Pajama Time: The Association of EHR Documentation Time with Family Medicine Resident Outcomes

Context: Multiple studies have identified that working on the electronic health record (EHR) after clinic hours (“pajama time”) is a source of burnout and decreasing professional satisfaction. No study has looked at its association with resident outcomes during training.

Objective: Compare the demographics of residents who report three or more hours per night of “pajama time” (high EHR use) to those who report fewer hours. Investigate if there are associations between high EHR use and resident outcomes.

Study Design and Analysis: Survey of US family medicine (FM) residents. Bivariate analysis of outcomes by high EHR use and regression predicting satisfaction and burnout.

Setting or Dataset: 2023 American Board of Family Medicine (ABFM) National Resident Survey (NRS) administered in October 2023 at the end of the ABFM (In-Training Exam) ITE merged with ABFM administrative data.

Population Studied: PGY2 and above US FM residents.

Intervention/Instrument: The NRS surveyed all family medicine residents who completed the ITE. Residents were asked about EHR use and satisfaction along with multiple other measures including assessment of professional satisfaction and training satisfaction.

Outcome Measures: ITE score, self-reported satisfaction with professions of medicine, specialty of FM, residency training program, and 2 item burnout screening measure.

Results: 3931 PGY2 and above residents completed the EHR questions (response rate: 41.2%). Overall, 33.6% reported spending on average over 3 hours per night working on their ambulatory EHR. There were no differences by EHR brand. High EHR users were more likely to identify as female (60.4% vs. 51.8%) or Underrepresented in Medicine (29.4% vs. 22.6%) and be an international medical graduate (29.1% vs. 23.7%). and had a significantly lower mean ITE scores (406 vs. 422). They were also less likely to report being satisfied with the profession of medicine (63.2% vs. 75.7%), FM as a specialty (74.1% vs 84.2%), and with their training program (65.5% vs. 77.5%), and more likely to have symptoms of burnout (65.0% vs. 49.5%). High EHR use was associated with lower satisfaction and higher burnout in regressions controlling for resident factors.

Conclusions: A third of upper year US FM residents report spending three or more hours per day working after hours on the ambulatory EHR. This “pajama time” is associated with lower medical knowledge, lower professional satisfaction, and higher levels of burnout.