Much research has gone into studying patient race and ethnicity and their effect on the care received. Medscape's Pediatrician Lifestyle Survey asked pediatricians 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 pediatricians reported burnout, placing them in 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]

Pediatricians 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 pediatricians who reported burnout, the average severity rating was 4.0, sixth from the lowest 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 at 4.5. Surprisingly, while infectious disease physicians were fifth most likely to be experiencing burnout, their severity rating was the lowest: 3.9.

Pediatricians 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 5.0, was "too many bureaucratic tasks," followed by "spending too many hours at work" at 4.8, and "feeling like just a cog in a wheel" and "increasing computerization," both at 4.4.

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."

Pediatricians rated "insurance issues" a 3.8. The option was added to this year's survey because it frequently appeared in write-in responses last year as an important contribution to burnout. Also added this year were "family stress" and "threat of malpractice," both of which pediatricians rated, on average, at 3.1.

In this year's Medscape Lifestyle Report, as in previous years, a higher percentage of female pediatricians (54%) reported burnout than their male peers (46%). Percentages have trended up for men but down for women since this question was first asked in Medscape's 2013 survey. That year, 32% of male and 61% of female pediatricians 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, two thirds (66%) of pediatricians identified as white/Caucasian. Much lower in prevalence were those describing themselves as Asian Indian (9%), Hispanic/Latino (7%), black/African American (5%), Chinese (4%), and Filipino (2%). Pediatricians self-identified as ethnicities not listed here at a rate of less than 2%.

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 pediatricians, the percentage of female relative to male respondents was very high. The highest percentage of women occurred among those who described themselves as black/African American (81%). The lowest was among those who identify as Hispanic/Latino (57%). Among white/Caucasian pediatricians, the most prevalent group, 58% are women and 42% are men.

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 some association between race/ethnicity and burnout in pediatricians. The highest percentage of burnout among groups comprising more than 2% of respondents occurred in those who described themselves as black/African American (53%). Self-identified Filipino pediatricians, at 38%, were the least likely to experience burnout among these groups.

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, pediatricians were asked if they believed that they had biases toward specific types or groups of patients, and respondents could choose more than one option. Among groups that comprised more than 2% of respondents, self-identified Chinese pediatricians most frequently acknowledged biases, at 60%. Respondents who described themselves as Asian Indian were least likely to report bias, at 30%. Fifty-four percent of white/Caucasian pediatricians, the largest group, admitted 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 pediatricians who admitted biases toward patients with specific characteristics were asked to identify them, emotional problems were most frequently cited, selected by a higher percentage of women (50%) than men (45%). The next most implicated traits were perceived low intelligence, named by 40% of male and 39% of female respondents, and heavier weight, chosen by 39% of men and 37% of women.

Fourteen percent of pediatricians who admitted bias said that it affects their treatment. This places them around the middle among all physicians, 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 14% of pediatricians who acknowledged an effect, the highest percentages admitted to negative treatment of patients with language differences (61%), perceived low intelligence (59%), and emotional problems (58%). Of interest, these characteristics also triggered positive treatment by some of the highest percentages of pediatricians (32%, 34%, and 31%, respectively).

More than one third (36%) of pediatricians 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]

Half of pediatricians age 45 or under expressed bias toward patients with emotional problems compared with 43% of those over age 45. In fact, younger respondents reported bias at a higher rate than their older peers toward all but two patient traits: physical unattractiveness (7% vs 9%) and lack of insurance (both at 14%). Differences between younger and older pediatricians were generally slight, though there was a 10% gap when it came to patients with perceived low intelligence (44% vs 34%).

In this survey, there appeared to be a slight relationship between spiritual or religious belief and bias among pediatricians. Of those who report that they have a spiritual belief, 49% admit to being biased. Of those with no belief, a slightly larger 53% admit to bias.

Pediatricians' political leanings on social issues also appear to have a negligible effect on their reported bias, with more socially liberal respondents admitting to bias (52%) compared with their socially conservative peers (49%).

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 pediatricians, men and women said that they are very to extremely happy outside of work at similar rates (64% vs 63%), while the difference was more pronounced when it came to work, with 43% of men and 32% of women saying that they are very or extremely happy in that environment. Not surprisingly, both male and female respondents are much happier away from the workplace.

Among all physicians who reported that they are very or extremely happy away from work, pediatricians ranked seventh highest at 63%. They ranked eighth from the top of those reporting that they are happy at work, at 36%. 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 pediatricians' non-work lives. Only half of burned-out respondents are very to extremely happy outside the workplace compared with more than three quarters (77%) of those who are not burned out.

Burnout seems to have an even more pronounced negative effect on pediatricians' happiness at work. Sixty-three percent of respondents with no burnout claimed to be very or extremely happy at work, compared with only 9% of their burned-out peers, a sevenfold difference.

There may be some relationship between pediatricians' burnout and regular exercise. Seventy percent of non-burned-out compared with 63% 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.

Pediatricians 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 44% of burned-out respondents acknowledging that they are overweight or obese compared with 37% 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 pediatrician respondents report very light to moderate drinking habits, and burnout appears to play no part. Sixteen percent of both those who reported burnout and those who did not had at least one drink per day.

Among pediatricians, slightly more male than female respondents (69% vs 63%) reported this year that they have adequate savings or more.

There was virtually no difference this year between male and female pediatricians regarding debt. Twenty-five percent of men and 24% of women said that they are debt-free; approximately two thirds of men (66%) and women (65%) who do carry debt said that it is manageable; and only 9% of both groups with debt 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 surprising that male and female pediatricians' responses to this question were so similar. A slightly higher percentage of men (56%) than women (52%) said they feel that their income and assets are currently sufficient; 30% of men and 29% of women said their income and assets are not currently sufficient but that they expect improvement; and 15% of men compared with a slightly greater 19% of women reported that they do not hold out hope for 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.