This year's Ophthalmology Lifestyle Report covers two important aspects of a physician's personal life that could affect patient care: 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 charts have been rounded and may not match 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%. Ophthalmologists were the second least burned out among physicians, at 41%. In last year's report, the highest percentages of burnout were in critical care (53%) and emergency medicine (52%). Notably, however, burnout rates for all specialties are higher this year than last, though not among ophthalmologists, who reported a burnout rate identical to this year's (41%) in the 2015 Lifestyle Report. A 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%.^[1]

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, ophthalmologists' rating of 4.2 was tied with three other specialties and was below average among all physicians on severity of burnout. Intensivists had the highest average severity rating, at 4.7. Physicians 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. Last year, ophthalmologists had a severity rating of 4.1, which was slightly lower than this year's rating and ranked about the same among other specialties.

In this year's Medscape lifestyle survey, as in previous years, more female ophthalmologists (54%) expressed burnout than their male peers (35%). These percentages have trended up in general for both male and female physicians since this question was first asked in Medscape's 2013 survey, but ophthalmologists are an exception to that rule. Among male ophthalmologists, burnout has remained relatively steady from 2013 to 2016 (from 35% to 36% in 2015, then back to 35% this year). Burnout decreased in women between 2013 and 2015 (from 64% to 52%), then increased slightly this year to 54%, lower than in 2013.

Ophthalmologists 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 5.0 was too many bureaucratic tasks, followed by increasing computerization at 4.6 and impact of the Affordable Care Act (3.7). This year, the survey added the option "Maintenance of certification requirements," which was in seventh place at 3.3 as a cause of burnout. Among ophthalmologists who commented anecdotally to the question on burnout causes, lack of respect and administrative bureaucracy were frequently cited.

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 that 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%). One third of ophthalmologists, who typically have direct contact with their patients, admitted bias. 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.^[3] 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.^[4] 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 ophthalmologists who admitted biases were asked to characterize them, 65% of them picked emotional problems in their patients as the factor most likely to trigger bias. The next three factors for ophthalmologists were intelligence (49%) and language differences and weight, both at 40%. Weight is often cited in other studies as a concerning physician bias,^[5] When asked to add other patient characteristics that evoke bias, ophthalmologists most frequently cited poor lifestyle choices, such as drug and alcohol abuse, smoking, and overeating; and poor attitudes, including entitlement.

Although 33% of ophthalmologists admitted bias (see slide 6), only 6% said that it affected their treatment, the same percentage reported by neurologists and endocrinologists. Our survey asked physicians two questions on such effects. The first was whether the effects were positive (ie, if their biases resulted in overcompensation and special treatment, such as extra time or a friendlier manner). The second was whether a biased attitude negatively affected treatment (eg, less time, less friendly). Responders could answer yes to both questions. Among all of the physicians who said that bias affected treatment, one quarter believed that their biases resulted in overcompensation and special treatment, whereas 29% admitted that they had only 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. Also among all physicians who said that bias affected treatment, 72% and 61% reported that emotional problems and weight, respectively, had a negative effect on treatment. Weight bias has specifically been observed in a number of studies to elicit negative attitudes, including lack of emotional rapport with obese patients.^[6,7]

In general, the older an ophthalmologist becomes, the lower the likelihood of admitting to bias. Nearly one half (49%) of the youngest ophthalmologists (35 or under) responded that they had biases, which declined to 18% in the oldest group (66 and over). There was a spike in the middle-most age group (46-55), who at 39% reported higher bias than did ophthalmologists age 36-45 (33%).

If one aspect of burnout is depersonalization, then one would expect there to be a relationship with bias. In this survey, ophthalmologists who reported burnout were more likely to also report bias. Thirty-eight percent of ophthalmologists who expressed burnout reported biases, whereas fewer (29%) of non–burned-out ophthalmologists said they had biases.

In this survey, there was little relationship between spiritual belief and bias. About one third (34%) of ophthalmologists who said that they were either spiritual or religious admitted to bias, and 29% of those without such beliefs expressed biases.

There seems to be a slight relationship between ophthalmologist bias and political leaning. About one third of ophthalmologists who defined themselves as socially liberal, regardless of whether they are fiscally liberal (31%) or fiscally conservative (32%), expressed bias. Socially conservative ophthalmologists were more likely to admit bias, whether they were fiscally liberal (54%) or fiscally conservative (35%).

In this year's Medscape survey, typically, the longer a physician resides in the United States, the more biased he or she becomes. Only 23% of ophthalmologists who came to the United States as adults said that they were biased; the highest percentage occurred among those who have lived here since childhood (38%), then decreased to 33% among those who were born in this country.

This year's lifestyle survey, as in previous ones, asked whether physicians were happy outside of work and ranked specialties by those who reported that they were very or extremely happy. Nephrologists and dermatologists were the happiest (68% and 66%) at home this year. At 63%, ophthalmologists are eighth from the top, though they reported the highest levels of happiness outside of work among all physicians in the 2014 survey. As is the case with other physician specialties, ophthalmologists are less likely to report that they are happy this year compared with 2014 (70%). Of note, a major recent survey of US physicians reported a decrease in satisfaction of work/life balance between 2011 and 2014 from 48.5% to 40.9%.^[1]

At 38%, ophthalmologists are second in happiness at work this year (either very or extremely happy at work), but less content than they were in 2014 (46%). Of all physicians who said that they were happy at work in this year's survey, dermatologists were the most content (39%). Dermatologists were happiest at work among physicians in the 2014 Medscape survey, but, as with ophthalmologists, the percentage then was much higher (53%).

Male ophthalmologists report higher happiness levels than do their female counterparts both at home (65% and 56%, respectively) and at work (43% and 27%, respectively). It is interesting to note that, as reported in slide 4, far more female ophthalmologists (54%) expressed burnout than their male peers (35%), which is reflected here.

At 68%, ophthalmologists ranked third highest this year among physicians who exercise twice a week or more. The least active are psychiatrists (43%) and endocrinologists (50%). The only two specialties that ranked higher than ophthalmologists are dermatologists (72%) and orthopedists (69%). It is perhaps not a coincidence that dermatologists and ophthalmologists are the happiest physicians at work.

Among physicians who reported that they were overweight to obese, ophthalmologists, at 28%, ranked second lowest. The physician specialties most likely to report excess weight are pulmonologists (51%), family physicians (49%), and emergency medicine physicians (47%). Of interest, dermatologists (23%) and ophthalmologists reported the lowest levels of overweight, and they also ranked highest in happiness and exercise frequency.

This is the second year that Medscape has included questions on marijuana use. More older ophthalmologists admit to having used marijuana in this year's survey (33% of those age 56-65 and 26% of those over 66) than their younger peers, with only 16% of those under 35 and 11% of those age 36-45 reporting ever having used the drug.

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. At this time, the evidence on marijuana's medical benefits is sparse,^[8] including its potential use in treatment of glaucoma. It's no surprise, then, that 97% of ophthalmologists have not prescribed it. Although marijuana has been cited as having some benefit for glaucoma, no ophthalmologist in this survey indicated they prescribed it for this indication and one commented, "Glaucoma cannot be treated with marijuana."

Men fare better than women in regard to savings and debt among most physicians, according to this year's Medscape survey. However, virtually identical percentages of male and female ophthalmologists reported adequate savings or more and no debt (70% and 69%, respectively) and minimal savings, unmanageable debt, or both (both at 25%).

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, 59% of male ophthalmologists, but only 50% of their female peers, believe that their income and assets are sufficient to meet their needs. Slightly more men (30%) than women (26%) say that their assets aren't enough right now, but they expect them to improve. And significantly fewer male than female ophthalmologists have no hope that they will ever be sufficient (11% and 24%, respectively).