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.
Professional obligations among physicians often conflict with personal and family life.1 2 3 4 5 While it has historically been suggested that long and sometimes unpredictable work hours among physicians may lead to higher rates of divorce,6 7 8 evidence on whether divorce rates among physicians exceed those in the general population has been limited and mixed.8 9 10 11 One of the first studies to analyze this was in the United States. Published nearly 40 years ago, this study found physicians to have substantially higher rates of divorce and poor self rated marital quality than other occupations, but the study was limited in its generalizability owing to its small, non-representative sample.11 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 surgeons (33%)—but was limited by its analysis of physicians from a single institution.9 Finally, a nationally 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.10 Although several studies done internationally have explored work-home conflicts among physicians and other healthcare professionals,4 5 12 13 14 15 16 17 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 pertinent, given the limited sample sizes of most studies, the changes in demographics, work hours, and earnings among US physicians,19 20 and the fact that overall divorce rates in the United States have fallen dramatically since the time of these studies (from 5.2 per 1000 Americans in 1980 to 3.6 per 1000 in 2011).21 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 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 differentially influenced the probability of divorce for male and female physicians.
We estimated both the prevalence and the incidence of divorce in various occupational groups using the American community survey, a nationally representative, cross sectional survey of approximately three million households annually, administered by the US Census Bureau. The survey is mandatory and is collected by mail, telephone, and personal visit interviews. The survey, which includes civilian as well as military households, collects information on respondent demographics (age, sex, race, current marital status, and, since 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%.22
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 married (6 649 708 people from 2008 to 2013). Physicians were identified based on a self reported occupation of “physician or surgeon.” Other healthcare professionals were identified based on a self reported occupation of either “dentist,” “pharmacist,” or “nurse.” Healthcare executives were identified as those with a self reported management occupation in a healthcare industry and with a graduate degree. We also identified 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 dentists, 13 883 pharmacists, 159 044 nurses, 18 920 healthcare executives, 59 284 lawyers, and 6 339 610 other non-healthcare professionals.
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 identified whether a respondent was currently divorced at the time of survey. This divorce measure provides a snapshot of whether the probability of being currently divorced at any given time varies by occupation. Secondly, because those who are currently married may have been remarried after a previous divorce, we identified whether respondents had ever been divorced, defined by whether they were either currently divorced or reported being married more than once. This divorce measure reflects the prevalence of divorce—that is, how likely someone was to have ever been divorced at any given time. Thirdly, we identified whether a respondent had divorced in the past year, which reflects the annual incidence of divorce, or what is commonly referred to as the annual divorce rate. Although in our descriptive analysis we reported unadjusted differences 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.
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 (categorized as non-Hispanic white, non-Hispanic black, Hispanic, other), occupation, annual income (categorized as
We adjusted for the number of years since a respondent became married in the most recent marriage for two reasons. Firstly, in comparing the prevalence of divorce across occupations, it is important to recognize that if people in specific occupations tend to marry at different ages, estimated differences in the prevalence of divorce across occupation could reflect differing ages at marriage across occupations rather than different underlying divorce risk. For example, if the annual rate of divorce was identical across occupations but physicians marry later in life, then at any given time physicians would be less likely to report ever having divorced 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 therefore important. Secondly, in comparing the incidence of divorce 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 after marriage and may decline with time, implying that the annual divorce rate for those in the 20th year of marriage would be lower than those in the first few years of marriage.23 Put differently, the divorce hazard may not be constant over time. If professionals in specific occupations marry at different ages, then a survey at a given time may misclassify occupations as having different divorce rates simply because people in those occupations were sampled at varying lengths of time after marriage. It is therefore important to adjust for the number of years since someone became married in the most recent marriage.
After estimating the logistic models, we reported the adjusted prevalence and incidence of divorce by occupation. We computed the adjusted probabilities by taking the predicted values from the logistic regression models holding all covariates except for occupation at their mean values (that is, we held the mean of other covariates constant across occupations). For categorical variables such as state and year, we computed the adjusted values at the means of the individual indicator variables (that is, reflecting 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 occupation, we did not separately adjust for weekly hours worked since the difference in hours worked between physicians and non-physicians is significant and may mediate the effect 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. Specifically, among physicians we estimated a multivariable logistic model of divorce as a function of these covariates and state and year as fixed effects. Given previous evidence that divorce rates are positively correlated with hours worked we also included weekly hours worked (categorized as
Finally, we stratified these models by physician sex to study whether factors such as weekly hours worked had differential 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 population of Americans, which showed that the work hours of women are more highly positively correlated with annual divorce rates than are the work hours of men.24
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 population. Statistical analyses were performed using STATA version 13.1 (Stata, College Station, TX).
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 dentists had the largest percentage of men (68.3% and 75.9%, 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).
Characteristics of study population, 2008-13