Introduction: Physician Burnout, Bias, and Race/Ethnicity This year we published the sixth annual Medscape Lifestyle Report, a major survey of physicians asking about their health and happiness in relation to a range of other factors. This year, as in previous reports, we examined the current state of physician burnout and bias, and how they might influence physician attitude and behavior. And, for the first time, the Medscape survey asked more than 14,000 physicians from over 30 specialties how they describe their own race or ethnicity in order to identify associations, if any, with the responses to other questions. The Medscape survey used race and ethnicity criteria set by the US Census Bureau.[1] This is a subjective question, and ethnicity and race are not straightforward, so respondents were allowed to choose more than one option, which 5% did. Given such limitations, the answers still provide some insight into how physicians might view themselves. In the survey, the majority (68.6%) of physicians reported that they are white/Caucasian. The next most prevalent racial group was Asian (19.1%), although ethnicities within this group varied, with Asian Indians being the most represented (8.3%).Only 5.2% of physicians reported as Hispanic/Latino and 3.6% as black/African American. Data from the Association of American Medical Colleges (AAMC)[2] on US medical school enrollment between the 2013-2014 and 2016-2017 school years found very little change in the percentages of the major racial groups over this period of time. In the AAMC report, 53% of graduates were white (declining slightly over 5 years from 56%). About 20% of graduates were Asian, 7% were black/African American, and 6% Hispanic/Latino. The proportion of black/African American and Hispanic/Latino physicians within the entire physician population does not necessarily reflect the overall proportion of these ethnicities within the general population. Only about 9% of all US physicians identify as black/African American, American Indian or Alaska Native, or Hispanic/Latino, according to the AAMC data.[3] Although black/African American citizens make up about 13% of the US population, they account for only 4% of the US physician workforce. A 2007 study suggested that major barriers to increasing the number of black/African American physicians include financial constraints, lack of role models and exposure to medicine as a career, little encouragement either at home or in school, and negative peer pressure.[4] Physician Race/Ethnicity and Gender According to this year's Medscape report, black/African American physicians include the highest percentage of women (67%), while the lowest percentage is among whites/Caucasians (36%). This result is generally supported by the AAMC, which has found a steady increase in women among black/African American physicians over time, with women currently representing about two thirds of black/African American medical school applicants. AAMC reports this same trend for all younger non-white physicians (those under 29 years), with women now outnumbering men 52% to 48%.[3] Among Asian physician subgroups responding to Medscape's survey, the only group with more women than men is Filipino physicians (56% to 44%). These findings are also supported by the AAMC,[3] which reported men outnumbering women among all Asian ethnic groups except for Filipino physicians. Physician Burnout The current Medscape survey once again asked about burnout among US physicians, which is defined in this and other major studies as a loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.[2016 reports, emergency medicine physicians, family physicians, and internists were also within the top five. Not surprisingly, other research has found high burnout rates in these three specialties.[In last year's report burnout rates were the same in women (55%) and nearly the same in men (46%). Causes of Burnout Physicians were asked to rate causes of their burnout on a scale of 1 to 7, where 1 equals "Does not contribute at all" and 7 equals "Significantly contributes." The burden of bureaucracy. Topping the list, with an average rating of 5.3, was "too many bureaucratic tasks," followed by "spending too many hours at work," at 4.7. These two factors ranked highest among both men and women and were also highest in the past two surveys as well. And the ratings for these factors as important causes of burnout have been trending up. When this question was asked for the 2015 report, those factors were rated 4.7 and 4.0, respectively. "Feeling like just a cog in a wheel" and electronic health records (EHRs) also rated high this year (4.6 and 4.5, respectively) as causes of burnout. In an October 2016 Medscape roundtable discussing EHRs and burnout, one of the panelists, Robert W. Brenner, MD, said, "If [EHR requirements are] implemented without a change in the workflow in the office, too much data entry falls on the physician. That is what is adding to the huge burden." Authors of a 2016 report in the Journal of Family Medicine went further[STEPS Forward, which is intended to significantly reduce burnout by re-engineering workflow to remove unnecessary tasks and to find other ways of performing needed ones.[12] Emotional issues. Initiatives to address emotional issues involved with burnout may also be important. One interesting study reported two significant factors leading to burnout in emergency medicine physicians: worry and a lack of existential meaning derived from work.[13] A 2016 systematic review in The Lancet identified a number of effective interventions that included not only organizational changes, such as limiting duty hours and changes in care delivery processes, but also mindfulness, stress management, and small group sessions as well.[14] This year's Medscape Lifestyle Report found a pronounced negative effect of burnout on physicians' happiness both at work and outside the workplace. The survey, as in previous years, asked respondents to rate their happiness on a scale of 1 to 7, with 1 being "extremely unhappy" and 7 being "extremely happy. While well over half (59%) of physicians with no burnout claimed to be very or extremely happy at work, only 7% of their burned-out peers reported the same, a nearly eightfold difference. Burnout also affected happiness outside of work, with nearly three quarters (74%) of non-burned-out versus slightly less than half (48%) of burned-out physicians reporting being very or extremely happy outside the workplace. When stratified by specialty, the same dichotomy applied, with very few burned-out physicians in any specialty (range, 2%-13%) claiming to be very to extremely happy at work (Figure 2). The range for those who were not burned out was 45%-69%. The highest percentage of physicians reporting being happy and not burned out was seen in dermatologists (69%), who also were the second happiest group (12%) among those reporting burnout. The highest percentage of burned-out physicians who reported that they were happy at work was found in intensivists, but it was only 13%. They were third from the bottom in happiness scores among their non-burned-out peers (48%). Figure 2. Physician burnout and happiness at work. Debt and burnout. The current survey did find some association between burnout and levels of debt (Figure 3). About a quarter (24%) of burned-out physicians were debt-free compared with 32% who are not burned out. For 12% of burned-out physicians, this debt was described as unmanageable, compared with only 5% of their non-burned-out peers. Although association is not causation, a 2011 study of internal medicine residents also found burnout to be associated with higher debt, and as the debt load increased, so did emotional exhaustion and depersonalization, key factors in burnout.[15] Burnout Severity Medscape also asked physicians to rate the severity of their burnout on a scale of 1 to 7, where 1 equals "It does not interfere with my life" and 7 equals "It is so severe that I am thinking of leaving medicine altogether." Among physicians reporting burnout, urologists had the highest average severity rating (4.6), followed by oncologists (4.5) and pathologists and cardiologists (both at 4.4).When compared with last year's findings, burnout severity remained fairly flat or declined for the majority of specialties (Figure 4). Burnout severity between 2016 and 2017. The Consequences of Burnout A 2016 meta-analysis[16] found that greater burnout among healthcare providers was associated with poorer healthcare and decreased patient safety. Other studies have also reported this association, but this paper was the first to systematically and quantitatively analyze the links between healthcare provider burnout and quality and safety across disciplines. Commenting on the study, Chris Ebberwein, PhD (University of Kansas School of Medicine), who specializes in healthcare provider burnout, said, "By confirming that burnout has a system impact, it might motivate decision makers in healthcare to redouble their efforts toward system solutions."[17] Physician Bias In response to questions about bias in the current Medscape survey, fully half of physicians reported that they had biases toward specific types or groups of patients. It should be pointed out that one limitation of the Medscape survey is the issue of implicit bias, which occurs without conscious awareness. Frequently at odds with one's personal beliefs, implicit bias can unwittingly perpetuate disparities and is more likely to be positive toward whites and negative toward non-whites,[18,19] A 2012 study of primary care physicians used a computer-based tool to assess implicit bias.[20,21] While no overt bias was detected, physicians had a moderate implicit bias toward blacks, associating their white patients with greater compliance. Bias and Gender When physicians who admitted biases were asked to characterize them, there were no great differences between genders, except perhaps in regard to bias toward patients with heavier weight. More than half (51%) of male physicians, compared with 42% of female physicians, cited overweight as a patient factor that elicited bias. Emotional problems in patients was the most frequently cited bias-eliciting characteristic among female respondents (51%) and was nearly matched among their male counterparts (50%). Perceived low intelligence ranked third as a bias trigger for both genders (40% of men and 38% of women), followed by language differences (28% of men and 26% of women). Nearly a quarter of men (21%) but a smaller percentage of women (15%) reported bias toward patients who lack insurance. Ten percent of male and 9% of female physicians expressed bias toward patients of race different from their own, and only 4% of female and 5% of male physicians reported bias toward patients of a different gender. Bias and Race/Ethnicity Just over half of black/African American physicians (56%) admitted to bias, compared with a slightly lower 53% of white/Caucasian and 52% of Hispanic/Latino physicians. A higher percentage of physicians who identified themselves as Korean or Vietnamese reported that they had biases (63% and 60%, respectively). The lowest percentages occurred among Asian Indians and other Asians (34% and 41%, respectively). In a study of primary care physicians on implicit bias, 48% of participants were white, 22% were black, and 30% were Asian. White and Asian physicians tended to be more positive in their interactions with white patients, while black professionals were mostly neutral.[21] Effect of Bias on Treatment The Medscape survey also asked whether biases affected treatment—positively, negatively, or both. Only 16% of all physicians who admitted having bias said that it did. Our survey asked that group whether the effect of their bias was positive (eg, extra time spent, friendlier manner) or negative (eg, less time spent, less friendly manner), and respondents could answer "yes" to both questions. The highest percentages of physicians who admitted to negative effects on treatment of patients as a result of bias cited language differences (61%) and emotional problems (58%). Half acknowledged a negative disposition toward those who are overweight, 49% toward those who they perceived to have low intelligence, and 45% toward those who lack insurance. The only bias that about half of respondents said leads to positive treatment is older age. In spite of the relatively low percentage of physicians who said that their biases affect treatment, evidence does suggest that bias can affect attitude and, by extension, care. In one study, although implicit bias did not have a direct effect on treatment recommendations, physicians were more likely to find white patients "cooperative" than black patients, which could have influenced their decisions.[22] A 2012 study[21] of primary care physicians suggested that implicit bias was linked to the way physicians communicated with their patients. Office visits for black patients were 20% longer and with a slower-paced dialogue, while white patients had visits that were 20% shorter and with faster dialogue. An analysis of studies on the relationship between patients' race/ethnicity and care found that there was greater overuse of care among white patients.[23] A 2015 study of surgeons did not find an association with clinical decision-making in spite of unconscious social class and race biases, although the authors advised further studies on real physician-patient interactions.[24] Other Lifestyle Factors and Race/Ethnicity Race/Ethnicity and Spiritual or Religious Belief? Nearly all Filipino (91%) and black/African American (88%) respondents reported that they have spiritual or religious beliefs, followed by Hispanic/Latino respondents (79%). The lowest percentages occurred among self-identified Chinese (48%), Japanese (51%), and Vietnamese (61%) respondents. Race/Ethnicity and Political Leaning. Respondents were asked whether they are socially conservative or liberal. The most liberal physicians identified themselves as Japanese (69%) or black/African American (68%). Filipino (46%) or other Asian (49%) physicians were the least likely to identify as liberal though still only about half identified as conservative. About 60% of all of the other groups reported being socially liberal. Race/Ethnicity and Healthy Exercise (at Least Twice a Week) Race/ethnicity does not appear to have any strong relationship to frequency of exercise among physicians. The respondents most likely to exercise at least twice a week identified themselves as white/Caucasian (69%) or Japanese (67%). The lowest percentages were found among respondents who described themselves as other Asian (58%) and Korean or black/African American (both at 59%). Race/Ethnicity and Weight Race does appear to have a relationship to weight. In a 2016 study of all American adults by the Robert Wood Johnson Foundation, 47.8% of blacks, 42.5% of Latinos, and 32.6% of whites were obese.[25] The highest percentages of physician respondents in the Medscape survey who said that they are overweight or obese followed suit: black/African American (52%), Hispanic/Latino (49%), and white/Caucasian (44%). When looking at rates of obesity alone, however, these physicians do better than their patients. Only 16% of black/African American, 12% of Hispanic/Latino, and 9% of white/Caucasian physicians are obese (Figure 5). In the Medscape survey, self-described Asian respondents were the least likely to report that they are overweight or obese, with the lowest percentages seen in physicians who reported as Vietnamese (17% and 4%, respectively) and Chinese (26% and 3%). (The Robert Wood Johnson study did not break out rates among Asian Americans.) Figure 5. Percentage overweight and obese by race/ethnicity. Race/Ethnicity and Alcohol Use (At Least One Drink per Day) In general, reported alcohol use among physicians is low. Respondents who most often indicated that they drink one or more alcoholic beverages per day identified themselves as white/Caucasian (22%). Japanese and Korean physicians followed at 17% and 15%, respectively. Physicians who described themselves as other Asian or Filipino were least likely to report alcohol use, at 8%. Race/Ethnicity and Sufficient Income and Assets The highest percentages of respondents who believe that their finances are sufficient to support life goals described themselves as Japanese (72%). They were followed by white/Caucasian (59%), Filipino (57%), and Chinese (54%) physicians. Only 43% of self-identified Korean and 46% of black/African American respondents reported sufficient income and assets, although a relatively high percentage of the latter group (42%) believed that the situation would improve. Summary In this year's Medscape Lifestyle Report, we found some interesting observations, ones we will look forward to re-examining in 2017. The Gender Difference Among Non-white Physicians Although white/Caucasian males continue to greatly outnumber their female peers in the field of medicine, this is not the case among black/African Americans, where two thirds of physicians are women. And although in most Asian subgroups men still are the dominant gender, this is shifting, according to the AAMC, with non-white women outnumbering men among young physicians by 53% to 48%.[2] The Current State of Burnout Burnout continues to be a serious threat to physician well-being and, therefore, to patient care. Over half of physicians (51%) suffer from this condition, up from 40% in 2013, the first year that Medscape surveyed the issue. Burnout rates among racial or ethnic groups were reported within a tight range (46% to 56%), underscoring that this is a phenomenon that affects all physicians. Looking at the major groups, black/African American and Hispanic/Latino physicians report only slightly lower burnout percentages (48% and 51%, respectively) than their white/Caucasian peers (52%). This year's report shows a pronounced association between burnout and physicians' happiness at work and outside of work. On average, 59% of physicians with no burnout claimed to be very or extremely happy at work, compared with a dismal 7% of their burned-out peers, more than an eightfold difference. This relationship continued when they left work, with nearly three quarters (74%) of non-burned-out versus 48% of burned-out physicians reporting being very or extremely happy outside the workplace. Some association was observed between burnout and debt. Less than a quarter (24%) of burned-out physicians were debt-free compared with about a third (32%) of their non-burned-out peers. And of those who had debt, 12% of burned-out physicians described it as unmanageable compared with only 5% of their non-burned-out colleagues. Source
