This year's lifestyle report covers two important aspects of a physician's personal life that could affect treatment: burnout and bias. Over 15,800 physicians responded from over 25 specialties, providing some surprising responses relating to these issues. The survey also repeated some of last year's questions on marijuana use and prescribing to determine whether there were any changes in responses, given its legitimacy in more states. (Note: Values in chart have been rounded and may not match the sums described in the captions.)
This year's Medscape survey, echoing other recent national surveys,[1,2] strongly suggests that burnout among US physicians has reached a critical level. Burnout in these surveys is defined as loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. In this year's Medscape report, the highest percentages of burnout occurred in critical care, urology, and emergency medicine, all at 55%. Family medicine and internal medicine follow closely at 54%. In last year's report, the highest percentages of burnout were also in critical care (53%) and emergency medicine (52%). Of note, however, burnout rates for all specialties are higher this year. The 2015 survey published in the Mayo Clinic Proceedings compared burnout between 2011 and 2014 and observed an increase in the percentage of physicians reporting at least one burnout symptom, from 45.5% to 54.4%.
Physicians were asked 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." Of the physicians reporting burnout, critical care had the highest average severity rating at 4.7, whereas those with the lowest burnout ratings were rheumatologists and psychiatrists (3.9). It should be noted, however, that just as the percentages of burnout have increased among all physicians compared with last year's Medscape Lifestyle Report, so have the severity ratings.
In this year's Medscape lifestyle survey, as in previous years, more female physicians (55%) expressed burnout than their male peers (46%). Of note, however, these percentages have trended up for both men and women since this question was first asked in Medscape's 2013 survey. In that year, 45% of women and 37% of men reported burnout.
Physicians were asked to rate causes of burnout on a scale of 1-7, where 1 equals "Does not contribute at all" and 7 equals "Significantly contributes." Top on the list, with an average rating of 4.8, was having too many bureaucratic tasks, followed by too many work hours (4.1) and increasing computerization at 4.0. These were the top three causes last year as well, but the rankings were slightly lower (4.7, 4.0, and 3.7, respectively). This year, the survey added the option "maintenance of certification requirements," which was tied for fifth place with "feeling like a cog in a wheel" as a cause of burnout.
Many physicians commented anecdotally on this question, adding some further factors that contributed to burnout. By far, the most frequently noted were insurance issues. Other often-mentioned causes were threat of malpractice, the change to the 10th edition of the International Classification of Diseases (ICD-10), and lack of patient respect and appreciation. Many physicians also added family stress as a factor.
In this year's Medscape survey, physicians were asked whether they believed that they had biases toward specific types or groups of patients. Overall, 40% of physicians admitted that they did. Within the top 10 of those who said they did indeed perceive that they had some degree of bias were physicians who had the most direct contact with patients: emergency medicine physicians (62%), orthopedists (50%), and psychiatrists (48%), followed by family physicians and ob/gyns (47%). Two of the specialties least likely to report bias were those also least likely to be directly involved with patients: pathologists (10%) and radiologists (22%), Cardiologists were also in the bottom three and reported percentages of bias equivalent to that reported by radiologists.
One limitation in this survey is the issue of implicit bias, which occurs without conscious awareness. It is frequently at odds with one's personal beliefs and can unwittingly perpetuate disparities. In one study, black patients tended to react less positively to physicians with relatively low explicit but relatively high implicit bias than to physicians who were either (1) low in both explicit and implicit bias, or (2) high in both explicit and implicit bias. One physician who responded to this survey commented, "[W]hile my subconscious attitudes and perceptions may be affected, I check these at the door and do my best to be empathic no matter what."
When physicians who admitted biases were asked to characterize them, 62% of both women and men picked emotional problems in their patients as the patient factor mostly likely to trigger bias. Weight, which is often cited in other studies as a concerning physician bias, came in second, with more men (56%) than women (48%) reporting bias related to weight. For most other bias characteristics, percentages were similar between men and women, although some differences were observed for insurance coverage (19% of women vs 26% of men) and income level (8% of women and 17% of men). Of interest, very few male and female physicians admitted to gender bias (8% and 7%, respectively).
When asked about other patient characteristics that evoke bias, physicians most frequently cited drug-seeking and abuse. Also mentioned very frequently were malingering, entitled, and noncompliant patients. Of interest, patients with chronic pain also evoked bias in many physicians.
Small percentages of physicians indicated that bias actually affected their treatment. As one would expect, bias does not influence treatment for specialists who rarely see patients (pathology at 1% and radiology at 2%). Of interest, however, the percentages of physicians who reported a bias effect on patient care was also low in oncologists, cardiologists, and critical care (all 4%). The specialists with the highest percentages of bias effect on treatment are emergency medicine physicians (14%) and plastic surgeons (12%). Other physicians who were over 10% were orthopedists, family physicians, psychiatrists, and rheumatologists (all 11%).
Twenty percent of physicians who admitted bias said that it affected their treatment-though not necessarily in a negative direction, because many physicians reported that their own bias led to positive effects. Our survey asked physicians two questions on the effects of their biases: whether they resulted in overcompensation and special treatment (eg, extra time, friendlier manner), or whether they negatively affected treatment (eg, spending less time or being less friendly). Responders could answer "yes" to both questions. Of those who said that bias affected treatment, one quarter believed that their biases resulted in overcompensation and special treatment, whereas 29% admitted that they had a negative effect on treatment. Twenty-four percent believed that their biases could have both effects, and another 22% suggested that neither choice was applicable.
The specific biases that garnered the largest responses from physicians were emotional problems, weight, and intelligence; however, for these and all categories, slightly more physicians reported that they overcompensate and give such patients special treatment rather than treat them negatively. Nevertheless, 72% and 61% of physicians reported that emotional problems and weight, respectively, had a negative effect on treatment. Weight bias has specifically been observed in many studies to elicit negative attitudes, including lack of emotional rapport with obese patients.[6,7]
When treatment effects of bias are examined by age group, over one half of physicians older than 46 years reported that biases affect treatment negatively (less time, less friendly), compared with less than one half saying that they result in overcompensation and giving patients special treatment. Among those aged 45 years or younger, the reverse holds: Over one half report that their biases result in more positive treatment, compared with fewer whose biases result in negative approaches.
If one aspect of burnout is depersonalization, then one would expect there to be a relationship with bias. In this survey, physicians who reported burnout were more likely to also report bias. Forty-three percent of physicians who expressed burnout reported that they also experienced bias; in contrast, just over one third (36%) of non-burned out physicians reported bias.
This year's lifestyle survey, as in previous ones, asked whether physicians were happy at home or at work. Of physicians who said they were either very or extremely happy at work, dermatologists and ophthalmologists were the most content-though it is notable that only one third of even these physicians (39% and 38%, respectively) reported happiness at work. Dermatologists and ophthalmologists were also the happiest at work in the 2014 Medscape survey, but the percentages were much higher (53% and 46%, respectively). The least happy at work this year were internists (24%) and intensivists (25%), percentages that reflect the combined group of physicians reporting they were very or extremely happy at work. The least happy at work in 2014 were family and emergency medicine physicians (36%), followed by internists (37%), which are still higher percentages than those reported by nearly all physicians this year, including those toward the top of the scale.
At 68% nephrologists were the happiest at home, followed by dermatologists (66%) and pulmonologists (65%). Dermatologists, were the happiest at home of all specialties in the 2014 survey (70%) and this 2016 report documents a small though notable decrease which was mirrored in results for almost all physician specialties. Of note, a major recent survey of US physicians reported a decrease in satisfaction with work/life balance between 2011 and 2014 from 48.5% to 40.9%.
Male and female physicians report the same happiness levels at home (60% and 59%, respectively), but at work, only 26% of all women are happy compared with one third of men. As reported in slide 4, more women than men also report burnout (55% vs 46%), which could certainly contribute to the happiness disparity.
The most active physicians (those who exercise at least twice a week) are dermatologists (72%), orthopedists (69%), and ophthalmologists (68%). It is perhaps not a coincidence that dermatologists and ophthalmologists are also the happiest physicians at work. The least active are psychiatrists (43%) and endocrinologists (50%).
When looking at physicians who reported they were overweight to obese, of interest, dermatologists and ophthalmologists reported the lowest rates of overweight (23% and 28%, respectively), and they also had the highest happiness and exercise percentages. The heaviest physicians are pulmonologists (51%), family physicians (49%), and emergency medicine physicians (47%).
This is the second year that Medscape has included questions on marijuana use. Both this year and last, one quarter of physicians claimed to have ever smoked marijuana. No differences in use were observed between 2015 and 2016 among any age groups, with the heaviest use being among physicians aged 56-65 years (about one third).
Given the increase in the number of states where marijuana has been legalized for medical use, we asked physicians in our survey whether they are now prescribing it. As one would expect, the highest percentages were in the Northwest (10%), West (8%), and Southwest (7%), although all of these percentages were quite low.
In this survey, physicians who prescribed marijuana most often did so for pain management (61%). Seventeen percent of physicians prescribed marijuana for multiple sclerosis, 10% for glaucoma, and 7% for inflammatory bowel disease, conditions for which there is some evidence of benefit. A recent JAMA review on the benefits of medical marijuana found high-quality evidence supporting its use for chronic and neuropathic pain and for spasticity in multiple sclerosis. Some physicians also prescribed marijuana for conditions that are more common, but for which the evidence of efficacy is much weaker (10% for insomnia, 12% for mood disorders, and 14% for drug-related adverse effects). Forty-three percent also chose "other."
Many wrote in a number of situations for which they prescribed marijuana that were not listed in the survey instrument, notably as an appetite stimulant for patients with anorexia, HIV, and cancer. It was also frequently prescribed for nausea and seizures.
Men fare slightly better than women in their savings and debts, according to the Medscape survey. Sixty-three percent of male vs 58% of female physicians have adequate savings or more, and no debt. Thirty-seven percent of female and one third of male physicians report minimal savings, unmanageable debt, or both.
In a 2015 Medscape survey on debt and net worth, 61% of physicians responded that they live within their means and have little debt, and 24% even live below their means. Nevertheless in this survey, only 52% of male physicians and 47% of their female peers believe their income and assets are sufficient to meet their needs. About one third of both men and women (33% and 35%, respectively) say that their assets aren't enough right now, but they expect them to improve; 15% of men and 19% of women have no hope they will ever be sufficient.