Much research has gone into studying patient race and ethnicity and their effect on the care received. Medscape's Neurologist Lifestyle Survey asked neurologists how they racially and ethnically self-identify in order to explore associations with patient care, personal choices, and levels of happiness. The survey also posed questions from previous years about burnout, bias, and other lifestyle factors. More than 14,000 physicians from over 27 specialties responded and provided some surprising results.

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

The Medscape survey once again asked physicians about burnout, 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 respondents have been trending up since 2013, the first year that Medscape examined them, when the overall rate was 40%. This year, it is 51%, more than a 25% increase over just 4 years. The results of another recent, major survey support this unfortunate trend, finding that burnout had worsened between 2011 and 2014, with more than half of physicians reporting it.^[2]

In this year's Medscape report, 51% of neurologists reported burnout, slightly above the middle among all physicians. The highest percentage occurred among those practicing emergency medicine (59%), followed by ob/gyns (56%) and family physicians, internists, and infectious disease physicians, all at 55%. These groups all deal directly with patients, often in exigent circumstances. Emergency medicine physicians, family physicians, and internists ranked in the top five in Medscape's 2015 and 2016 reports as well. Not surprisingly, other research has found high burnout rates in these groups.^[3-6]

Neurologists 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 neurologists who reported burnout, the average severity rating was 4.0, fourth lowest (before rounding) among all physicians.

Of note, although relatively high percentages of emergency and family physicians said that they experienced burnout, their average severity ratings fell below the middle, at 4.2. Urologists' rating was the highest, at 4.6, followed by otolaryngologists' and oncologists', both 4.5. Surprisingly, while infectious disease physicians were fifth most likely to be experiencing burnout, their severity rating was the lowest: 3.9.

Neurologists were asked to rate the 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 5.4 was "too many bureaucratic tasks," followed by "spending too many hours at work" (4.9) and "feeling like just a cog in a wheel" (4.4).

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. Neurologists rated them 4.2, 3.5, and 3.3, respectively.

In this year's Medscape Lifestyle Report, as in previous years, a higher percentage of female neurologists (58%) reported burnout than their male peers (46%). Percentages have trended slightly up for both male and female neurologists since this question was first asked in Medscape's 2013 survey. That year 56% of women and 40% of men reported burnout.

Using US Census Bureau criteria,^[7] we asked physicians about their race or ethnicity. Because such classifications are not necessarily straightforward, respondents could choose more than one option, and about 5% did so. That being considered, the majority (63%) of neurologists identified as white/Caucasian. Following in prevalence were those describing themselves as Asian Indian (14%) and Hispanic/Latino or Chinese (both at 5% after rounding). Only 1% of neurologists identified themselves as black/African American.

A 2015 Kaiser Family Foundation report on medical school graduates' race, based on data from the Association of American Medical Colleges,^[8] found 7% of respondents self-identifying as multiracial, 58.8% white/Caucasian, 19.8% Asian, 5.7% black/African American, and 4.6% Hispanic/Latino.^[9] These findings may suggest a decline in the percentage of all physicians who are white/Caucasian and a slight increase in those who are black/African American.

In this year's Medscape report, among racial/ethnic groups that comprised more than 4% of neurologists, the percentage of female relative to male respondents was very low. The highest percentage of women occurred among those who described themselves as Chinese (61%) and the lowest among those who identify as other Asian Indian (19%). Among white/Caucasian neurologists, 62% were men and 38% women.

The highest percentage of women (63%) among all physicians in this year's report occurred among black/African American respondents, and the lowest (38%) among whites/Caucasians. 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.^[10]

This year's responses indicated a slight association between race/ethnicity and burnout in neurologists. The highest percentage of burnout among groups comprising more than 4% of neurologists occurred in those who identified themselves as Chinese (56%). The lowest percentage was 46%, among self-identified Asian Indian respondents.

A 2007 study of medical students found that 47% experienced burnout, and the rate was lower among non-whites than whites.^[11] Notably, however, non-white students who had experienced adverse treatment due to their race had a higher burnout rate than their non-white peers. (There was no difference, though, 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 face a more demanding patient base than do their white peers. Nevertheless, Hispanic/Latino and black/African American physicians reported no difference in stress from their white peers, although Asians and Pacific Islanders reported higher average stress than white physicians.^[12]

In this year's Medscape report, neurologists were asked if they believed that they had biases toward specific types or groups of patients, and respondents could choose more than one option. Keeping in mind that these results include only groups that comprise more than 4% of the neurologist population, 61% of Chinese respondents admitted to biases toward certain patient populations. Among white/Caucasian respondents, the largest racial/ethnic group, 57% acknowledged biases.

In addition to small sample sizes, a limiting factor in the Medscape survey and other studies 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.^[13,14]

When neurologists who admitted biases toward patients with specific characteristics were asked to identify them, 63% of female compared with 55% of male respondents chose emotional problems. Women were also more likely than men to cite perceived low intelligence (41% vs 29%). In all other categories, men reported bias at higher percentages than did women.

Eighteen percent of neurologists who admitted bias said that it affects their treatment. This places them slightly above the middle among all respondents, with critical care physicians ranking highest at 24%, followed by psychiatrists and nephrologists, both at 23% following rounding. Pathologists were least likely to report that bias affected their patient care, at 6%.

Some research suggests that implicit bias might affect physicians' judgment.^[13] In one study, although implicit bias did not have an effect on treatment recommendations, physicians were more likely to view white patients as "cooperative" than black patients, which, they admitted, could have influenced their decisions.^[15]

Medscape asked whether the effect of bias on treatment was positive (eg, extra time spent, friendlier manner) or negative (eg, less time spent, less friendly manner), and respondents could answer "yes" to both. Of the 18% of neurologists who acknowledged an effect, the highest percentages admitted to negative treatment of patients with language differences (78%) and those with perceived emotional problems (62%). The highest percentage of positive treatment triggered by bias among respondents was toward patients of the opposite gender (33%), although 67% reported both positive and negative effects.

Just under half (43%) of neurologists who answered this question acknowledged negative treatment of patients whose race or ethnicity differed from their own. 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.^[16]

Sixty-three percent of neurologists age 45 or younger compared with 43% of their older peers expressed bias toward patients with emotional problems. In general, however, older respondents acknowledged biases at higher percentages than did their younger peers.

In this survey, there appeared to be a slight relationship between spiritual or religious belief and bias among neurologists. Of those who report that they have a spiritual belief, 50% admit to being biased. Of those with no belief, a slightly larger 56% admit to bias.

Neurologists' political leanings on social issues appear to have some relationship to their reported bias, with more socially liberal respondents admitting to bias than their socially conservative peers (57% vs 48%).

The lifestyle survey, like in previous years, asked physicians to rate their happiness at work and outside of work on a scale of 1 to 7, with 1 equaling "extremely unhappy" and 7 equaling "extremely happy." Among neurologists, higher percentages of men than women reported that they are very to extremely happy both away from work (63% vs 48%) and while there (38% vs 27%). Both male and female neurologists, however, are far happier outside of work.

At 57%, neurologists ranked sixth from the bottom among all physicians reporting that they are very or extremely happy outside of work. They ranked around the middle among those reporting that they were happy at work, at 34%. In this year's report, dermatologists (43%) and ophthalmologists (42%) ranked first and second for happiness at work, which was also the case in the 2016 and 2014 reports. The happiest physicians outside of work this year were urologists, at 69%, followed by ophthalmologists and dermatologists, both at 67%.

Burnout appears to have a marked effect on neurologists' non-work lives. Only 43% of burned-out respondents said they are very to extremely happy outside the workplace compared with 71% of those who are not burned out.

Burnout seems to have an even more pronounced negative effect on neurologists' happiness at work. Fifty-nine percent of neurologists with no burnout claimed to be very or extremely happy at work compared with a dismal 9% of their burned-out peers.

There appears to be some relationship between neurologists' burnout and regular exercise. Sixty-eight percent of non-burned-out compared with 58% of burned-out respondents reported exercising at least twice a week.

According to the most recent report on the topic from the Centers for Disease Control and Prevention, the prevalence of obesity among American adults in 2011-2014 was 36.5%, a rate that has remained relatively unchanged since 2003.^[17] The 2013 JAMA Internal Medicine study of lifestyle behaviors in healthcare workers^[18] showed little difference in rates of overweight or obesity between the healthcare professionals studied and their patients.

Neurologists who reported their body mass index in the Medscape survey do better than the general public, but a significant number are overweight or obese. Burnout does appear to play some role, with 48% of burned-out respondents acknowledging that they are overweight to obese compared with 38% of those who are not burned out.

According to the latest government statistics on alcohol use, 71% of American adults said they drank within the past year and 57% in the past month.^[19] Medscape neurologist respondents report very light drinking habits, and burnout does not appear to play a role. Only 14% of those reporting burnout had at least one drink per day compared with 12% of those who did not report burnout.

Among neurologists responding to the Medscape survey, 56% of men and 58% of women reported having adequate savings or more, while 42% of men and 40% of women said they have minimal or no savings.

Fewer male than female neurologists reported that they have no debt (27% vs 33%). Among respondents who are carrying debt, 59% of male and 51% of female neurologists said it is manageable, and 11% of men and 15% of women said it is not.

There is an ongoing income disparity between all male and female physicians, as reported in this year's Medscape Compensation Report. However, this gap is not as pronounced with neurologists, with 48% of men and 42% of their female peers reporting that their income and assets are currently sufficient to meet their needs. Thirty-eight percent of men and 42% of women said that their income and assets are not sufficient right now but that they expect them to improve. An approximately equivalent 14% of men and 16% of women have no hope of seeing improvement.

Debt appears to have a marked relationship to burnout for nearly every specialty. With the exception of neurologists, more non–burned-out physicians are debt-free compared with their burned-out peers. There are some interesting surprises, however. Urologists reported the highest severity rating of burnout (4.6) and are the specialists with the largest disparity between burned-out and non–burned-out physicians with regard to debt; almost one half (42%) of non–burned-out urologists are debt-free, double the percentage (20%) of their burned-out peers in the same position. In contrast, emergency medicine physicians had the highest frequency of burnout, but there was little difference in percentages of burned-out and non–burned-out emergency medicine physicians reporting that they were debt-free (23% vs 28%). Between 19% and 31% of all burned-out specialists have no debt; the corresponding range for non–burned-out specialists was 27%-42%. At 19%, family physicians with burnout were the least likely group to report that they were debt-free.