and noneconomic factors,” Staiger and colleagues said.

The drop in fees probably accounts for some of the change, they said, by reducing the incentive to work long hours. But other factors — such as increased competition and the rise of managed care — may also have played a part, they said.

The study was not designed to tease out any possible causal connection between fees and work hours, they cautioned. There were also no data on physician specialty, they added.

The “trend toward lower hours, if it continues, will make expanding or maintaining current levels of physician supply more difficult,” Staiger and colleagues said, although larger medical school classes or more immigration by physicians could reduce that concern.

But the trend could also “frustrate stated goals of health reform,” which may require more doctors, they concluded.

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