After-hours electronic health record work was associated with burnout, lower satisfaction and lower examination scores in a national survey of upper-year U.S. family medicine residents. The study gives residency programs a strong reason to examine documentation burden, but it does not show that electronic records caused those outcomes.
Researchers surveyed residents after the 2024 American Board of Family Medicine In-Training Examination. Of 9,653 residents answering the EHR questions, 3,124, or 32.3%, reported spending an average of at least three hours per day on ambulatory records after usual work hours. The study called that threshold high "pajama time."
The Study Measured Association
The analysis was cross-sectional: EHR exposure, burnout screening, satisfaction and examination performance were assessed in the same survey period. Researchers used regression models to adjust for measured resident characteristics, but the design cannot determine whether after-hours records caused burnout or lower scores.
Other explanations may contribute. Residents with heavier clinic loads, more complex patients or less efficient support may both spend more time in the record and report worse outcomes. Burnout itself could also make documentation slower. The study identifies a pattern that deserves intervention and prospective testing, not a proven one-way mechanism.
The Burnout Signal Was Substantial
Residents in the high-pajama-time group had 1.61 times the adjusted odds of meeting the study's two-item burnout-screen threshold compared with residents reporting less after-hours EHR use. The confidence interval ran from 1.46 to 1.78.
That is an odds ratio, not a claim that every resident working late will burn out. The screen also measured emotional exhaustion or depersonalization occurring at least weekly; it was not a full clinical psychiatric diagnosis. Those distinctions keep a strong association from becoming an individual prognosis.
Training Outcomes Moved in the Same Direction
High after-hours EHR use was associated with 1.28 times the adjusted odds of a lower examination score. It was also associated with lower odds of professional satisfaction and training-program satisfaction, with adjusted odds ratios of 0.61 and 0.62 respectively.
The alignment matters because it moves the issue beyond general dislike of software. Time spent finishing records may compete with study, reflection and recovery. But the survey did not directly measure which activity was displaced or prove that reducing EHR time would improve examination performance.
The Burden Was Not Evenly Reported
High pajama time was reported more often by older residents, women, international medical graduates and residents from groups underrepresented in medicine. Third-year residents and those spending more time in clinic also reported more after-hours work.
Those differences should trigger workflow review rather than assumptions about individual efficiency. Programs need to examine patient volume, inbox allocation, documentation expectations, supervision and support before deciding that the answer is simply to train residents to click faster.
The Study Did Not Measure Suicide or Patient Harm
Suicide risk was not an outcome in this study. Neither were medication errors, missed diagnoses, adverse events or other direct measures of patient safety. Connecting the survey to those outcomes without separate evidence would turn a burnout association into a clinical claim the researchers did not test.
Fatigue and documentation burden can reasonably concern training leaders, but concern is not the same as measured harm. The immediate evidence is specific: high after-hours EHR use tracked with the burnout screen, satisfaction measures and examination scores in this resident population.
Programs Need a Workload Test, Not a Wellness Slogan
The authors called for strategies at both system and learner levels. That can include measuring after-hours use, reviewing templates, redistributing inbox work and testing whether support changes the documented burden. Any intervention should be judged by actual time saved and resident outcomes.
Ambient tools, scribes or automation may help, but this study did not test them. A new layer of software is not a solution if residents must spend the same evening correcting its output. The relevant measure is whether the workday truly becomes shorter without weakening the record.
Documentation Is a Training Design Choice
Residency will remain demanding. The hard question is how much of that demand teaches clinical judgment and how much comes from preventable workflow. When nearly one-third of a national upper-year family medicine cohort reports three or more hours of daily after-hours EHR work, programs cannot dismiss the pattern as a few slow users.
The study does not prove that electronic paperwork causes burnout, failed learning or patient harm. It does show that heavy after-hours use travels with worse resident outcomes. Health systems should now test whether removing low-value work changes those outcomes. Until they do, resilience training risks becoming a way to ask young doctors to adapt to a workload their institutions have not seriously tried to reduce.