Much research has gone into studying patient race and ethnicity and their effect on the care received. This year is the first in which otolaryngologists are included in Medscape's Lifestyle Report. The survey asked this group 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 response to this year's Medscape survey, 53% of otolaryngologists reported burnout, placing them in the upper third 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]

Otolaryngologists 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 otolaryngologists who reported burnout, the average severity rating was 4.5, second highest 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', then oncologists', whose severity rating also averaged 4.5. Surprisingly, while infectious disease physicians were fifth most likely to be experiencing burnout, their severity rating was the lowest: 3.9.

Otolaryngologists 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 5.5, was "too many bureaucratic tasks," followed by "increasing computerization" at 5.2 and "spending too many hours at work" at 4.8.

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 by physicians as important contributions to burnout in last year's write-in responses to this question, the options were added to our survey. Otolaryngologists rated them 4.6, 4.0, and 3.0, respectively.

In the Medscape Lifestyle Report, a slightly higher percentage of female otolaryngologists (54%) reported burnout than their male peers (52%).

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, three quarters of otolaryngologists identified as white/Caucasian. Drastically lower in prevalence were those describing themselves as Asian Indian (6%); Chinese (3%); Hispanic/Latino, Korean, and Filipino (all at 2%); and other Asian (1%). Otolaryngologists self-identified as black/African American at a rate of less than 1%.

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 the Medscape report, among racial/ethnic groups that comprised more than 4% of otolaryngologists (only two), the percentage of female relative to male respondents was very low. A higher percentage of those who described themselves as Asian Indian were women (30%). Among white/Caucasian respondents, 80% are men and only 20% are 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]

Burnout among racial/ethnic groups comprising more than 4% of respondents was reported by 60% of those otolaryngologists who identified themselves as Asian Indian and by 52% of white/Caucasian otolaryngologists.

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 the Medscape report, otolaryngologists were asked if they believed that they had biases toward specific types or groups of patients, and they could choose more than one option. Keeping in mind that these results include only groups that comprise more than 4% of respondents, more white/Caucasian than Asian Indian otolaryngologists admitted to biases toward certain patient populations (57% and 50%, respectively).

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 otolaryngologists who admitted biases toward patients with specific characteristics were asked to identify them, 77% of women, compared with 50% of men, chose emotional problems. With the exception of physical unattractiveness, female respondents implicated every bias-triggering trait at higher percentages than did men. In addition to the 27% difference between men and women reporting bias toward patients with emotional problems, there were significant gaps when citing heavier weight (55% vs 38%), language differences (55% vs 32%), and older age (23% vs 8%) in patients.

Twenty percent of otolaryngologists who admitted bias said that it affects their treatment. This places them fourth from the top among all respondents, with critical care physicians ranking highest at 24% and psychiatrists and nephrologists in second and third place at 23%. 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 otolaryngologists who acknowledged an effect, the highest percentages admitted to negative treatment of patients with emotional problems (67%), perceived low intelligence (58%), and language differences (53%). The highest percentage of positive treatment triggered by bias was toward older patients (50%), though this was equaled by the percentage reporting a negative effect.

One fifth of otolaryngologists who answered this question acknowledged negative treatment of patients whose race or ethnicity differed from their own, though the same percentage reported positive treatment and 60% reported both effects. 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-two percent of otolaryngologists age 45 or under expressed bias toward patients with emotional problems compared with less than half (47%) of their older peers. Younger respondents reported a higher rate of bias toward more patient traits than did those over age 45. For "older age," 16% of younger otolaryngologists compared with a scant 3% of older ones acknowledged bias. In contrast, older respondents cited "lack of insurance" and "physical unattractiveness" at rates higher by double digits than did their younger peers (37% vs 26% and 17% vs 7%, respectively).

In this survey, there appeared to be some relationship between spiritual or religious belief and bias among otolaryngologists. Of those who report that they have a spiritual belief, 54% admit to being biased. Of those with no belief, a slightly larger 60% admit to bias.

Otolaryngologists' political leanings on social issues appear to have a slight relationship to their reported bias, with more socially liberal respondents admitting to any bias (61%) compared with their socially conservative peers (50%).

The lifestyle survey 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 otolaryngologists, more men (63%) than women (49%) said they are very to extremely happy outside of work, while 34% of both men and women reported high happiness levels at work. Not surprisingly, both male and female respondents are far happier away from the workplace.

Otolaryngologists ranked slightly above the middle among all physicians reporting that they are very or extremely happy away from work (60%) and at work (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 otolaryngologists' non-work lives. Only 47% of burned-out respondents are very to extremely happy outside the workplace, compared with 75% of those who are not burned out.

Burnout seems to have an even more pronounced negative effect on otolaryngologists' happiness at work. Sixty-seven percent of respondents with no burnout claimed to be very or extremely happy at work, compared with a dismal 5% of their burned-out peers.

There appears to be some relationship between otolaryngologists' burnout and regular exercise. Seventy-nine 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.

Otolaryngologists who reported their body mass index in the Medscape survey do better than the general public, but a significant number are overweight or obese. There appears to be a small relationship to burnout, with 51% of burned-out respondents acknowledging that they are overweight to obese compared with 40% of those who are not.

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 otolaryngologist respondents report very light to moderate drinking habits, and burnout appears to play little, if any, part. Twenty-three percent of those who reported burnout had at least one drink per day compared with 19% of those who did not report burnout.

Among otolaryngologists, slightly more female than male respondents (77% vs 71%) reported that they have adequate savings or more. Furthermore, 29% of men compared with 20% of women said they have no or only minimal savings.

More male than female otolaryngologists (34% vs 26%) reported that they have no debt. Among those who do carry debt, however, more women than men reported that it is manageable (66% vs 60%), while only 4% of men and 6% of women reported that it is unmanageable.

Given the ongoing income disparity between all male and female physicians, as reported in this year's Medscape Compensation Report, it is perhaps somewhat surprising that nearly equal percentages of male and female otolaryngologists said they believe that their income and assets are currently sufficient (58% vs 57%), that their income and assets are not sufficient but that they expect improvement (26% vs 29%), or that they do not hold out hope for improvement (16% vs 14%).

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.