Newswise — For many family medicine residents, the workday doesn’t end when clinic doors close. Instead, it continues late into the evening in the glow of a laptop screen: reviewing lab results and imaging, answering messages from patients, and catching up on documentation, in after-hours electronic health record (EHR) work, or what many call “pajama time.”
A new national study led by Wendy Barr, MD, MPH, instructor of medicine (general internal medicine) at Yale School of Medicine (YSM), alongside researchers at the American Board of Family Medicine, finds that after-hours EHR work is strongly associated with burnout among family medicine residents. The findings were published this month in Academic Medicine.
Among more than 9,000 residents surveyed for the study, those who reported spending three or more hours per night on pajama time were significantly more likely to experience burnout.
“We used a brief, two-item screening tool that’s widely used in burnout research,” says Barr. “It asks how often, over the past two weeks, residents have experienced emotional exhaustion or depersonalization—feeling detached from patients. If either occurs at least once a week or more, that meets the threshold for burnout.”
The survey was administered by the American Board of Family Medicine following the 2024 in-training examination and achieved a 99% response rate, offering a rare national snapshot of resident experiences. Because the survey is conducted by the certifying board, it captures nearly the entire population of upper-year family medicine residents, something few other specialties do at this scale, says Barr.
The study also examined whether high levels of pajama time were associated with residents’ performance on their in-training examinations. Residents with the least after-hours EHR time had the highest scores, and scores steadily declined as EHR time increased.
“We suspected that if residents were spending a lot of time in the EHR, they might have less time to read, reflect, and study, which could affect exam performance,” Barr says. “What surprised us was the strength of the association and the clear dose-response pattern.”
Barr, who also serves as founding residency program director of the Yale Family Medicine Residency Program at Lawrence + Memorial Hospital, points to differences in pajama time between training years: Third-year residents, who spend more time in clinic, reported higher levels of after-hours EHR use than second-year residents.
“The more you’re in clinic, the more pajama time you seem to have,” Barr says. “That tells us there’s a systems aspect to this.”
The study also found meaningful differences in the demographics of those who reported high levels of pajama time. Older residents, women, international medical graduates, and residents underrepresented in medicine were more likely to spend three or more hours per night on after-hours EHR work.
While the study did not examine the reasons behind these disparities, Barr notes that prior research in practicing physicians, including work conducted at Yale, has suggested that women physicians, for example, may receive higher volumes of patient messages and clinical tasks, contributing to greater after-hours workload. The findings raise concerns that residents who already face inequities in training environments, such as bias, differential task assignment, and unequal access to support, may also be disproportionately burdened by after-hours administrative work.
Barr suggests that potential solutions may lie in redistributing administrative work across care teams, such as having other members of the care team manage refills, prior authorizations, or inbox tasks. Emerging tools like AI scribes may also help, though early studies in practicing physicians have shown mixed results.
Barr emphasizes that residents are experiencing many of the same workflow pressures facing practicing primary care physicians nationwide.
“If someone has high pajama time as a resident, are they less likely to work full-time later? That becomes a workforce issue,” Barr says. “As residency programs, we should be measuring this and intervening early.”
Administered nationally, the dataset also offers a rare opportunity to follow residents into practice over time, says Barr, allowing researchers to examine whether high levels of pajama time during training predict future burnout or reduced clinical hours.
As health systems grapple with physician burnout and primary care shortages, the findings suggest that addressing pajama time during residency may be an important step toward strengthening both physician well-being and the future primary care workforce.
“It’s not just about documentation or efficiency,” Barr says. “It’s about helping physicians build a way of practicing that they can sustain for a lifetime.”
General Internal Medicine, one of 10 sections in the Yale Department of Internal Medicine, is committed to the core missions of patient care, research, education, and community health from the “generalist” perspective. To learn more, visit General Internal Medicine.
Original release: https://medicine.yale.edu/news-article/after-hours-electronic-health-record-use-associated-with-resident-burnout/
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