Much research has gone into studying patient race and ethnicity and their effect on the care received. Medscape's Psychiatrist Lifestyle Survey asked psychiatrists 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, 42% of psychiatrists reported burnout, the lowest rate 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 2016 report as well. Not surprisingly, other research has found high burnout rates in these groups.^[3-6]

Psychiatrists 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 psychiatrists who reported burnout, the average severity rating was 4.0, seventh 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.

Psychiatrists 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 5.2 was "too many bureaucratic tasks," followed by "feeling like just a cog in a wheel" and "spending too many hours at work," 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."

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. Psychiatrists rated them 4.0, 3.4, and 3.1, respectively.

In this year's Medscape Lifestyle Report, as in previous years, a higher percentage of female psychiatrists (46%) reported burnout than their male peers (38%). Percentages have trended down for women but up for men since this question was first asked of psychiatrists in Medscape's 2013 survey, when 62% of female and 30% of male respondents 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, approximately two thirds (69%) of psychiatrists identified as white/Caucasian. Much lower in prevalence were those describing themselves as Asian Indian (9%), Hispanic/Latino (7%), black/African American or Chinese (both rounding to 3%), and other Asian or Filipino (both rounding to 2%). Psychiatrists self-identified as ethnicities not listed here 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 this year's Medscape report, among racial/ethnic groups that comprised more than 2% of psychiatrists, men were more prevalent than women among respondents who described themselves as other Asian or Chinese (67% vs 33% in each group), Asian Indian (55% vs 45%), or white/Caucasian (54% vs 46%). Women were more prevalent than men among psychiatrists who identified as Hispanic/Latino (57% vs 43%), black/African American (55% vs 45%), or Filipino (53% vs 47%).

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 appear to indicate an association between race/ethnicity and burnout in psychiatrists. The highest percentages of burnout among groups comprising more than 2% of respondents occurred in self-identified Hispanic/Latino (52%), Chinese (44%), and white/Caucasian (43%) psychiatrists. Black/African American and other Asian respondents reported burnout at the lowest rates (32% and 33%, respectively).

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, psychiatrists were asked if they believed that they had biases toward specific types or groups of patients, and they could choose more than one option. Among groups that comprised more than 2% of respondents, 68% of black/African American and 67% of Chinese and white/Caucasian psychiatrists admitted biases. The lowest percentage (38%) was found among other Asian respondents.

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 psychiatrists who admitted biases toward patients with specific characteristics were asked to identify them, there was very little difference between male and female respondents. The traits that both genders cited most frequently were perceived low intelligence (28% of both), language differences (25% of men vs 26% of women), and heavier weight (24% vs 23%). Least implicated were patients of the opposite gender (7%, after rounding, of both men and women) or of a race different from one's own (11% of both), and those with low income levels (13% of both).

Nearly one quarter (23%) of psychiatrists who admitted bias said that it affects their treatment, placing them second from the top among all physicians, with critical care physicians ranking highest at 24%. 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 23% of psychiatrists who acknowledged an effect, the highest percentages admitted to negative treatment of patients with language differences (69%), perceived low intelligence (53%), and those who lack insurance or whom they find physically unattractive (both at 50%). Older age triggered negative treatment by the lowest percentage of respondents (26%), and positive treatment by the highest (50%).

Forty-two percent of the psychiatrists who answered this question acknowledged negative treatment of patients whose race 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]

Psychiatrists over age 45 and those age 45 and under reported bias toward most patient characteristics at similar rates, though in virtually all cases younger psychiatrists' percentages were somewhat higher. Younger respondents cited emotional problems and older age at twice the rate of their older peers (21% vs 11% in both cases). The younger group also identified race different from self as a bias trigger at twice the rate of their older colleagues (14% vs 7%).

In this survey, there appeared to be some relationship between spiritual or religious belief and self-reported bias among psychiatrists. Of those who report that they have a spiritual belief, 59% admit to being biased. Of those with no belief, a larger 67% admit to bias.

Psychiatrists' political leanings on social issues may also have an effect on their reported bias, with more socially liberal respondents admitting to harboring any biases compared with their socially conservative peers (66% vs 53%).

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 psychiatrists, somewhat more men than women said they are very to extremely happy both outside of work (61% vs 55%) and at work (39% vs 35%). 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, psychiatrists ranked eighth from the bottom, at 58%. They ranked fourth highest among those reporting that they were 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 psychiatrists' non-work lives. Well under half (41%) of burned-out respondents are very to extremely happy outside the workplace compared with more than two thirds (70%) of those who are not burned out.

Burnout seems to have an even more pronounced negative effect on psychiatrists' happiness at work. Fifty-nine percent of respondents with no burnout claimed to be very or extremely happy at work compared with a dismal 7% of their burned-out peers.

There may be some relationship between psychiatrists' burnout and regular exercise. Seventy percent of non-burned-out compared with 55% 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.

Psychiatrists 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 may be a slight relationship to burnout, with 47% of burned-out respondents acknowledging that they are overweight or obese compared with 41% 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 psychiatrist respondents report very light to moderate drinking habits, and burnout does not appear to play a part. Fifteen percent of respondents who reported burnout and 18% of those who did not had at least one drink per day.

Among psychiatrists, more male than female respondents (70% vs 61%) reported this year that they have adequate savings or more.

There was not much difference this year between male and female psychiatrists regarding debt. Nearly one third (32%) of men and just over one quarter (26%) of women said that they are debt-free; 60% of men and 62% of women who do carry debt said that it is manageable; and 5% of men and 9% of women said 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 not surprising that a higher percentage of men (63%) than women (54%) said they feel that their income and assets are currently sufficient. Additionally, slightly more men (30%) than women (28%) said their income and assets are not now sufficient but that they expect improvement, and a scant 7% of men compared with nearly three times as many women (19%) 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.