Divorce among physicians and other healthcare professionals in the US
Analysis of census survey data
Dan P Ly and colleagues. Divorce among physicians and other healthcare professionals in the United States: analysis of census survey data. BMJ 2015;350:h706
Objectives To estimate the prevalence and incidence of divorce among US physicians compared with other healthcare professionals, lawyers, and non-healthcare professionals, and to analyze factors associated with divorce among physicians.
Design Retrospective analysis of nationally representative surveys conducted by the US census, 2008-13.
Setting United States.
Participants 48 881 physicians, 10 086 dentists, 13 883 pharmacists, 159 044 nurses, 18 920 healthcare executives, 59 284 lawyers, and 6 339 310 other non-healthcare professionals.
Main outcome measures Logistic models of divorce adjusted for age, sex, race, annual income, weekly hours worked, number of years since marriage, calendar year, and state of residence. Divorce outcomes included whether an individual had ever been divorced (divorce prevalence) or became divorced in the past year (divorce incidence).
Results After adjustment for covariates, the probability of being ever divorced (or divorce prevalence) among physicians evaluated at the mean value of other covariates was 24.3% (95% confidence interval 23.8% to 24.8%); dentists, 25.2% (24.1% to 26.3%); pharmacists, 22.9% (22.0% to 23.8%); nurses, 33.0% (32.6% to 33.3%); healthcare executives, 30.9% (30.1% to 31.8%); lawyers, 26.9% (26.4% to 27.4%); and other non-healthcare professionals, 35.0% (34.9% to 35.1%). Similarly, physicians were less likely than those in most other occupations to divorce in the past year. In multivariable analysis among physicians, divorce prevalence was greater among women (odds ratio 1.51, 95% confidence interval 1.40 to 1.63). In analyses stratified by physician sex, greater weekly work hours were associated with increased divorce prevalence only for female physicians.
Conclusions Divorce among physicians is less common than among non-healthcare workers and several health professions. Female physicians have a substantially higher prevalence of divorce than male physicians, which may be partly attributable to a differential effect of hours worked on divorce.
Why do the study?
It has been suggested that physicians’ long and unpredictable working hours lead to higher rates of divorce than the general population. Data on this subject, however, are limited to small, outdated studies, largely examining US couples. But with the implementation of duty hour reforms in the United States and the European Working Time Directive, changes in annual income, demography, and availability of psychological support for doctors, new analysis is needed to find out whether being in the medical profession means you are more likely to get divorced than people in other professions. The authors sought to answer this question by analysing US census survey data.
What did the authors do?
The authors analysed nationally collected data from the US Census Bureau. The American Community Survey (ACS) is a mandatory survey completed by three million households a year and is considered a nationally representative sample. Civilian and military households are interviewed via mail, telephone, and/or personal interview. Response rates range between 93% and 98%.
By using the cross sectional data taken from this annual survey, the study authors were able to calculate prevalence at a given time—that is, the proportion of a population found to have a particular outcome.
The study authors used respondents’ self reported answers to questions on demographic, occupation, income, and hours worked. Respondents aged 25 years or more who were employed in the previous year and reported as having ever being married were included in the study analysis. Occupation was self defined by the respondent—for example,“physician or surgeon,” “lawyer,” and “nurse.” Data on physician specialty were not collected.
Prevalence and incidence of divorce were the primary outcomes in this study, and divorce outcomes were characterised in three ways.
Firstly, to determine variance within occupations in the probability of being currently divorced at any given time, respondents were asked if they were divorced at time of the census survey.
Secondly, to identify a previous divorce and current remarriage, respondents were asked if they were married more than once (or ever divorced), including the year in which the respondent was married during their most recent marriage.
Thirdly, to gather annual incidence of divorce, respondents were asked if they had divorced in the past year.
The authors compared these three measures of divorce among physicians, dentists, pharmacists, nurses, healthcare executives, lawyers, and others employed outside the healthcare industry.
Using multivariable logistic models they then estimated factors associated with divorce prevalence, ever divorce, and divorce incidence in the past year. Various characteristics were included: age, sex, race, occupation, annual income, hours worked, and number of years since a respondent became married in the most recent marriage. Calendar year and state of residence were also included as categorical variables.
What were the results?
The sample included 48 881 physicians, 10 086 dentists, 13 883 pharmacists, 159 044 nurses, 18 920 healthcare executives, 59 284 lawyers, and 6 339 610 other non-healthcare professionals.
The mean age of physicians surveyed was 48.6 years (standard deviation 12.3 years), which was similar to the other occupations studied, with a similar proportion of people sampled within four arbitrary age groups (25-39, 40-49, 50-59, >60 years).
Physicians had the highest income of those occupations surveyed, with a mean of $223 427 (£149 216; €206 643). Nurses earned a mean of $63 995 and dentists $189 222. Physicians also worked the highest number of hours a week, with a mean of 50.4 (SD 16.1) hours, compared with their lawyer colleagues working 45.1 hours and healthcare executive colleagues working 46 hours.
The survey data showed that divorce was less common among physicians compared with the other occupations surveyed (table 1). At the time of the survey, 7.7% of physicians (95% confidence interval 7.5 to 8.0) were divorced compared with 8.8% of pharmacists, 17.8% of nurses, 12.7% of healthcare executives, 10.7% of lawyers, and 17.2% of other non-healthcare occupations.
|Characteristics||Physicians||Dentists||Pharmacists||Nurses||Healthcare executives||Lawyers||Other occupations|
|No of people||48 881||10 086||13 883||159 044||18 920||59 284||6 339 610|
|Divorced at time of survey||7.7 (7.5 to 8.0)||8.0 (7.4 to 8.5)||8.8 (8.3 to 9.2)||17.8 (17.6 to 18.0)||12.7 (12.3 to 13.2)||10.7 (10.5 to 11.0)||17.2 (17.2 to 17.2)|
|Ever divorced||22.1 (21.8 to 22.5)||22.9 (22.1 to 23.7)||21.5 (20.8 to 22.2)||37.0 (36.8 to 37.3)||31.3 (30.7 to 32.0)||27.7 (27.3 to 28.0)||36.6 (36.5 to 36.7)|
|Divorced in past year||1.01 (0.92 to 1.10)||0.87 (0.69 to 1.05)||1.09 (0.91 to 1.26)||1.64 (1.57 to 1.70)||1.15 (1.00 to 1.30)||1.29 (1.20 to 1.38)||1.74 (1.73 to 1.75)|
|Married once||83.8 (83.5 to 84.1)||83.1 (82.4 to 83.9)||85.5 (84.9 to 86.0)||75.7 (75.5 to 75.9)||78.3 (77.8 to 78.9)||80.5 (80.1 to 80.8)||75.9 (75.8 to 75.9)|
|Married twice||13.9 (13.5 to 14.2)||14.1 (13.4 to 14.8)||12.6 (12.0 to 13.1)||19.5 (19.3 to 19.7)||18.2 (17.6 to 18.7)||16.4 (16.1 to 16.7)||19.4 (19.4 to 19.5)|
|Married >3 times||2.4 (2.2 to 2.5)||2.8 (2.5 to 3.1)||2.0 (1.7 to 2.2)||4.8 (4.7 to 4.9)||3.5 (3.2 to 3.8)||3.2 (3.0 to 3.3)||4.7 (4.7 to 4.7)|
The prevalence of physicians having ever been divorced (22.1% (21.8 to 22.5)) was similar to pharmacists and dentists but lower than all nurses (37%) and other occupations (36.6%). The incidence of divorce in the past year was similar to dentists but lower than all other professions. Occupational differences in divorce were minimally affected by adjustment for covariates.
The prevalence and incidence of divorce among physicians were more common in older people surveyed. When compared with male physicians, female physicians were 1.51 (1.40 to 1.63) times more likely to be have been divorced and 1.46 (1.14 to 1.88) times more likely to have divorced in the past year.
The number of hours worked a week was associated with the probability of having been divorced only among female physicians; those who worked 40-49 hours a week had a 1.34 (1.16 to 1.54) chance of being ever divorced (table 2). Male physicians who worked >40 hours a week, however, had a lower odds of having divorced than male physicians who worked <40 hours a week.
|Hours worked a week||Adjusted odds ratio of ever divorce (95% CI)|
|<39||1 (reference)||1 (reference)|
|40 to 49||0.77 (0.68 to 0.88)||1.34 (1.16 to 1.54)|
|50 to 59||0.66 (0.58 to 0.75)||1.16 (0.99 to 1.37)|
|>60||0.59 (0.52 to 0.67)||1.10 (0.93 to 1.28)|
Factors not associated with physician divorce included race and annual income.
Strengths and limitations
The major strength of this study is the use of the ACS, a large, nationally representative data source with a high response rate. Since 2008, the ACS has included comprehensive information on divorce measures, meaning defining divorce prevalence and divorce incidence, the latter albeit only over one year, is readily available and likely to be accurate.
The data, however, are limited by it being cross sectional and not longitudinal in design. Future research should follow up cohorts and compare divorce rates of physicians with non-physicians over time to find out whether certain professions are more likely to divorce over a longer period of time.
As this is a retrospective analysis of the responses to the ACS questions, the analysis is limited to the information collected. Answers to questions regarding physician specialty, previous spousal occupation (if divorced), and marital satisfaction would be of interest in targeting who may be likely to get divorced and target interventions for high risk groups.
Generalisability remains a major limitation. Although this was a nationally representative sample of the US population, how applicable are these findings to international populations where baseline characteristics differ? For example, in the United Kingdom a modest estimate of the mean annual income of physicians (£100 000) is about 80% of the mean annual income of US physicians. Similarly, hours worked in the US differ from the UK, with the latter having implemented the European Working Time Directive and imposing a 48 hour a week cap on hours worked. Furthermore, in most European countries medicine is taught as an undergraduate degree, thereby producing qualified doctors who are younger than North American graduates, who are mostly required to do an undergraduate degree before starting a four year degree in medicine.
Furthermore, the physicians surveyed by the ACS were mostly men. In the UK at least, the number of women entering medicine has increased 10-fold compared with the past four decades, whereas the number of men entering medicine has only doubled. Data from 2005-9 show that US medical student intake is consistently about 48% women. Future census data may reflect this changing demographic of medicine. Based on the findings of this study we may see the effects of the increasing number of women studying medicine, which may result in an increased prevalence and/or incidence of divorce.
What does the study mean?
Do physicians have a higher rate of divorce compared with other healthcare and non-healthcare professions? In this one US study, the answer is no. In fact, physicians were divorced less often compared with other professions.
Of those divorced, female physicians were more likely to be divorced than male physicians, but the reasons behind this are unclear.
The reasons for divorce are complex, and although we can draw statistics from large cohort studies such as this one, there needs to be more in-depth understanding of why doctors’ marriages breakdown. Qualitative studies to identify contributing factors, such as a long commute or job specific stress, would shed further light on whether being in the medical profession can be attributed as a contributing factor for divorce.
Copyright: GivenNeil Chanchlani, foundation year 2 doctor1, James Goodhand, specialist registrar in gastroenterology2
1Colchester General Hospital, UK, 2Newham University Hospital, Barts Health NHS Trust, UK
Correspondence to: email@example.com
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
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Cite this as: Student BMJ 2015;23:h2106