Avocation

Sir William Osler suggested in 1899 that avocations (leisure activities) in doctors are related to an increased sense of vocation (professional engagement) and a decreased level of burnout. This study evaluated those claims in a large group of doctors practicing in the UK while taking into account a wide range of background variables.

avocation

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In this cross-sectional study there is evidence, even after taking into account a wide range of individual difference measures, that doctors with greater Avocation/Leisure activities also have a greater sense of Vocation/Engagement. In contrast, being BurnedOut did not relate to Avocation/Leisure activities (but did relate to many other measures). Osler was probably correct in recommending to doctors that, 'While medicine is to be your vocation, or calling, see to it that you also have an avocation'.

Osler had earlier, in 1899, provided an important piece of advice to young doctors on how to avoid burnout, suggesting that as well as having a vocation, doctors should also have an avocation, saying:

'While medicine is to be your vocation, or calling, see to it that you also have an avocation... some intellectual pastime which may serve to keep you in touch with the world of art, of science, or of letters. Begin at once the cultivation of some interest other than the purely professional. The difficulty is in a selection and the choice will be different according to your tastes and training. No matter what it is B but have an outside hobby.' (p.204)

A search of MEDLINE (7th April 2011) retrieved 476,849 studies containing 'doctor* OR physician*', and 12,729 studies containing 'avocation OR leisure* OR hobby OR hobbies', with 733 studies referring to both. The vast majority of these studies were, however, not relevant to the present study. A large number were on the hobbies of deceased doctors, sometimes historical, were on possible hobbies for doctors (for example, photography, music, succulent collecting or numismatics), or on how leisure activities affect patients (for example, in diabetes, or as a risk factor for breast cancer), on disease presentations as a result of leisure activities in the general population (for example, vertebral artery dissection after a roller coaster ride, Lyme Disease in people with outdoor leisure activities, or injuries acquired during campanology), and on one occasion on disease resulting from the leisure activities of doctors themselves, in a study of tennis-elbow [6]. None were relevant to the purposes of the present analysis, although it might be worth mentioning one somewhat contrarian paper which emphasized the sometime dangers to health resulting from leisure and leisure activities, and suggested that leisure activities are not therefore an unmitigated good [7].

A frequent comment in studies, which typically followed the line described earlier by Osler, was of the beneficial role of increasing leisure activities, shown most clearly in the sub-title of one article, which said, 'Hobbies relieve stress and allow self expression' [42]. A similar claim is made in a study of burnout that, '...enriching leisure activities ... [is one of several] important measures to preventing burnout' [43], and hobbies were regarded by specialists in palliative medicine as an important way to prevent burnout [44], as well as a way of preventing 'physician disability'" [45]. An extension of the claim is that, 'more leisure and unstructured contemplation of the humanities help physicians to cherish empathy' [46] (and there is a recurrent belief, rarely substantiated with evidence, that the humanities nurture humane behaviour in doctors specifically, and in general [47]). Few studies have considered the specific type of the leisure activities, although one study specifically looked at cultural activities, and in comparison with a control, university-educated, population found less time watching television, more time reading non-medical books, and more time devoted to music [48]. Comment has also been made upon an apparent tendency for doctors to be proficient in a range of non-medical areas, both as talented amateurs [49], and also the extent that what was once an avocation becomes a vocation, with distinction achieved outside medicine [50].

To assess the widely held intuition, most venerably put forward by Osler, that the non-medical activities of doctors (their avocations) are related to their involvement and commitment to their daily professional activities (their vocation).

Given that stress, burnout and engagement are known to relate to individual difference measures, we assess to what extent any relationships with leisure activities are themselves secondary to differences in personality (assessed using the standard Big Five conceptualization). It may be that, for example, burnout and leisure activities are intercorrelated because the same personality characteristic predisposes to burnout and a lack of leisure activities. Perhaps it is not avocations per se that are important, but that those individuals with more avocations also have a personality that encourages a sense of vocation.

The central interest of this paper has been in the suggestion that having a vocation, which many doctors claim to have and can be seen as an integral part of professional behavior, is benefited by having an avocation. Sir William Osler thought that having an avocation would benefit doctors by increasing their sense of vocation and preventing what now we would call burnout, so that he recommended, 'the young doctor should look about early for an avocation, a pastime, that will take him away from patients, pills and potions' [52]. To summarize our results, Osler's ideas are partly supported, in that we find a robust correlation between work engagement and more extensive leisure activities, a result that remained even when twenty-five wide-ranging background variables, including personality, work variables and demographics were taken into account. In contrast, and contra Osler, there was no suggestion that leisure activities related to burnout and stress. It is also worth stressing that the measures of leisure, burnout and engagement are robust, with 30.8%, 48.3% and 35.7% of the accountable variance in each being explained by the twenty-five background variables, which is an impressive proportion.

The data described here are cross-sectional, and therefore cannot prove causality. However, the complete absence of a correlation between Avocation/Leisure and BurnedOut strongly suggests that there can be no causal influence, so that on one prediction based on his writing, Osler was wrong; hobbies do not seem to prevent the flame withering if it is likely to do so. However, on the other side, hobbies do seem to be associated with Osler's sense of 'zeal', described here as Vocation/Engagement, and the correlation remains robust even when a wide range of confounders is taken into account. The direction of causality cannot of course be inferred directly, although it would seem unlikely that higher rates of engagement, which might cause an associated increase in workload, would also result in more leisure activities, so that it is more likely that the causal relation is in the opposite direction. Either way, it might be argued that the association is convincing enough to carry out a longitudinal study or, perhaps better still, a randomized controlled trial, encouraging doctors to increase their avocations, with work engagement as the outcome variable.

Osler was somewhat ambiguous about whether he felt particular avocations to be important. Despite recognizing, 'how absorbing is the profession of medicine', Osler nevertheless advised students that they should 'every day do some reading or work apart from our profession'. Osler was undoubtedly a strong believer in reading being of especial importance (and he quotes Seneca who said, 'If you are fond of books you will escape the ennui of life'). Osler's 'Bed-side library for medical students', was unashamedly literary, containing among others, Shakespeare, Montaigne, Plutarch, Epictetus and Don Quixote [106]. He wrote that such reading would enable a student, 'to get the education, if not of a scholar, at least of a gentleman'. Elsewhere Osler is less dogmatic, saying of the particular nature of an avocation, 'I care not what it may be; gardening or farming, literature or history or bibliography...' (although he then does add, 'any one of which will bring you into contact with books'). Nevertheless, the presumption seems to be that what really matters is high culture ('the world of art, of science, or of letters'), an idea reinforced by Sir Geoffrey Keynes in his first Oslerian Lecture [107], where he said, '[Osler] believed that 'culture' ... was of the utmost value to medical men' (and that concept is also found in writers such as C. P. Snow, who said there ought to be 'a literary component through the course of medical education' [108]). That can also be seen when Osler writes, '... it makes precious little difference what the outside interest may be ... [but] I would like to make a plea for the book' [52 p.927]. Factor analysis of our list of leisure activities (as elsewhere [82, 105]) clearly shows a split into what we have called High Culture and Popular Culture (and those two factors also emerged in a much earlier study of medical students by one of us [105]). However, and it is a key interpretative finding, although High Culture shows a slightly higher correlation with Vocation/Engagement than does Popular Culture, both measures show very significant correlations. In analyses not reported here, it was also the case that no particular subset of the 29 activities particularly correlated with Vocation/Engagement (see the last column of Table 1). As far as the beneficial effect of any particular vocation is concerned, Osler was perhaps more right to say, 'I care not what it may be'.

One intriguing result in table 4, is that although five of the six measures of stress/burnout/engagement and satisfaction correlate in very similar ways with the avocation and leisure methods, an exception is that Depersonalization correlates significantly and negatively with High Culture, whereas it correlates significantly and positively with Popular Culture (and, perhaps as a result, the correlation with Avocation/Leisure is much smaller and only just reaches the 0.05 level of significance). Whether these differences are meaningful is not clear, although it is possible that emotional exhaustion and depersonalization are different psychological states, as is suggested by the fact that they may have different causal relations with one another in men and women [109], they can have different correlations with job-related measures [110], and perhaps also have different correlates with personality (for example, EE has been said to correlate mainly with neuroticism, whereas DP correlates mainly with lower extraversion, lower agreeableness and lower openness to experience [111], correlations which, it must be said, are not entirely replicated in the presented data). It is a possibility, though, that popular culture is depersonalizing, treating people as things, whereas high culture encourages the opposite, treating people as individuals. 041b061a72