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' . 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.
Although Osler talks of 'zeal' (work engagement) and 'the smothering of the flame' (burnout), and implies that they are opposite ends of a single continuum, current research suggests that is not the case. Vocation, which makes medical practice less a job and more an all-consuming passion, is in modern terms 'work engagement', a positive state of work-related well-being characterized by vigor, dedication and absorption ; the result is that engaged employees not only have the capacity to be energetic, they enthusiastically apply that energy to their work. They do not hold back. They do not keep their energy in reserve for something important; they become absorbed in their work, experiencing flow in which they lose track of time and diminish their response to distractions . As suggested earlier, the crucial point here is that engagement is seen as the polar opposite of burnout, and some studies have suggested that [98–100]. However, more recent studies have suggested that burnout and engagement are independent constructs [1, 101], each having a unique relationship with important factors such as working hours, job characteristics, work outcomes, quality of social relationships, and perceived health . The present study supports that position, not only finding a relatively weak correlation between burnout and engagement, but also finding very different patterns of correlation with other variables, in particular personality, burnout being related to neuroticism (as has been reported in another study elsewhere ), and work engagement to extraversion and conscientiousness. As a result doctors can have low levels of work engagement despite not being burnt out. One possible explanation for such a situation might be if a doctor's energy and enthusiasm were focussed outside work, so that work engagement might suffer. However, Sonnentag and colleagues, studying employees in five different industries, found a beneficial effect of disengaging from work when at home . Whether that is true of all individuals is far from clear, and the precise causal relationship between avocations and vocations requires further work.
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.
Our study also says much about the three main sets of variables: leisure activities, burnout and engagement. Leisure activities in particular have rarely been studied in large cohorts of individuals (although an early attempt was carried out by one of the authors ). Leisure activities themselves vary strongly, and it is no surprise to any parent that those with younger children report fewer leisure activities. The strongest correlates of leisure activities we found were with the personality trait of Openness to Experience, and the dimension of empathy known as Fantasy. Interestingly, neither shows a strong relationship to Vocation/Engagement or to BurnedOut, suggesting different underlying processes in their determination. Perhaps of particular importance from the present perspective is that measures related to work, with occasional minor exceptions, show almost no relationships to leisure activities. That suggests that leisure activities are driven to a large extent from within (by personality and by sex), and by the family environment.
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 . 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 , 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' ). 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 ). 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 , they can have different correlations with job-related measures , 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 , 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.
Further investigations are needed to identify the mechanisms or processes by which Avocations/Leisure activities relate to higher levels of Vocation/Engagement. One possibility is that leisure activities, like all cultural activities, vicariously increase a person's knowledge of the world, be it the physical world and its geography and environment, the social world, with its historical and geographical differences, or the interpersonal world, with its complex emotional interactions between people with different needs [47, 112]. Avocations, in other words, increase cultural capital, and that capital can then be used to advantage within the professional engagements of a medical career. An alternative possibility is that leisure activities result in positive mood states  precisely because it is the person himself or herself who has chosen those activities, and they are under personal control (and then the particular avocation itself would matter little). To finish with Osler's words, it may be precisely the 'selection and the choice' which are important, a selection and choice which are entirely under the control of the doctor and the doctor alone, and hence 'will be ... according to [the doctor's] tastes'.