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References

  1. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377-1385. http://archinte.jamanetwork.com/article.aspx?articleid=1351351 Accessed November 16, 2016.
  2. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600-1613.
  3. Bell RB, Davison M, Sefcik D. A first survey. Measuring burnout in emergency medicine physician assistants. JAAPA. 2002;15:40-42, 45-48, 51-52.
  4. Arora M, Asha S, Chinnappa J, Diwan AD. Review article: burnout in emergency medicine physicians. Emerg Med Australas. 201325:491-495.
  5. Ben-Itzhak S, Dvash J, Maor M, Rosenberg N, Halpern P. Sense of meaning as a predictor of burnout in emergency physicians in Israel: a national survey. Clin Exp Emerg Med. 2015;2:217-225. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5052904/ Accessed November 16, 2016.
  6. United States Census Bureau Quick Facts. http://www.census.gov/quickfacts/table/RHI125215/00 Accessed November 16, 2016.
  7. Association of American Medical Colleges (AAMC), Data and Analysis, Total Graduates by U.S. Medical School and Race and Ethnicity, 2014-2015. http://www.aamc.org/data/facts/enrollmentgraduate/ Accessed November 21, 2016.
  8. Distribution of Medical School Graduates by Race/Ethnicity. The Henry J. Kaiser Family Foundation. 2015. http://kff.org/other/state-indicator/distribution-by-race-ethnicity Accessed November 16, 2016.
  9. Diversity in the Physician Workforce: Facts & Figures 2014. Section II: Current Status of the US Physician Workforce. Association of American Medical Colleges. http://aamcdiversityfactsandfigures.org/section-ii-current-status-of-us-physician-workforce/ Accessed November 16, 2016.
  10. Dyrbye LN, Thomas MR, Eacker A, et al. Race, Ethnicity, and Medical Student Well-being in the United States. Arch Intern Med. 2007;167:2103-2109. http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/413324 Accessed November 16, 2016.
  11. Glymour MM, Saha S, Bigby J, Society of General Internal Medicine Career Satisfaction Study Group. Physician race and ethnicity, professional satisfaction, and work-related stress: results from the Physician Worklife Study. J Natl Med Assoc. 2004;96:1283-1294. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2568518/pdf/jnma00179-0035.pdf Accessed November 16, 2016.
  12. Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013;28:1504-1510. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3797360 Accessed November 16, 2016.
  13. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105:e60-e76.
  14. Oliver MN, Wells KM, Joy-Gaba JA, Hawkins CB, Nosek BA. Do physicians' implicit views of African Americans affect clinical decision making? J Am Board Fam Med. 2014;27:177-188 http://www.jabfm.org/content/27/2/177.long Accessed November 16, 2016.
  15. Kressin NR, Groeneveld PW. Race/Ethnicity and overuse of care: a systematic review. Milbank Q. 2015;93:112-138. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4364433/ Accessed November 16, 2016.
  16. The State of Obesity. Trust for America's Health and the Robert Wood Johnson Foundation. November 2016. http://stateofobesity.org/disparities/ Accessed November 16, 2016.
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Carol Peckham
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Editorial Services
Art Science Code LLC
New York, New York

Disclosure: Carol Peckham has disclosed no relevant financial relationships.

Caption Writer

Sarah Grisham
Freelance writer
Albuquerque, New Mexico

Disclosure: Sarah Grisham has disclosed no relevant financial relationships.

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Medscape Internist Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout

Carol Peckham  |  January 11, 2017

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Slide 1

Much research has gone into studying patient race and ethnicity and their effect on the care received. The recent Medscape Internist Lifestyle Survey asked internists to identify their race and/or ethnicity in order to explore associations with patient care, behavior, and levels of happiness. The survey again posed questions from previous years about burnout, bias, and other lifestyle factors. More than 14,000 physicians from over 30 specialties responded and provided some surprising results.

Note: Values in charts have been rounded and may not match the sums described in the captions.

Slide 2

The 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.[1] Burnout rates for all internist respondents have been trending up since 2013, the first year that Medscape asked about it, when the overall rate was 42%. This year it is 55%. A recent major survey supports these findings, reporting that burnout and satisfaction with work-life balance had worsened between 2011 and 2014, with more than half of physicians reporting burnout.[2]

In this year's Medscape report, the highest percentages of burnout occurred among physicians practicing emergency medicine (59%), followed by ob/gyns (56%) and family physicians, internists, and infectious disease physicians (all at 55%). The top four are all physicians who deal directly with patients with a range of complex problems. In Medscape's 2015 and 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 professions.[1,3-5]

Slide 3

Respondents 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 note, emergency and primary care physicians—groups that are consistently at the top in reporting burnout—did not have the highest rates of burnout severity. Internists rated their burnout severity at 4.3, slightly above the middle of all physicians. Among physicians reporting burnout, urologists had the highest average severity rating (4.6), followed by otolaryngology and oncology (both at 4.5). Surprisingly, infectious disease physicians, who were within the top five for experiencing burnout, had the lowest severity rating (3.9).

Slide 4

Internists 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." Topping the list, with an average rating of 5.5, was "too many bureaucratic tasks," followed by "spending too many hours at work," at 4.9. These two factors ranked highest in the past two surveys as well.

"Feeling like just a cog in a wheel" and electronic health records (EHRs) also rated high as causes of burnout this year (4.7 and 4.5, respectively). 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."

Because "insurance issues," "threat of malpractice," and "family stress" were mentioned frequently as important contributions to burnout in last year's write-in responses to this question, the options were added to our survey. They rated 4.1, 3.8, and 3.2, respectively.

Slide 5

In this year's report, as in prior years', burnout was reported at a higher percentage by female internists (58%) compared with their male peers (52%). Percentages have trended up for both men and women since this question was first asked by Medscape in 2013. That year, 45% of women and 37% of men reported burnout, with higher rates each year since then.

Slide 6

Internist burnout rates were highest this year in the Northeast (60%), Mid-Atlantic (58%), and Northwest regions (57%) and lowest in the Southeast (48%) and North Central (49%) regions. The relatively small degree of variance in incidence underscores that this is a national phenomenon.

Slide 7

Using US Census Bureau criteria,[6] we asked internists about their race/ethnicity. Because such classifications are not necessarily straightforward, respondents could choose more than one option, and 5% did. That being considered, the majority (48.2%) identified as white/Caucasian. Following in prevalence were those reporting Asian ethnicities (25.8%), which includes 12.5% of all respondents identifying as Indian, 4.6% Chinese, and 3.2% other Asian. About 5% of responding internists reported as Hispanic/Latino and 4.3% as black/African American.

A 2015 report based on data from the Association of American Medical Colleges[7] on medical school graduates' racial self-identification, published by the Kaiser Family Foundation, found 7% of respondents choosing multiple races, 58.8% noting white/Caucasian, 19.8% Asian, 5.7% black/African American, and 4.6% Hispanic/Latino.[8]

Slide 8

In this year's Medscape report, the highest percentage of female family physicians were found in Japanese respondents (63%), followed by Vietnamese (58%), and black/African American (57%). The lowest percentage occurred among white/Caucasian (41%) and other Asian (42%) internists.

These results differ from the results in the general physician population, in which female black/African American physicians are the only group that outnumber their male counterparts (63% vs 37%). This finding mirrored a survey by the American Association of Medical Colleges, which concluded that among physicians of all ages, female black/African American physicians were the only non-white group in which there is currently a higher percentage of women than men. Among physicians age 29 and younger, however, there are also more female than male Asians and Hispanics/Latinos. Furthermore, the survey concluded that among black/African American medical school applicants, fully two thirds are female.[9]

Slide 9

This year's report shows some relationship between race/ethnicity and burnout, with the highest rates of burnout in internists who self-identify as Hispanic/Latino (63%), Chinese (59%), and other Asian (58%). The lowest percentages occurred among respondents who defined themselves as Asian Indian (48%) and Japanese or Korean (both at 50%). It should be noted, however, that, except for Asian Indians, half or more of all internists, regardless of race/ethnicity, are burned out.

A 2007 study of all medical students found that 47% experienced burnout, and the rate was lower among non-whites than whites.[10] Notably, however, non-white students who had experienced adverse treatment because of their race had a higher burnout rate than their non-white peers. (There was no difference, however, in the percentages of those who reported that they were depressed.) A study on race and work-related stress found that, in general, non-white physicians faced a more demanding patient base than did their white peers. Nevertheless, Hispanic/Latino and black/African American physicians reported no difference in stress versus their white peers, although Asians and Pacific Islanders reported higher average stress than white physicians.[11]

Slide 10

In this year's Medscape survey, internists were asked if they believed that they had biases toward specific types or groups of patients; nearly half (49%) said that they do. When looking at race/ethnicity, internists who identified themselves as Japanese most frequently reported that they do (75%), followed by Filipino (63%) internists. The lowest percentages following in order were reported among other Asians (29%) and Asian Indian internists (36%).

One limitation of any survey involving race and ethnicity is implicit bias, which occurs without conscious awareness. Implicit bias is frequently at odds with one's reported feelings and beliefs, and it is more likely that attitudes toward whites will be more positive while negative biases are more often found directed towards non-whites.[12,13],

Slide 11

Among internist respondents who admitted biases, emotional problems in patients were cited most frequently by both female and male respondents (53% and 55%, respectively). Heavier weight ranked second among the men at 48% compared with 39% among women. Perceived low intelligence ranked third for both groups (40% of men and 33% of women), followed by language differences (33% of men and 24% of women). Bias toward patients of a different race from the respondent's own was reported by 13% of male and 10% of female internists, and gender bias by only 8% of male and 4% of female internists.

Slide 12

When asked if their bias affects treatment, 18% of internists who admitted bias said that it did. Among racial/ethnic groups, 17% of Korean, 16% of Chinese, and 14% of Filipino internists acknowledged that it does. Respondents least likely to report that their treatment is affected by bias described themselves as other Asian, Hispanic/Latino, or Asian Indian (all 5%). Some research suggests that implicit bias may play a role in treatment.[12] In one study, although implicit bias did not have an effect on treatment recommendations, physicians were more likely to find white patients "cooperative" than black patients and said that this bias could have influenced their decisions.[14]

Slide 13

Eighteen percent of all internists who admitted bias said that it affected their treatment. 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 internists who admitted to negative effects on treatment of patients as a result of bias cited emotional problems (54%) and heavier weight (52%). Over half (51%) acknowledged a negative disposition toward those with language differences. The only bias that over half of respondents said leads to positive treatment is older age (61%). Of note, one analysis of studies on the relationship between patients' race/ethnicity and care found that there was greater overuse of care among white patients though the reasons for this are unclear.[15]

Slide 14

When bias was examined by age group, internists under 45 years of age tended to admit to more biases than their older peers. Of particular note, more younger internists admitted bias toward patients with emotional problems and perceived low intelligence compared with older peers (56% and 49%, and 39% and 30%, respectively). Bias toward overweight patients, in contrast, was reported at about the same rate in younger (44%) and older (43%) internists.

Slide 15

Nearly all Filipino (95%) internist respondents reported that they have spiritual or religious beliefs, followed by 89% of black/African American respondents. The lowest percentages occurred among self-identified Chinese (47%), Vietnamese (62%), and Korean (67%) internists.

Slide 16

Internist respondents were asked if they are socially conservative or liberal. The most liberal internists identified themselves as Japanese (75%) or black/African American (67%). Filipino (36%), other Asian (45%), and Vietnamese (46%) internists were the least likely to identify as liberal. Over half of those in all of the other groups reported being socially liberal.

Slide 17

This year's lifestyle survey, like previous years', asked whether internists are happy at work and outside of work. Respondents were asked to rate their happiness on a scale of 1 to 7, with 1 being "extremely unhappy" and 7 being "extremely happy." Among those who said they are very to extremely happy, there was almost no difference between male and female internists' happiness levels outside of work (54% and 55%, respectively). When looking at happiness at work, however, those percentages were very low for both, with men being happier (30%) than women (25%).

Slide 18

In this year's report, only 28% of internists said they are either very or extremely happy at work. The highest percentages were seen among dermatologists (43%) and ophthalmologists (42%). Dermatologists and ophthalmologists were also the top two happiest at work in the 2016 and 2014 reports. In 2016, however, the percentages for these two specialties were lower (39% and 38%), respectively.

Sixty-three percent of internists reported being very or extremely happy outside of work. At 76%, urologists were at the top of this list, though ophthalmologists and dermatologists also placed high, tied for second place at 74%.

At the bottom of the list, rheumatologists and nephrologists were the least happy, both at work (both 24%) and outside of work (61% and 62%, respectively).

Slide 19

Among this year's internist respondents, 62% of Vietnamese and 61% of Korean internists reported being very to extremely happy outside of work. The lowest percentages occurred among those who described themselves as black/African American (42%), Chinese (49%), and Japanese (50%).

Slide 20

Burnout seems to have a pronounced negative effect on internists' happiness at work. Fifty-four percent of internists with no burnout claimed to be very or extremely happy at work, compared with a dismal 6% of their burned-out peers, a whopping ninefold difference.

Slide 21

The highest percentages of internists reporting happiness at work this year occurred among those who identified themselves as Japanese (50%), Vietnamese (42%), and Asian Indian (37%). At 20%, Filipino, Chinese, and black/African American internists were the least happy.

A 2007 study on the relationship between physician race and stress found that Hispanic/Latino—and, to a lesser degree, black/African American—physicians reported higher work satisfaction levels than their white peers. The study showed significantly lower job satisfaction among Asian physicians than white physicians, but unlike Medscape's survey, it did not break down Asian groups.[11]

Slide 22

Race/ethnicity appears to have some relationship to frequency of exercise among internists. The respondents most likely to exercise at least twice a week identified themselves as white/Caucasian (68%). The lowest percentages were found among respondents who described themselves as black/African American (55%) or other Asian (56%).

Slide 23

Race/ethnicity also appears to have a relationship to internists' weight. The highest percentages of internist respondents who said they are overweight or obese were among self-identified Hispanic/Latino (52%), black/African American (48%), and white/Caucasian (47%) internists. These numbers echo the findings of a 2016 study of all American adults by the Robert Wood Johnson Foundation, although it should be noted that the study did not break out rates among Asian Americans.[16] 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 Vietnamese (23%) internists.

Slide 24

In general, reported alcohol use among internists is low. Respondents who most often indicated that they drink one or more alcoholic beverages per day identified themselves as white/Caucasian (20%). No other ethnic/racial group of internists reported this frequency above 11%.

Slide 25

Unlike most physician groups, female internists fare slightly better than their male counterparts when it comes to savings, according to the Medscape survey. Sixty-one percent of women and 59% of men said they have adequate savings or better, an increase for both from last year (51% of male and 55% of female internists).

Slide 26

In spite of the ongoing income disparity between male and female internists, in this year's report there was almost no difference between groups in the amount of reported debt. Fifty-nine percent of male and female internist respondents said their debt is manageable, and only 9% of women and 8% of men characterized it as unmanageable. Over a quarter of both men and women (29% and 28%, respectively) said they have no debt at all.

Slide 27

In this year's report, a slightly higher percentage of male versus female internists (53% and 49%, respectively) believe their income and assets are sufficient to support their goals. In contrast, 13% of men and 17% of women have no hope that they will ever be sufficient. Thirty-four percent of both men and women say that their income and assets aren't enough right now, but that they expect them to improve.

Slide 28

The highest percentages of respondents who believe that their finances are sufficient to support life goals occurred among those who described themselves as Japanese (75%). They were followed by Filipino (64%) and white/Caucasian (54%) internists. Only 35% of self-identified Vietnamese, 39% of Korean, and 40% of black/African American internists reported sufficient income and assets, although a relatively high percentage of Vietnamese internists (58%) believed the situation would improve.

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