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Trends in United States Physician Work Hours and Career Satisfaction

      Perspectives Viewpoints
      • US primary care and subspecialty physicians report working fewer hours and decreasing career satisfaction from 1997 to 2005.
      • This study also shows that decreased work hours are correlated independently with higher career satisfaction.
      • With the anticipated shortage of primary care providers, it is important to identify modifiable factors to promote growth of the primary care workforce. Our study suggests that decreasing physician work hours may help increase physician career satisfaction.
      Physician career satisfaction has the potential to affect the future of medicine in many ways. Dissatisfied physicians are more likely to cut back on hours and shorten the duration of their medical career, whether to retire early or pursue careers outside of medicine.
      • Landon B.E.
      • Reschovsky J.D.
      • Pham H.H.
      • Blumenthal D.
      Leaving medicine: the consequences of physician dissatisfaction.
      Career satisfaction predicts whether physicians will advise medical students to enter their specialty.
      • Wetterneck T.B.
      • Linzer M.
      • McMurray J.E.
      • et al.
      Worklife and satisfaction of general internists.
      Multiple projections predict a drastic shortage of primary care providers within the next 20 years.
      • Petterson S.M.
      • Liaw W.R.
      • Phillips Jr., W.R.
      • Rabin D.L.
      • Myers D.S.
      • Bazemore A.W.
      Projecting US primary care physician workforce needs: 2010-2025.

      Association of American Medical Colleges. The impact of health care reform on the future supply and demand for physicians updated projections through 2025. June 2010. Available at: https://www.aamc.org/download/158076/data/updated_projections_through_2025.pdf. Accessed April 26, 2024.

      • Brotherton S.
      • Etzel S.I.
      Graduate medical education, 2007-2008.
      To bolster the primary care physician work force, it is imperative to identify factors that limit career satisfaction. If policymakers can address those factors, it increases the likelihood that medical students and residents choose primary care fields.
      Prior studies demonstrate that physician satisfaction remained largely stable over the past 20 years.
      • Landon B.E.
      • Reschovsky J.
      • Blumenthal D.
      Changes in career satisfaction among primary care and specialist physicians 1997-2001.
      • Scheurer D.
      • McKean S.
      • Miller J.
      • Wetterneck T.
      US physician satisfaction: a systematic review.
      The constantly evolving US health care system has resulted in changes in the roles and responsibilities of physicians during this time, including changes in work hours and the distribution of the daily work load. Excluding changes in resident work hours, recent studies demonstrate decreasing physician work hours. Using US census data, Staiger et al
      • Staiger D.O.
      • Auerbach D.I.
      • Buerhaus P.I.
      Trends in the work hours of physicians in the United States.
      report a 5.7% decrease in work hours nationwide from 1976 to 2008. More substantial decreases have been noted in studies at the state level.
      • Wilper A.P.
      • Weppner W.G.
      • Smith C.S.
      Changes in Idaho primary care physician clinical work hours, 1996-2009.
      However, prior studies have not examined the differences between primary care and subspecialty providers with respect to changing work hours or types of duty. Very few recent data analyze the relationship between work hours and career satisfaction among US physicians. In this study, we aimed to assess trends in work hours and predictors of career satisfaction for both primary care and subspecialty physicians using the nationally representative Community Tracking Survey.

      Methods

      Data Source

      The Community Tracking Study Physician Survey (CTSPS) is a publicly available data set generated from telephone surveys to a nationally representative sample of physicians. Administered by the Centers for Studying Health System Change,
      Center for Studying Health System Change
      Community Tracking Study Physician Survey, 1996–1997: ICPSR Version.
      Center for Studying Health System Change
      Community Tracking Study Physician Survey, 1998–1999: ICPSR Version.
      Center for Studying Health System Change
      Community Tracking Study Physician Survey, 2000-2001: ICPSR Version.
      Center for Studying Health System Change
      Community Tracking Study Physician Survey, 2004-2005: ICPSR Version.
      these surveys target nonfederal and nonresident physicians who spent at least 20 hours per week in direct patient care. Survey content included physician demographics, patient population, practice environment, career satisfaction, and physician time allocation. The first 4 iterations of CTSPS were used for this study, namely 1996-1997 (12,385 respondents, 65% response rate), 1998-1999 (12,280 respondents, 61% response rate), 2000-2001 (12,389 respondents, 59% response rate), and 2004-2005 (6628 respondents, response rate 52%). No CTSPS was performed for the 2002-2003 period. The sample includes physicians from all specialties, including primary care-specific fields such as family practice, general practice, general internal medicine, internal medicine/pediatrics, pediatrics, and geriatrics. CTSPS also surveyed physicians in nonprimary care specialties including medicine and pediatric subspecialties, obstetrics/gynecology, and surgical specialties. Given lack of direct patient care, specialties such as radiology and pathology were excluded. Primary care physicians were identified based on self-designation as such in the survey.
      The Health Tracking Physician Survey (4720 respondents) is the 2008 successor survey to CTSPS.
      Center for Studying Health System Change
      2008 Health Tracking Physician Survey.
      However, it differs from CTSPS by using a mailed questionnaire with changes in the wording of questions and used different methodology to derive its nationally representative sample. Due to these significant changes, it was not employed for this study.
      We analyzed each survey cycle independently and then concatenated files to derive the cohort sample. Changes in demographics were examined using Rao-Scott chi-squared tests adjusted for the survey design. CTSPS provides weights that allow calculation of national estimates. Means and proportions were weighted to arrive at national estimates. To more closely examine the changing perceptions of satisfaction within a cohort, individuals were identified that had participated in all 4 years of the study (ie, 1996-1997, 1998-1999, 2001-2002, and 2004-2005). These individuals were included in the repeated-measure analyses examining differences across years (n = 1928) for all subsequent analyses. Analyses were performed using SAS 9.1 (Cary, NC) statistical software survey procedures to account for the complex survey design.

      Quantifying Physician Work Hours

      CTSPS defined work hours as “hours spent in medically relevant work,” which was evaluated by the question “During your last complete week of work, approximately how many hours did you spend in all medically related activities? Please include all time spent in administrative tasks, professional activities and direct patient care. Exclude time on call when not actually working.” The distribution of work hours was then further divided into hours spent in direct patient care and charity care. Time spent in direct patient care was evaluated by the question: “Of these [reported] hours, how many did you spend in direct patient care activities?” Time spent in charity care was measured by asking: “During the last month, how many hours, if any, did you spend providing charity care?”
      Center for Studying Health System Change
      Community Tracking Study Physician Survey, 1996–1997: ICPSR Version.
      Center for Studying Health System Change
      Community Tracking Study Physician Survey, 1998–1999: ICPSR Version.
      Center for Studying Health System Change
      Community Tracking Study Physician Survey, 2000-2001: ICPSR Version.
      Center for Studying Health System Change
      Community Tracking Study Physician Survey, 2004-2005: ICPSR Version.
      Responses were quantified through analysis of variance tests for changes in work hours over time.

      Evaluating Physician Career Satisfaction

      Career satisfaction was evaluated by CTSPS with the question: “Thinking very generally about your satisfaction with your overall career in medicine, would you say that you are currently very dissatisfied, somewhat dissatisfied, neither satisfied nor dissatisfied, somewhat satisfied, or very satisfied?” Responses were reported as a Likert scale of 1 to 5, with 3 representing “neither satisfied or dissatisfied.”
      Center for Studying Health System Change
      Community Tracking Study Physician Survey, 1996–1997: ICPSR Version.
      Center for Studying Health System Change
      Community Tracking Study Physician Survey, 1998–1999: ICPSR Version.
      Center for Studying Health System Change
      Community Tracking Study Physician Survey, 2000-2001: ICPSR Version.
      Center for Studying Health System Change
      Community Tracking Study Physician Survey, 2004-2005: ICPSR Version.
      Physicians who reported being “somewhat satisfied” or “very satisfied” were combined in the definition of being satisfied with a career as a physician. Responses were quantified through chi-squared tests to evaluate for changes in career satisfaction over time.

      Variables Affecting Career Satisfaction

      We examined the relationship between physician work hours and career satisfaction via 2 separate approaches. The first approach was developed given concerns about outlier responses in time variables skewing the analysis. The population sample was divided to quartiles for each measure of hours worked, with the middle quartiles combined. Then the percentage of physicians reporting career satisfaction, specifically, being “somewhat satisfied” or “very satisfied” on the survey instrument, was quantified for each quartile of the various measures of work hours.
      For the second approach, we developed a multivariate logistic regression model to examine the relationship between work hours and career satisfaction. We controlled for major demographic variables: age, sex, race, country of medical education, self-designation as primary care provider, type of practice, self-employment status, and region of practice in the US.

      Institutional Review Board Approval

      The institutional review board of the Puget Sound Veterans Affairs Medical Center approved this study. Additionally, the Inter-University Consortium for Political and Social Research, the organization that manages the CTSPS data sets, approved the study and provided access to files containing variables restricted from public viewing. Funding for this project was provided by a grant from the Mountain States Tumor and Medical Research Institute. This material is the result of work supported by resources from the Boise Veterans Affairs Medical Center, Boise, Idaho.

      Results

      The complete physician sample demographic characteristics are presented in Table 1. During the study period, the physician population aged significantly (χ2[6] = 151.2, P <.0001). The calculated mean age of physicians increased from 48.5 years (95% confidence interval [CI], 48.3-48.7) in the 1996-1997 survey to 50.0 years (95% CI, 49.6-50.3) in 2004-2005. Over the same period, we document an increase in the proportion of female physicians from 17.6% in 1996-1997 to 25.0% in 2004-2005 (χ2[3] = 84.3, P <.0001). Surveyed physicians also reported decreasing self-employment (including full and partial ownership), from 61.0% in 1996-1997 to 54.6% in 2004-2005 (χ2[6] = 54.9, P <.0001), accompanied by an increase in non-self-employed status from 38.0% in 1996-1997 to 45.4% in 2004-2005.
      Table 1Characteristics of Sample. Demographics of Physician Respondents to Each Survey Cycle of the Community Tracking Study Physician Survey (Total Sample N = 42,911)
      Characteristic1996-19971998-19992000-20012004-2005P-Value
      P-value Rao-Scott χ2 testing difference in cohort from 1996-1997 to 2004-2005.
      Age<.0001
       <45 years45.0%44.1%39.7%34.9%
       46-65 years47.0%50.1%53.7%57.1%
       >65 years8.1%5.7%6.5%7.9%
      Percent female18.0%20.9%23.6%25.2%<.0001
      Race/ethnicity.04
       WhiteNot available81.4%80.2%78.1%
       Black3.5%3.6%4.3%
       Native American/Alaska0.3%0.4%0.4%
       Asian/Pacific Islander11.7%12.3%13.6%
       Other3.1%3.5%3.7%
      Medical training
       US graduate80.5%78.8%78.8%78.0%.0441
       International graduate19.5%21.2%21.2%22.0%
       MD93.0%93.4%92.8%92.2%.1302
       DO7.0%6.6%7.2%7.8%
      Years in practice<.0001
       1 year0.6%0.5%0.1%0.5%
       2-1033.9%35.2%33.1%30.8%
       >1065.5%64.3%66.8%68.7%
      Specialty
       Family medicine/General practitioner17.6%16.7%17.0%16.6%<.0001
       Pediatrics8.2%8.5%7.8%8.3%
       General Internal Medicine12.5%12.7%14.3%11.8%
       Medical specialty25.2%27.9%29.4%30.9%
       Surgical specialty22.4%20.7%18.8%18.9%
       Psychiatry7.6%6.9%6.5%6.7%
       OB/GYN6.5%6.5%6.3%6.8%
       Primary care38.8%38.5%39.8%36.7%.0115
      Place of practice.0281
       Hospital10.7%12.6%12.0%12.0%
       Nonhospital89.3%87.4%88.0%88.0%
      Employment<.0001
       Self-employed37.0%33.2%31.9%31.2%
       Partner24.6%23.5%24.0%23.1%
       Non-self-employed38.4%43.3%44.1%45.6%
      Region of the country.0755
       Region 1 – Northeast23.6%23.8%24.1%21.9%
       Region 2 – Midwest20.8%19.8%19.3%19.4%
       Region 3 – South34.0%35.1%35.4%35.8%
       Region 4 - West21.6%21.3%21.2%22.9%
      Accepting Medicaid or Medicare patients
       Medicare89.9%89.1%88.8%88.2%Medicare .05
       Medicaid87.1%86.8%85.4%85.4%Medicaid .02
      P-value Rao-Scott χ2 testing difference in cohort from 1996-1997 to 2004-2005.

      Physician Work Hours

      We present changes in measures of physician work hours in Table 2. There was no significant trend for either primary or nonprimary care physicians in weeks per year practicing medicine. There was a decrease in the mean hours per week spent in all medically related activities, which include both direct patient care and charity care responsibilities. For primary care physicians, hours spent in medically related activities decreased from 55.0 hours (95% CI, 54.4-55.6) in 1996-1997 to 54.1 hours (95% CI, 53.6-54.6) in 2004-2005 (P = .0004). For nonprimary care providers, hours spent in medically related activities decreased from 57.0 hours (95% CI, 56.5-57.5) in 1996-1997 to 51.1 hours (95% CI, 50.5-51.7) in 2004-2005 (P = .0015).
      Table 2Trends in Physician Work Hours
      Characteristic1996-19971998-19992000-20012004-2005P-Value
      P-value from analysis of variance testing changes over time by primary care physician status and adjusted for complex survey design and major demographic covariates.
      Weeks per year practicing medicine
       Primary care47.2 (0.2)47.8 (0.1)47.6 (0.2)47.2 (0.4).06
       Non primary care47.5 (0.2)47.6 (0.1)47.4 (0.1)47.2 (0.1).51
      Hours per week in medical related activity
       Primary care55.0 (0.6)54.2 (0.5)52.9 (0.5)54.1 (0.5).0004
       Non primary care57.0 (0.5)55.7 (0.5)55.4 (0.5)51.1 (0.6).0015
      Hours per week in direct patient care
       Primary care44.7 (0.5)44.6 (0.5)45.5 (0.5)44.2 (0.7).39
       Non primary care45.7 (0.5)45.0 (0.5)47.5 (0.5)46.5 (0.5).0072
      Hours per week in charity work
       Primary care6.0 (0.4)6.1 (0.4)6.0 (0.5)5.4 (0.4).18
       Non primary care9.3 (0.5)9.7 (0.7)7.6 (0.4)8.2 (0.5).05
      Mean values (with SE) are reported for various measures of physician work hours for the different survey cycles of the Community Tracking Study Physician Survey (subsample participating in all 4 surveys, N = 1928).
      P-value from analysis of variance testing changes over time by primary care physician status and adjusted for complex survey design and major demographic covariates.
      Time in direct patient care demonstrated a significant trend only for nonprimary care physicians over the study period. Hours per week spent in direct patient care increased for nonprimary care physicians from 45.7 hours (95% CI, 45.2-46.2) in 1996-1997 to 46.5 hours (95% CI, 46.0-47.0) in 2004-2005 (P = .0072). Time spent in charity care also demonstrated a significant change only for nonprimary care providers. Hours per week spent in charity care decreased by 11.8% for nonprimary care physicians from 9.3 hours (95% CI, 8.8-9.8) in 1996-1997 to 8.2 hours (95% CI, 7.7-8.7) in 2004-2005 (P = .05).

      Predictors of Career Satisfaction

      During the study period, there was a statistically significant decrease in career satisfaction (χ2[12] = 50.5, P = .0026) for all physicians, from 86.60% of physicians in 1996-1997 reporting being “somewhat satisfied” or “very satisfied” to 84.70% in 2004-2005 (Table 3). This change was significant only for nonprimary care providers in our stratified analysis.
      Table 3Physician Career Satisfaction. Percent of Physicians Reporting Overall Career Satisfaction by Survey Cycle (Subsample Participating in All 4 Surveys N = 1928)
      Survey Cycle1996-1997

      Percent

      (95% CL)
      1998-1999

      Percent (95% CL)
      2000-2001

      Percent (95% CL)
      2004-2005

      Percent (95% CL)
      P-Value
      P-value Rao-Scott χ2 testing difference in cohort from 1996-1997 to 2004-2005.
      All physicians86.60% (84.81-88.39)81.75% (79.70-83.80)82.20% (80.12-84.28)84.70% (82.73-86.66).0026
      Primary care87.03% (84.64-89.43)84.69% (82.01-87.38)81.83% (78.85-84.81)83.65% (80.13-87.17).13
      Non primary care86.39% (84.00-88.79)80.55% (77.88-83.22)82.32% (79.74-84.91)85.23% (82.88-87.59).0059
      CL = confidence limits.
      P-value Rao-Scott χ2 testing difference in cohort from 1996-1997 to 2004-2005.
      We found that physicians in the lowest quartile of work hours reported highest career satisfaction, as demonstrated in Table 4. Physicians in the lowest quartile of weeks worked per year reported highest satisfaction for all rounds of the survey. Additionally, physicians in the lowest quartile of hours worked per week in all medically relevant activities, as well as in hours worked per week in direct patient care, reported higher career satisfaction.
      Table 4Relationship between Work Hours and Career Satisfaction
      Survey YearPopulation Quartiles for Measures of Work TimeRao χ2 DF(2)P-Value
      <25th Percentile25th-75th Percentile>75th Percentile
      Weeks per year practicing medicine
      1996-199784.584.177.355.5<.0001
      1998-199983.582.076.430.7<.0001
      2000-200183.783.577.522.5<.0001
      2004-200588.386.779.521.1<.0001
      Hours per week in all medically relevant work
      1996-199782.282.982.10.597.7418
      1998-199981.483.479.311.9.0026
      2000-200183.784.179.317.5.0002
      2004-200589.886.781.625.7<.0001
      Hours per week in direct patient care
      1996-199781.682.782.51.1.5737
      1998-199981.482.278.78.9.0119
      2000-200183.783.079.212.8.0017
      2004-200588.287.180.917.6.0002
      Hours per week in charity care
      1996-199782.784.279.822.3<.0001
      1998-199979.783.279.314.0.0009
      2000-200180.483.681.07.1.0284
      2004-200586.085.884.80.4.8142
      The population sample was divided into quartiles for each measure of time worked, with the middle quartiles combined. The percentage of physicians reporting career satisfaction, specifically selecting “somewhat satisfied” or “very satisfied” on the survey instrument, is reported for each quartile.
      In multivariate analysis controlling for demographics, increased career satisfaction was associated with decreased number of weeks worked per year (odds ratio 0.982; 95% CI, 0.973-0.992) and decreased hours spent in all medically relevant activities (odds ratio 0.990; 95% CI, 0.988-0.993).

      Discussion

      Our study demonstrates decreasing work hours among both primary care and subspecialty physicians. The 1.6% decrease for primary care physicians and 10.4% decrease for nonprimary care physicians in work hours are consistent with prior studies.
      • Staiger D.O.
      • Auerbach D.I.
      • Buerhaus P.I.
      Trends in the work hours of physicians in the United States.
      • Wilper A.P.
      • Weppner W.G.
      • Smith C.S.
      Changes in Idaho primary care physician clinical work hours, 1996-2009.
      These data confirm the change in work hours for both primary care and subspecialty physicians, though it is more pronounced for nonprimary care physicians. Our study also shows a small, but statistically significant, relationship between physician work hours and career satisfaction. Decrease in work hours appears to be correlated with increasing career satisfaction.
      Although overall work hours decreased, time spent in direct patient care increased for nonprimary care providers. This increase may indicate that administrative duties decreased. Reduced administrative work might have resulted from the decreased physician self-employment observed.
      • Glasheen J.J.
      • Misky G.J.
      • Reid M.B.
      • Harrison R.A.
      • Sharpe B.
      • Auerbach A.
      Career satisfaction and burnout in academic hospital medicine.
      No recent data confirm that increased numbers of nurse practitioners and physician assistants have decreased physician administrative duties.
      • Druss B.J.
      • Marcus S.C.
      • Olfson M.
      • Tanielian T.
      • Pincus H.A.
      Trends in care by nonphysician clinicians in the United States.
      The decrease in time spent in charity care may partially explain the overall decrease in work hours. However, the decrease in total work hours was greater than the decrease in charity care. As noted, CTSPS did not include a specific question about administrative duties. However, recent data suggest that time spent by US physicians on administrative tasks is substantially greater than their Canadian counterparts.
      • Katerndahl D.
      • Parchman M.
      • Wood R.
      Perceived complexity of care, perceived autonomy, and career satisfaction among primary care physicians.
      Given the anticipated shortage of primary care providers in the US, identifying modifiable factors to promote growth of the primary care workforce is essential. Many factors that affect physician career satisfaction have previously been identified. These factors include perceived clinical autonomy, control of work schedule, job demand, income and incentives, access to health information technology, foreign training, and peer collegiality.
      • Elder K.T.
      • Wiltshire J.C.
      • Rooks R.N.
      • BeLue R.
      • Gary L.C.
      Health information technology and physician career satisfaction.
      • Chen P.G.
      • Curry L.A.
      • Bradley E.H.
      • Desai M.M.
      Career satisfaction in primary care: a comparison of international and US medical graduates.
      • Stoddard J.J.
      • Hargraves J.L.
      • Reed M.
      • Vratil A.
      Managed care, professional autonomy, and income: effects on physician career satisfaction.
      • Grayson M.S.
      • Newton D.A.
      • Patrick P.A.
      • Smith L.
      Impact of AOA status and perceived lifestyle on career choices of medical graduates.
      • Schwartz M.D.
      • Durning S.
      • Linzer M.
      • Hauer K.E.
      Changes in medical students' views of internal medicine careers from 1990 to 2007.
      Top performing medical graduates are increasingly entering subspecialties as these are identified as lifestyle friendly, based on availability of leisure time, time with family, and predictable work hours.
      • Linzer M.
      • Manwell L.B.
      • Williams E.S.
      • et al.
      Working conditions in primary care: physician reactions and care quality.
      US Department of Health and Human Services
      Healthy People, 2010: Understanding and Improving Health.
      Therefore, to attract medical students into primary care fields, the factors affecting career satisfaction must be addressed. Improving physician career satisfaction also has important implications on the health of the US population. While physician satisfaction has not been directly associated with measureable changes in quality of care,
      • Isaacs S.L.
      • Jellinek P.S.
      • Ray W.L.
      The independent physician—going, going….
      the availability of primary care providers has been associated with improved outcomes in patients.
      • Morra D.
      • Nicholson S.
      • Levinson W.
      • Gans D.N.
      • Hammons T.
      • Casalino L.P.
      US physician practices versus Canadians: spending nearly four times as much money interacting with payers.
      • Chang C.H.
      • Stukel T.A.
      • Flood A.B.
      • Goodman A.C.
      Primary care physician workforce and Medicare beneficiaries' health outcomes.
      Our study has limitations. As a longitudinal cohort study, we tested for changes in a cohort of physicians. Our study may be biased if work hours predicted nonresponse, that is, if busier physicians were less likely to participate in the survey. This factor may skew our results toward the observed trend of decreasing work hours. While we controlled for self-employment in the logistic regression predicting career satisfaction, future study could determine whether decreasing self-employment status may have affected the trends observed in work hours. Because we were unable to analyze time in administrative tasks, we cannot explicitly account for which component of physician commitments is responsible for the decrease in work hours. Also, the work hours documented were derived from participant recall rather than documented work hours and therefore is at risk for recall bias. Additionally, unmeasured confounders may affect the relationship between work hours and career satisfaction. Future analyses could evaluate the influence of gender on the relationship between work hours and career satisfaction. The Women Physicians Health Study suggests that nearly one third of female providers consider changing specialty or would chose not to become a physician again despite similar projections of career satisfaction.
      • Frank E.
      • McMurray J.E.
      • Linzer M.
      • Elon L.
      Career satisfaction of US women physicians.
      Finally, our findings suggest a somewhat paradoxical conclusion. Decreased work hours are weakly associated with increased career satisfaction. Meanwhile, we document decreases in both work hours and satisfaction. One possible explanation for these results could be a threshold effect, that is, only once working less than a specific number of hours does satisfaction increase. Alternatively, unobserved confounders could be driving down both hours and satisfaction.
      Changes to the US health care system propose an increasing emphasis on primary care. Meanwhile, estimates project a deficit of primary care providers. Maintaining or increasing physician career satisfaction, especially in the primary care specialties, is gaining relevance for the future of the health care workforce. Our study suggests that one avenue toward bolstering the primary care work force may be a focus on decreasing physician work hours to increase physician career satisfaction.

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      Linked Article

      • Physicians Should Work More, Not Less
        The American Journal of MedicineVol. 128Issue 4
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          The first conclusion of Christopher et al,1 that decreased work hours are correlated independently with higher career satisfaction, is not surprising, because the desire to work less and make more appears to be a basic feature of human nature.
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