This year's Pulmonary Medicine 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%. Pulmonologists are fifth from last at 43%. In last year's report, the highest percentages of burnout were in critical care (53%) and emergency medicine (52%). Although burnout rates for most physicians are higher this year than last, pulmonologists reported a burnout rate of 47% 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, pulmonologists at 4.3 are tied with four other specialties and are roughly in about the middle of 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 most physicians compared with last year's Medscape Lifestyle Report, so have the severity ratings. Last year, pulmonologists had a severity rating of 4.0, which was lower than this year's rating.

In this year's Medscape lifestyle survey, as in previous years, more female pulmonologists (51%) expressed burnout than their male peers (42%). Among all physicians these percentages have trended up for both male and female physicians since this question was first asked in Medscape's 2013 survey. Among pulmonologists, however, while burnout increased among men between 2013, 2015, and 2016 (38%, 46%, and 42%, respectively), it decreased in women (63%, 50%, and 51%).

Pulmonologists 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 having too many bureaucratic tasks, followed by increasing computerization (4.5) and too many work hours (4.4). This year, the survey added the option "Maintenance of certification requirements," which was in fourth place at 4.0 as a cause of burnout.

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%). Twenty-nine percent of pulmonologists, 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 pulmonologists who admitted biases were asked to characterize them, 63% of them picked emotional problems in their patients as the patient factor most likely to trigger bias. Weight, which is often cited in other studies as a concerning physician bias,^[5] came in second at 46%. The other common bias was intelligence (40%.) When asked to add other patient characteristics that evoke bias, pulmonologists most frequently cited drug seeking and abuse and chronic pain.

While 29% of pulmonologists admitted bias (see slide 6), only 5% said that it affected their treatment, which tied with three other specialties. 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]

When looking at bias by age group, there is almost no difference between any age group. About 30% of pulmonologists at any age express bias. Slightly fewer pulmonologists (26%) between the ages of 56 and 65 years admit to bias.

If one aspect of burnout is depersonalization, then one would expect there to be a relationship with bias. In this survey, pulmonologists who reported burnout were slightly more likely to also report bias. One third of pulmonologists who expressed burnout reported biases, whereas fewer (26%) of non–burned-out pulmonologists said that they had biases.

In this survey, there was a slight relationship between spiritual belief and bias. Twenty-seven percent of pulmonologists who said that they were either spiritual or religious admitted to bias, and 35% of those without such beliefs expressed biases.

There seems to be a slight relationship between pulmonologist bias and political leaning. Only 8% of pulmonologists who defined themselves as fiscally liberal/socially conservative admitted to bias, compared with one third of those who are socially liberal, regardless of fiscal stance, and 36% of those who were both fiscally and socially conservative.

This survey suggests that the longer one resides in the United States, the more biased one becomes. Only 22% of pulmonologists who came to the United States as adults said that they were biased compared with 27% of those who have lived here since childhood and 34% of those who were born in this country.

This year's lifestyle survey, as in previous ones, asked whether physicians were happy at home and ranked specialties by those who reported that they were very or extremely happy outside of work. Nephrologists and dermatologists were the happiest (68% and 66%) at home this year. At 65%, pulmonologists are third from the top; in the 2014 survey, they ranked toward the bottom in happiness at home. Unlike most other physician specialties, pulmonologists are happier this year compared with 2014 (60%). 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 33%, pulmonologists were fifth from the top in happiness at work (either very or extremely happy at work) but far less content than they were in 2014 (49%). Of all physicians who said that they were happy at work, dermatologists and ophthalmologists were the most content (39% and 38%, respectively). Dermatologists and ophthalmologists were also the happiest at work in the 2014 Medscape survey, but, as with pulmonologists, the percentages then were much higher (53% and 46%, respectively).

Male and female pulmonologists report about the same happiness levels at home (65% and 67%, respectively), but men are happier at work (35% and 24%, respectively). It is interesting to note that, as reported in Slide 4, more female pulmonologists (51%) expressed burnout than their male peers (42%), which is reflected here when ranking happiness levels.

At 62%, pulmonologists are tied with plastic surgeons, both of whom ranked toward the middle of the scale among physicians who exercise twice a week or more. The least active are psychiatrists (43%) and endocrinologists (50%). 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.

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

This is the second year that Medscape has included questions on marijuana use. Far more pulmonologists in the 56-65 years age group (38%) admit to having used marijuana than in the other age groups reported in this survey. Only 10% of pulmonologists between the ages of 36 and 45 years admit to use.

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] It's no surprise, then, that 97% of pulmonologists have not prescribed it.

Like most physicians, male pulmonologists fare better than their female peers in their savings and debt, according to the Medscape survey. Sixty-eight percent of male vs 53% of female pulmonologists have adequate savings or more and no debt. Forty-two percent of female and 29% of male pulmonologists 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, 55% of male pulmonologists but only 31% of their female peers believe that their income and assets are sufficient to meet their needs. More women (38%) than men (32%) say that their assets aren't enough right now, but they expect them to improve; only 13% of male but nearly a third (31%) of female pulmonologists have no hope that they will ever be sufficient.