Much research has gone into studying patient race and ethnicity and their effect on the care received. Medscape's Orthopedist Lifestyle Survey asked orthopedists 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, 49% of orthopedists reported burnout, below 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]

Orthopedists 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 orthopedists who reported burnout, the average severity rating was 4.1, below the middle 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.

Orthopedists 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 5.6, was "too many bureaucratic tasks," followed by "increasing computerization" at 4.9 and "spending too many hours at work" at 4.5.

In an October 2016 Medscape roundtable discussing electronic health records (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. Orthopedists rated them 4.4, 3.7, and 2.9, respectively.

In this year's Medscape Lifestyle Report, as in previous years, a higher percentage of female orthopedists (63%) reported burnout than their male peers (47%). Percentages have trended sharply up for both male and female respondents since this question was first asked in Medscape's 2013 survey, when 39% of men and 47% of women 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, 84% of orthopedists, the majority by far, identified as white/Caucasian. Following drastically behind in prevalence were respondents who described themselves as Asian Indian (4%), and Chinese or black/African American (3%). Respondents self-identified as a race/ethnicity not listed above at a rate of 2% or less.

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 2% of orthopedists, the percentage of female relative to male respondents was low. The highest percentage of women occurred among those who described themselves as black/African American (40%). The lowest was found among those who identify as white/Caucasian or Asian Indian (both at 13%).

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 an association between race/ethnicity and burnout in orthopedists. The highest percentages of burnout among groups comprising more than 2% of respondents occurred in those who identified themselves as Chinese or black/African American (both at 80%). Asian Indian orthopedists, at 47%, were the least likely to experience burnout among these racial and ethnic groups. White/Caucasian orthopedists, the largest racial/ethnic group, reported a rate of 48%.

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, orthopedists 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 2% of orthopedists, self-identified black/African American respondents most frequently acknowledged biases toward certain patient populations, at 70%. Orthopedists who described themselves as Asian Indian were least likely to report bias, at 33%. In the largest racial/ethnic group, 60% of white/Caucasian orthopedists 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 orthopedists who admitted biases toward patients with specific characteristics were asked to identify them, the highest percentages of both male and female respondents cited heavier weight (70% vs 57%) and emotional problems (64% vs 54%). More female (46%) than male (37%) respondents implicated perceived low intelligence, but men reported bias more frequently than women toward patients lacking insurance (35% vs 23%) or with language differences (31% vs 20%).

Twenty percent of orthopedists who admitted bias said that it affects their treatment, placing them near the top among all respondents. Critical care physicians rank highest at 24%, followed by psychiatrists and nephrologists, both at 23% after rounding. Pathologists were least likely to report that bias affected treatment, 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 20% of orthopedists who acknowledged an effect, the highest percentages admitted to negative treatment of patients with language differences (67%) and heavier weight (65%). The highest percentage of positive treatment triggered by bias was toward older patients (50%).

Half of orthopedists 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-nine percent of orthopedists age 45 or under expressed bias toward patients with emotional problems and those of heavier weight. Orthopedists over age 45 cited these characteristics at rates of 48% and 67%, respectively. In fact, younger respondents reported bias at a higher rate in all instances but one—physical unattractiveness—and then by only one percentage point, at 10% compared with 11% of older respondents.

In this survey, there appeared to be no relationship between spiritual or religious belief and bias among orthopedists. Of both those reporting that they have a spiritual belief as well as those that do not, 59% admit to being biased.

Orthopedists' political leanings on social issues also appear to have no relationship to their reported bias, with only slightly more socially liberal respondents admitting to bias (62%) than their socially conservative peers (60%).

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 orthopedists, higher percentages of men than women said that they are very or extremely happy both outside the workplace (65% vs 49%) and while on the job (38% vs 27%). Both male and female respondents, however, are far happier outside of work.

Among all physicians reporting that they are very or extremely happy outside of work, orthopedists ranked eighth from the top at 63%. They ranked sixth from the top among those reporting that they are happy at work, at 37%. 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 orthopedists' non-work lives. Only 49% of burned-out respondents are very to extremely happy outside the workplace, compared with 76% of those who are not burned out.

Burnout seems to have an even more pronounced negative effect on orthopedists' happiness at work. Sixty-two percent of respondents with no burnout claimed to be very or extremely happy at work compared with a dismal 11% of their burned-out peers.

There may be a slight relationship between orthopedists' burnout and regular exercise. Seventy-six percent of non-burned-out compared with 66% 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.

Orthopedists 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 not appear to play a role, with 47% of burned-out respondents acknowledging that they are overweight to obese compared with 44% 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 orthopedist respondents report very light to moderate drinking habits, and there is no indication of a relationship to burnout. Twenty percent of both those who reported burnout and those who did not have at least one drink per day.

Among orthopedists responding to the Medscape survey, 74% of men and 61% of women reported having adequate savings or more, and conversely, 25% of men and 39% of women said they have minimal or no savings.

This year, fewer male orthopedists (28%) said they are debt free than did their female peers (33%). When they did report having debt, 63% of male and 55% of female respondents said that it is manageable, and only 7% of men and 12% of women said that it is not.

Given the ongoing income disparity between all male and female physicians, as reported in this year's Medscape Compensation Report, it is perhaps not surprising that in this year's report, 57% of male orthopedists compared with only 39% of their female peers believe that their income and assets are currently sufficient to meet their needs. Thirty-four percent of men and 39% of women said that their income and assets are not sufficient right now but that they expect them to improve, and 9% of men and 22% 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.