Divorce among physicians and other healthcare professionals in the United States: analysis of census survey data

RESEARCH

1the bmj |

BMJ

2015;350:h706 | doi: 10.1136/bmj.h706

Department of Medicine,

Massachusetts General

Hospital, Boston, MA, USA

Department of Emergency

Medicine and Leonard D

Schaeer Center for Health

Policy and Economics,

University of Southern

California, Los Angeles, CA, USA

Department of Health Care

Policy, Harvard Medical School,

Boston, MA 02115, USA;

Department of Medicine,

Massachusetts General Hospital

and National Bureau of

Economic Research, Cambridge,

MA, USA

Correspondence to: A B Jena

jena@ hcp.med.harvard.edu

Cite this as: BMJ ;:h

doi: 10.1136/bmj.h706

Accepted: 6 January 2014

Divorce among physicians and other healthcare professionals

inthe United States: analysis of census survey data

Dan P Ly,

Seth A Seabury,

Anupam B Jena

ABSTRACT

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

Aer 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% condence 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% condence interval 1.40 to 1.63). In

analyses stratied 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 dierential eect

of hours worked on divorce.

Introduction

Professional obligations among physicians oen con-

ict with personal and family life.

1–5

While it has histor-

ically been suggested that long and sometimes

unpredictable work hours among physicians may lead

to higher rates of divorce,

6–8

evidence on whether

divorce rates among physicians exceed those in the gen

eral population has been limited and mixed.

8–11

One of

the rst studies to analyze this was in the United States.

Published nearly 40 years ago, this study found physi

cians to have substantially higher rates of divorce and

poor self r

ated marital quality than other occupations,

but the study was limited in its generalizability owing to

its small, non-representative sample.

A subsequent,

larger study of 1118 medical graduates of Johns Hopkins

University found cumulative rates of divorce of 29%—

with rates higher among psychiatrists (50%) and sur

geons (33%)—but was limited by its analysis of

ysicians from a single institution.

Finally, a nation-

ally representative analysis that used 1970 and 1980 US

census data found similar likelihoods of divorce

between physicians and other professional groups, but

this study was conducted more than two decades ago.

Although several studies done internationally have

explored work-home conicts among physicians and

other healthcare professionals,

4 5 12–18

to our knowledge

none have explored whether divorce among physicians

is more common than in the general population.

There are many reasons to question whether previous

estimates of divorce among US physicians are perti

nent, given the limited sample sizes of most studies, the

hanges in demographics, work hours, and earnings

among US physicians,

19 20

and the fact that overall

divorce rates in the United States have fallen dramati

cally since the time of these studies (from 5.2 per 1000

Americans in 1980 t

o 3.6 per 1000 in 2011).

In this

study, we revisit the question of whether physicians are

more or less likely than other professionals to become

divorced, by examining more than 40 000 physicians

and 200 000 other healthcare professionals surveyed

open access

WHAT IS ALREADY KNOWN ON THIS TOPIC

It has been speculated that the demanding nature of physicians’ work leads to

divorce rates that exceed those in the general population

Evidence on this both in the United States and internationally has been limited to

small and dated studies and evidence has been mixed

Current, nationally representative estimates of divorce among physicians and other

healthcare professionals in the United States are unknown, as are factors

associated with divorce among US physicians

WHAT THIS STUDY ADDS

Despite concerns about whether the demanding nature of physicians’ work leads to

higher rates of divorce, divorce among physicians is less common than among the

general population and several healthcare professions

Female physicians are substantially more likely to divorce than male physicians,

which may be partly attributable to a dierential eect of hours worked on divorce

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RESEARCH

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2015;350:h.706 | the bmj

nationally between 2008 and 2013 in the American

community survey, a large, nationally representative,

annual survey of Americans conducted by the US

Census Bureau. With these data we examined how the

probability of divorce among physicians compared with

other healthcare professionals as well as those not

employed in healthcare. We analyzed factors associated

with divorce among physicians, including how the

number of hours worked dierentially inuenced the

probability of divorce for male and female physicians.

Methods

Data sources

We estimated both the prevalence and the incidence

of divorce in various occupational groups using the

American community survey, a nationally representa

tive, cross sectional survey of approximately three mil-

lion households annually, administered by the US

Census Bur

eau. The survey is mandatory and is col

lected by mail, telephone, and personal visit interviews.

he survey, which includes civilian as well as military

households, collects information on respondent demo

graphics (age, sex, race, current marital status, and,

sin

ce 2008, limited questions on marital history) as well

as occupation, annual income, and hours worked.

Response rates vary from year to year but range between

93% and 98%.

Study population

Each respondent self reported information on age, sex,

race, current marital status, occupation, annual

income, and weekly hours usually worked (based on

hours worked at all jobs). We included individual

respondents aged 25 years or more who were employed

in the previous year and who reported ever being mar

ried (6

649 708 people from 2008 to 2013). Physicians

were identied based on a self reported occupation of

“physician or surgeon”. Other healthcare professionals

were identied based on a self reported occupation of

either “dentist”, “pharmacist”, or “nurse”. Healthcare

executives were identied as those with a self reported

management occupation in a healthcare industry and

with a graduate degree. We also identied lawyers—

based on a self reported occupation of “lawyer”—given

their comparability to physicians in terms of graduate

education and income. The survey does not collect data

on physician specialty.

Our sample included 48 881 physicians, 10 086 den

tists, 13

883 pharmacists, 159 044 nurses, 18 920 health-

care executives, 59 284 lawyers, and 6 339 610 other

non-healthcare professionals.

Divorce measures

Before 2008 the American census survey only recorded

current marital status (married, separated, divorced,

widowed, or never married). However, since 2008, the

census has asked people several additional questions

related to marriage and divorce, including the year in

which the respondent was married during their most

recent marriage, whether or not he or she divorced in

the past year, and the number of times he or she has

been married. Based on these data, we characterized

divorce outcomes in three ways. Firstly, we identied

whether a respondent was currently divorced at the

time of survey. This divorce measure provides a snap

shot of whether the probability of being currently

vorced at any given time varies by occupation. Sec

ondly, because those who are currently married may

ve been remarried aer a previous divorce, we identi

ed whether respondents had ever been divorced,

dened by w

hether they were either currently divorced

or reported being married more than once. This divorce

measure reects the prevalence of divorce—that is, how

likely someone was to have ever been divorced at any

given time. Thirdly, we identied whether a respondent

had divorced in the past year, which reects the annual

incidence of divorce, or what is commonly referred to as

the annual divorce rate. Although in our descriptive

analysis we reported unadjusted dierences across

occupation in each of these three measures of divorce,

in our statistical analysis—which adjusted for factors

associated with divorce—we used the prevalence and

incidence of divorce as the primary outcomes.

Statistical analysis

We began by comparing unadjusted measures of

divorce (the probability of being divorced at the time of

the census survey, the probability of being ever

divorced, and the probability of divorcing in the past

year) among physicians, dentists, pharmacists, nurses,

healthcare executives, lawyers, and others employed

outside of the healthcare industry. Those who reported

being currently separated from a spouse at the time of

survey were not considered to be divorced.

We then estimated multivariable logistic models of

divorce prevalence (whether someone had ever been

divorced) and divorce incidence (whether someone

divorced in the past year). Models were estimated as a

function of age (categorized as 25 to 39 years, 40 to 49

years, 50 to 59 years, and ≥60 years), sex, race (catego

rized as non-Hispanic white, non-Hispanic black,

Hispanic, other), occupation, annual income (catego

rized as <$50

000 (£32 800; €44 140), $50 000 to

$99 999, $100 000 to $149 999, $150 000 to $199 999,

and ≥$200 000), the number of years since a respon

dent became married in the most recent marriage (con-

tinuous variable, dened by subtracting the year in

hich the respondent was married during the most

recent marriage from the census survey year), and state

and year xed eects.

We adjusted for the number of years since a respon

dent became married in the most recent marriage for

o reasons. Firstly, in comparing the prevalence of

divorce across occupations, it is important to recognize

that if people in specic occupations tend to marry at

dierent ages, estimated dierences in the prevalence

of divorce across occupation could reect diering ages

at marriage across occupations rather than dierent

underlying divorce risk. For example, if the annual rate

of divorce was identical across occupations but physi

cians marry later in life, then at any given time physi-

cians would be less likely to report ever having divorced

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compared with people in other occupations, simply

because they were at risk for less time. Accounting for

the length of time since someone was married is there

fore important. Secondly, in comparing the incidence of

vorce across occupations, it is important to note that

the annual incidence of divorce (that is, the hazard rate

of divorce) may vary depending on how long someone

has been married. Divorce rates may be highest in the

years aer marriage and may decline with time, imply

ing that the annual divorce rate for those in the 20th

ear of marriage would be lower than those in the rst

few years of marriage.

Put dierently, the divorce haz-

ard may not be constant over time. If professionals in

specic occupations marry at dierent ages, then a sur

vey at a given time may misclassify occupations as hav-

ing dierent divorce rates simply because people in

those oc

cupations were sampled at varying lengths of

time aer marriage. It is therefore important to adjust

for the number of years since someone became married

in the most recent marriage.

Aer estimating the logistic models, we reported the

adjusted prevalence and incidence of divorce by occu

pation. We computed the adjusted probabilities by tak-

ing the predicted values from the logistic regression

models holdin

g all covariates except for occupation at

their mean values (that is, we held the mean of other

covariates constant across occupations). For categori

cal variables such as state and year, we computed the

adj

usted values at the means of the individual indicator

variables (that is, reecting the mean proportion of the

sample in each category, for example, the proportion of

the sample in a given state and year). In this estimation

of adjusted divorce prevalence and incidence by occu

pation, we did not separately adjust for weekly hours

orked since the dierence in hours worked between

physicians and non-physicians is signicant and may

mediate the eect of being a physician on divorce.

In addition to estimating the adjusted prevalence and

incidence of divorce by occupation we examined the

impact of age, race, sex, annual income, and hours

worked on the prevalence and incidence of divorce

among physicians, adjusting for the number of years

since someone became married. Specically, among

physicians we estimated a multivariable logistic model

of divorce as a function of these covariates and state

and year as xed eects. Given previous evidence that

divorce rates are positively correlated with hours

worked we also included weekly hours worked (catego

rized as <39 hours, 40 to 49 hours, 50 to 59 hours, and

≥

60 hours) in these within-occupation models.

Finally, we stratied these models by physician sex to

study whether factors such as weekly hours worked had

dierential impacts on the prevalence and incidence of

divorce among male compared with female physicians

and other healthcare professionals. This analysis was

motivated by previous research in the general popula

tion of Americans, which showed that the work hours of

omen are more highly positively correlated with

annual divorce rates than are the work hours of men.

Sampling weights were provided by the survey and

reflected the survey sampling procedures used to

weight all estimates to bring the characteristics of the

sample more in agreement with those of the full US pop

ulation. Statistical analyses were performed using

TATA version 13.1 (Stata, College Station, TX).

Results

Characteristics of study population

Table 1 lists the characteristics of the study population.

The mean age of physicians was 48.6 SD 12.3) years,

intermediate among other healthcare and non-

healthcare occupations. The percentage of physicians

surveyed who were white was 70.2%, lower than in

other healthcare occupations (for example, dentists,

77.4%; nurses, 77.0%; healthcare executives, 79.1%).

Among healthcare occupations, physicians and den

tists had the largest percentage of men (68.3% and

5.9%, respectively, compared with 8.5% among nurses

and 47.7% among pharmacists). Annual income was

highest among physicians (mean $223 427, SD $155 417)

with 47.1% of physicians earning more than $200 000

annually. Average hours worked per week were highest

among physicians (50.4 hours compared with 37.6 hours

among dentists, 38.5 hours among pharmacists, 37.1

hours among nurses, 46.0 hours among healthcare

executives, 45.1 hours among lawyers, and 39.8 hours in

other non-healthcare occupations).

Divorce among physicians versus other occupations

Divorce was less common among physicians than other

occupations according to several measures (table 2).

The unadjusted probability of being currently divorced

at the time of survey was lowest among physicians

(7.7%, 95% condence interval 7.5% to 8.0%) compared

with other occupations (dentists, 8.0%; pharmacists,

8.8%; nurses, 17.8%; healthcare executives, 12.7%; law

yers, 10.7%; and other non-healthcare occupations,

7.2%). Divorce prevalence, dened as the percentage of

people who reported ever being divorced at the time of

survey, was lower among physicians than among most

other occupations as well. Among physicians, 22.1%

(95% condence interval 21.8% to 22.5%) had ever been

divorced by the time of survey, compared with 22.9%

among dentists, 21.5% among pharmacists, 37.0%

among nurses, 31.3% among healthcare executives,

27.7% among lawyers, and 36.6% among other occupa

tions. Divorce incidence was generally lower among

ysicians as well. For example, 1.01% (95% condence

interval 0.92% to 1.10%) of physicians divorced in the

year before the survey, an annual divorce rate that was

higher than that for dentists but statistically indistin

guishable or lower than for all remaining occupations.

inally, physicians were less likely to have been married

more than once by the time of survey compared with all

other occupations except pharmacists.

Occupational dierences in divorce were minimally

aected by adjustment for covariates (table 3). The

adjusted probability of being ever divorced—that is,

divorce prevalence estimated at mean covariate val

ues—among physicians was 24.3% (95% condence

int

erval 23.8% to 24.8%), compared with 25.2% among

dentists (P=0.14 for comparison with physicians), 22.9%

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among pharmacists (P=0.008), 33.0% among nurses

(P<0.001), 30.9% among health executives (P<0.001),

26.9% among lawyers (P<0.001), and 35.0% among

other non-healthcare professionals (P<0.001). The

adjusted probability of becoming divorced in the past

year—that is, divorce incidence or divorce rate esti

mated at mean covariate values—among physicians

as 1.0% (95% condence interval 0.9% to 1.1%), com

pared with 1.0% among dentists (P=0

.73 for comparison

with physicians), 1.0% among pharmacists (P=0.62),

1.3% among nurses (P<0.001), 1.1% among healthcare

executives (P=0.26), 1.2% among lawyers (P=0.01), and

1.4% among other non-healthcare professionals

(P<0.001).

Factors associated with divorce among physicians

In adjusted analysis among physicians (table 4), both

divorce prevalence and divorce incidence were more

Table  | Characteristics of marriage and divorce, by occupation. Values are percentages (% condence intervals) unless stated otherwise

Characteristics

Physicians

(n= )

Dentists

(n= )

Pharmacists

(n= )

Nurses

(n= )

Healthcare

executives

(n= )

Lawyers

(n= )

Other

occupations

(n=  )

Divorce:

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)

P value — 0.69 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001

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)

P value — 0.20 0.22 < 0.001 < 0.001 < 0.001 < 0.001

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)

P value — 0.03 0.59 <0.001 0.06 0.002 < 0.001

Marriage:

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)

P value — 0.09 <0.001 <0.001 <0.001 <0.001 < 0.001

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)

P value — 0.70 0.001 <0.001 <0.001 <0.001 <0.001

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)

P value — 0.002 0.004 <0.001 <0.001 <0.001 <0.001

P values are based on comparison with physicians.

Sample in table is those that were ever married. Divorce prevalence for a given occupation is reflected by percentage of people within an occupation who reported having ever been divorced at

time of survey. Annual divorce incidence for a given occupation, or divorce rate, is reflected by percentage of people within an occupation who divorced in year previous to survey.

Table  | Characteristics of study population, –

Characteristics

Physicians

(n= )

Dentists

(n= )

Pharmacists

(n= )

Nurses

(n= )

Healthcare

executives

(n= )

Lawyers

(n= )

Other

occupations

(n=  )

Age:

Mean (SD) age (years) 48.6 (12.3) 50.5 (12.5) 46.3 (12.8) 46.8 (11.2) 49.1 (10.4) 49.2 (12.4) 47.1 (11.8)

25–39 27. 3 22.8 35.8 29.1 20.3 26.2 29.0

40–49 26.7 23.7 24.7 2 7.4 30.2 25.4 28.5

50–59 25.6 2 7.7 22.5 29.9 32.4 26.1 26.9

>60 20.4 25.8 17.0 13.7 17. 2 22.4 15.6

Race:

White 70.2 7 7. 4 74.6 7 7.0 79.1 8 7.1 70.4

Black 4.5 2.8 5.2 8.8 6.9 4.0 8.9

Hispanic 5.7 5.7 3.4 4.7 4.5 4.3 13.7

Other 19.6 14.1 16.8 9.5 9.5 4.6 7.0

Sex:

Female 31.7 24.1 52.3 91.5 49.9 31.4 47.1

Male 68.3 75.9 4 7.7 8.5 50.1 68.6 52.9

Annual income ($):

Mean (SD) annual income ($) 223 427 (155 417) 189 222 (140 054) 109 975 (61 652) 63 995 (38 163) 143 913 (117 284) 167 015 (139 497) 53 266 (58 104)

<50 000 9.5 10.7 13.1 34.8 10.6 13.3 62.0

50 000 to 99 999 17.0 19.7 23.3 54.3 32.5 25.7 27.4

100 000 to 149 999 13.6 20.7 51.7 8.8 26.9 21.8 6.6

150 000 to 199 999 12.8 12.4 7.7 1.3 11.7 12.2 1.9

>200 000 (%) 47.1 36.6 4.3 0.9 18.3 27.0 2.2

Hours worked a week:

Mean (SD) hours worked a week 50.4 (16.1) 37.6 (10. 7 ) 38.5 (10.9) 37.1 (10.3) 46.0 (10.6) 45.1 (12.8) 39.8 (12.3)

<39 14.6 46.8 28.4 4 4.1 9.0 15.2 25.6

40 to 49 28.2 39.5 59.3 46.7 48.4 40.5 55.6

50 to 59 22.5 9.4 8.4 6.1 28.2 28.2 11.8

>60 34.7 4.3 3.9 3.1 14.4 16.1 7.0

$1.00 (£0.66; €0.88).

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2015;350:h.706 | doi: 10.1136/bmj.h706

common among those who were older. Female physi-

cians had higher adjusted odds of being ever divorced

or divorced in the past year compared with male physi

cians (adjusted odds ratio of being ever divorced 1.51

ompared with males, 95% condence interval 1.40 to

1.63; adjusted odds ratio of divorcing in past year 1.46

compared with males, 95% condence interval 1.14 to

1.88). The adjusted odds of a physician being ever

divorced or divorced in the past year were not consis

tently associated with annual income. The adjusted

odds of bein

g ever divorced decreased with weekly

hours worked (for example, odds ratio of being ever

divorced among physicians who worked more than 60

hours a week compared with those who worked less

than 39 hours was 0.79, 95% condence interval 0.72 to

0.87). However, no association was noted between

hours worked and the adjusted probability of divorcing

in the past year. Condence intervals around odds

ratios in the model of divorce in the past year were gen

erally larger than in the model of being ever divorced,

owin

g to the much lower frequency of events in the for

mer group.

Sex dierences in eect of hours worked by

physicians on divorce

The number of hours worked per week was positively

associated with the probability of being ever divorced

only among female physicians (table 5). Female physi

cians who worked more than 40 hours a week had a

gher probability of being ever divorced compared

with female physicians who worked less than 40 hours

a week (for example, adjusted odds ratio 1.34 for female

physicians working 40–49 hours a week compared with

<40 hours, 95% confidence interval 1.16 to 1.54;

adjusted odds ratio 1.16 for female physicians working

50 to 59 hours a week compared with <40 hours, 95%

condence interval 0.99 to 1.37). In contrast, male phy

sicians who worked more than 40 hours a week had

low

er odds of being ever divorced than male physicians

who worked less than 40 hours a week (adjusted odds

ratio 0.77 for male physicians working 40–49 hours a

week (95% condence interval 0.68 to 0.88) and 0.66

(0.58 to 0.75) for male physicians working 50–59 hours

a week, both compared with male physicians working

<40 hours a week).

Discussion

The demanding nature of physicians’ work has led to

several historical investigations in the United States of

whether divorce is more common among physicians

than among other professionals. However, evidence on

this has been dated, limited, and mixed.

8 9–11

Using

large, nationally representative survey data collected by

the US census from 2008 to 2013, we compared both the

prevalence and incidence of divorce among physicians

and other healthcare and non-healthcare professionals.

Our study had several ndings. Firstly, divorce

among US physicians is no more common than in other

healthcare professions and non-healthcare profes

sions. In fact, the prevalence and incidence of divorce

amon

g physicians were similar to pharmacists and

Table  | Adjusted prevalence and incidence of divorce among physicians and other healthcare and non-healthcare professionals,  to 

Variables Physicians Dentists Pharmacists Nurses

Healthcare

executives Lawyers Other occupations

Divorce prevalence:

% of respondents ever

divorced, adjusted (95% CI)

24.3 (23.8 to 24.8) 25.2 (24.1 to 26.3) 22.9 (22.0 to 23.8) 33.0 (32.6 to 33.3) 30.9 (30.1 to 31.8) 26.9 (26.4 to 27.4) 35.0 (34.9 to 35.1)

P value — 0.14 0.008 <0.001 <0.001 <0.001 <0.001

Divorce incidence:

% of respondents divorced in

past year, adjusted (95% CI)

1.0 (0.9 to 1.1) 1.0 (0.7 to 1.2) 1.0 (0.8 to 1.2) 1.3 (1.2 to 1.4) 1.1 (1.0 to 1.3) 1.2 (1.1 to 1.4) 1.4 (1.4 to 1.4)

P value — 0.73 0.62 <0.001 0.26 0.01 <0.001

P values are based on comparison with physicians.

Adjusted prevalence and incidence of divorce across occuptions were estimated from multivariable logistic model of divorce as a function of occupational category, age, sex, race, annual

income, years since became married in most recent marriage, and state and year xed eects. The predicted values were calculated holding all covariates at their mean values.

Table  | Characteristics associated with prevalence and incidence of divorce among

physicians

Characteristics

Adjusted odds ratios (% CI)

Ever divorced Divorced in past year

Age (years):

25–39 1 (reference) 1 (reference)

40–50 5.79 (5.16 to 6.49) 1.87 (1.35 to 2.59)

51–60 28.0 (24.6 to 31.9) 1.84 (1.25 to 2.70)

>60 133 (112 to 158) 1.91 (1.17 to 3.11)

Race:

White 1 (reference) 1 (reference)

Black 1.09 (0.92 to 1.28) 0.61 (0.32 to 1.17)

Hispanic 1.13 (0.99 to 1.30) 1.09 (0.67 to 1.78)

Other 0.43 (0.39 to 0.47) 0.56 (0.40 to 0.78)

Sex:

Male 1 (reference) 1 (reference)

Female 1.51 (1.40 to 1.63) 1.46 (1.14 to 1.88)

Annual income ($):

<50 000 1 (reference) 1 (reference)

50 000 to 99 999 1.00 (0.87 to 1.16) 0.93 (0.59 to 1.48)

100 000 to 149 999 1.07 (0.93 to 1.24) 1.24 (0.79 to 1.96)

150 000 to 199 999 1.06 (0.92 to 1.23) 1.02 (0.63 to 1.63)

>200 000 1.03 (0.90 to 1.17) 0.94 (0.60 to 1.46)

Hours worked a week:

<39 1 (reference) 1 (reference)

40 to 49 1.02 (0.93 to 1.12) 1.41 (0.98 to 2.02)

50 to 59 0.86 (0.78 to 0.95) 1.36 (0.90 to 2.04)

>60 0.79 (0.72 to 0.87) 1.10 (0.76 to 1.61)

$1.00 (£0.66; €0.88).

Table reports adjusted odds ratios from multivariable logistic model of divorce (prevalence or incidence) as

function of age, race, sex, annual income, hours worked a week, years since became married in most recent

marriage, and state and year xed eects. Predicted values were calculated holding all covariates at their mean

values. Divorce prevalence is percentage of individuals who reported having ever been divorced at time of

survey. Annual divorce incidence is the percentage of individuals who divorced in year previous to survey and

can be interpreted as annual divorce rate.

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2015;350:h.706 | the bmj

dentists and substantially lower than that of nurses,

healthcare executives, lawyers, and other non-

healthcare professionals. Despite evidence that profes

sional obligations among physicians, including long

and sometimes unpr

edictable work hours, may conict

with personal and family life,

1–3

we found no evidence

that divorce among physicians was more common as a

result. Secondly, female physicians were substantially

more likely to be divorced than male physicians. Hours

worked per week were positively correlated with divorce

only for female physicians and not for male physicians,

suggesting that dierences in divorce rates between

male and female physicians may be partly attributable

to dierential responses of divorce to hours worked.

Meaning of the study and relation to other studies

of US healthcare professionals

Our ndings of a lower prevalence and incidence of

divorce among physicians compared with lawyers and

other professionals not employed in healthcare mirror

ndings from analyses of 1970 and 1980 US census data

reported more than two decades previously.

In that

analysis, physicians were compared with lawyers with

similar sociodemographic characteristics, including

advanced education, comparatively high income, and

later age at marriage. That analysis did not, however,

compare divorce between physicians and other health

care professionals who may face similar professional

demands

. In that respect we found physicians to be

similarly likely to divorce as dentists and pharmacists

but to have a lower prevalence of divorce than nurses

and healthcare executives.

An important measure that we could not assess is the

subjective evaluation of marital quality, which is distinct

from proneness to divorce, which we assessed.

10 25 26

Sev-

eral survey studies in the United States have evaluated

marital quality among physicians and have examined

factors associated with self reported marital quality,

including hours worked, physician specialty area, prac

tice setting, spousal occupation, and presence of chil-

dren.

26–29

For example, in a US survey of 891 spouses of

physicians, satisfaction was strongly independently asso

ciated with time spent awake with their physician partner

and number of ni

ghts on call a week but was not associ

ated with other professional

characteristics such as total

hours worked a week, specialty area, or practice setting.

Our nding that female physicians are substantially

more likely than male physicians to report being

divorced raises important questions as to the origin of

this association. In US surveys, female physicians on

average report making greater professional adjust

ments than male physicians to accommodate for house-

hold responsibilities such as child rearing.

Greater

trade-os between professional obligations and family

life may contribute to lower quality of relationships and

higher prevalence of divorce among female physi

cians.

31 32

For example, in a US survey of 1043 female

and 6815 male surgeons, female surgeons were sub

stantially more likely to report having experienced a

onict with their spouse or partner’s career (52.6% v

41.2%), more likely to report experiencing a work-home

conict in the three weeks preceding the survey being

administered (62.2% v 48.5%), and more likely to report

symptoms of burnout and depression.

Our analysis also found a positive association

between hours worked per week and divorce for female

physicians. In contrast, hours worked per week were

negatively associated with divorce for male physicians.

This nding is consistent with previous evidence from

the general American population that work hours of

women are more highly positively correlated with

divorce than are work hours of men.

Our nding that

hours worked a week may have dierent impacts on

divorce for female versus male physicians is consistent

with evidence that female physicians report making

greater trade-os between professional and family obli

gations.

30 –32

Although we studied the impact of number

of hours worked on divorce, our analysis did not allow

us to study the association of divorce with the structure

of hours worked—for example, irregular shis or night-

time work—which in a previous study was associated

with self reported marital dissatisfaction among

spouses of physicians.

Relation to international studies

We were unable to identify published studies exploring

divorce among physicians and other healthcare profes

sionals outside of the United States. However, several

studies c

onducted internationally have explored rates

of physician burnout and factors associated with well

being, and specically explored sex dierences in work-

home c

onict.

4 5 12–18

For example, in a survey of 1208

Norwegian physicians, work-home conict was among

the strongest predictors of burnout among female phy

sicians but was not statistically signicant among male

ysicians.

Similarly, in an analysis of multiple cohorts

of newly qualied physicians in the United Kingdom

between 1974 and 1993, 11.7% of male doctors were mar

ried compared with 21.5% of men in the general popula-

tion, whereas only 14.1% of women doctors were

married

compared with 38.9% of women in the general

population.

This study, while informative about sex

dierences in marriage formation among UK physi

cians, did not analyze rates of divorce. Finally, in a com-

parative analysis of sex dierences in burnout among

ysicians in the United States compared with the

Netherlands, US female physicians experienced more

Table  | Eect of hours worked on physician divorce,

according to physician sex

Hours worked

a week

Adjusted odds ratio of ever divorce (% CI)

Men Women

<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)

Table reports adjusted odds of physician divorce (prevalence and

incidence) as function of hours worked a week. Results are from

multivariable logistic model, which also adjusted for age, race, annual

income, years since became married in most recent marriage, and state

and year xed eects. Separate models were estimated by physician sex.

Predicted values were calculated holding all covariates at their mean

values in each estimation sample. Divorce outcome is percentage of

individuals who reported having ever been divorced at time of survey.

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7the bmj |

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2015;350:h.706 | doi: 10.1136/bmj.h706

burnout than US male physicians, whereas there was

no sex dierence in burnout among Dutch physicians.

However, consistent with other studies, female physi

cians in both the United States and the Netherlands

eported more work-home conicts than did men, with

the size of the sex dierence twice as high in the United

States as in the Netherlands.

Strengths and weaknesses of this study

This study is the rst in the past three decades to esti-

mate the prevalence and incidence of divorce among US

physicians using large, nationally representative data;

to compare those estimates with other healthcare pro

fessionals, lawyers, and other non-healthcare profes-

sionals; and to analyze factors associated with divorce

amon

g physicians.

Our study has several limitations. Firstly, although

the analysis of divorce rates across occupations lends

itself to a hazard analysis (for example, Cox propor

tional hazards analysis of differences in divorce haz-

ards across occupations), the census does not follow

people lon

gitudinally as it is a cross sectional survey

of people. Future work should use hazard analysis to

compare divorce rates of physicians with non-physi

cians in longitudinal data, which would allow for

irect estimation of the differences across occupa

tions in adjusted probability of divorce for people

er time.

A second limitation is that divorce is an imperfect

measure of marital satisfaction, the latter which we

were unable to directly assess in our study. A compari

son of marital satisfaction between physicians and

other pr

ofessionals may reveal dierences that a com

parison of divorce may not. Thirdly, the American com-

munity survey did not contain information on physician

special

ty. Although a failure to account for physician

specialty would not aect our comparison of divorce

between physicians and other professionals, there may

be important dierences in divorce among specialties.

For example, in a previous study of medical school

graduates from Johns Hopkins University, specialties

such as psychiatry and surgery were found to have sub

stantially higher rates of divorce than internal medi-

cine, pediatrics, and pathology.

Fourthly, our data did

not allow us to estimate the prevalence of divorce

among dual-physician couples. Dual-physician couples

have increased in prevalence, with several estimates

suggesting that nearly half of all physicians are married

to other physicians.

30 33 34

Dual-physician couples may

also be more common among female physicians than

among male physicians.

2 35

Marital satisfaction and

divorce may dier between physicians who are married

to other physicians and those who are not. For example,

in a study of 7095 surgeons, surgeons in dual-physician

couples reported greater diculty balancing profes

sional and personal obligations compared with sur-

geons whose spouse was not a physician.

In contrast,

in a study of 1208 physicians, those in dual-physician

couples reported an equivalent likelihood to non-

physician couples of achieving both career and family

goals.

Both groups also reported equivalent levels of

conict between professional obligations and family

roles. Although our data allowed us to identify spousal

occupation, we could not analyze the prevalence of

divorce among dual-physician couples because

divorced people in the survey had no occupational data

recorded for the previous spouse. Finally, our data were

specic to the United States and may not generalize to

divorce among healthcare professionals internation

ally, although some evidence exists that rates of burn-

out, which likely correlate with rates of divorce, may be

similar between healthcare professionals in the United

States and United Kingdom.

15 36

Conclusion

Despite oen reported conicts between professional

obligations and family life, we found no evidence that

physicians in the United States have a higher preva

lence or incidence of divorce than other healthcare and

non-

healthcare professionals. Female physicians and

other female healthcare professionals are substantially

more likely to be divorced than their male counterparts,

an area that requires further investigation.

Contributors: DPL, SAD, and ABJ contributed to the design and

conduct of the study, data collection and management, interpretation

of the data; and preparation, review, or approval of the manuscript.

ABJ is guarantor. The study sponsors were not involved in the study

design, data interpretation, writing, or decision to submit the article

for publication.

Funding: This study was supported by the Oce of the Director,

National Institutes of Health.

Competing interests: All authors have completed the ICMJE uniform

disclosure form at www.icmje.org/coi_disclosure.pdf (available on

request from the corresponding author) and declare: ABJ had support

from the Oce of the Director, National Institutes of Health (NIH early

independence award, grant 1DP5OD017897–01) for the submitted

work; no nancial relationships with any organisations that might have

an interest in the submitted work in the previous three years; and no

other relationships or activities that could appear to have influenced

the submitted work.

Data sharing: No additional data available.

Ethical approval: Not required.

Transparency: The lead author (ABJ) arms that the manuscript is an

honest, accurate, and transparent account of the study being reported;

that no important aspects of the study have been omitted; and that

any discrepancies from the study as planned (and, if relevant,

registered) have been explained.

This is an Open Access article distributed in accordance with the

Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,

which permits others to distribute, remix, adapt, build upon this work

non-commercially, and license their derivative works on dierent terms,

provided the original work is properly cited and the use is non-

commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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