Burnout and Racial Bias Among Residents: Chicken or Egg?

Diana Phillips

July 26, 2019

Burnout brings racial bias to the surface among resident physicians, according to new research.

In a study of nearly 3400 second-year residents in the United States, nearly half of these physicians-in-training reported symptoms of burnout, and the presence of those symptoms was associated with greater implicit and explicit bias against black people.

The findings, published online today in JAMA Network Open, have important quality of care implications, according to lead author Liselotte Dyrbye, MD, of the Division of Community Internal Medicine at the Mayo Clinic in Rochester, Minnesota, and colleagues.

"If the association between burnout and bias toward black people is present among physicians in practice or after residency, it may be a factor in the explicit use of race in medical decision-making," they write, noting that the impact "could be substantial."

Although both burnout and racial bias have been identified as independent threats to the delivery of safe, high-quality, equitable care by medical residents, the association between the two has not be studied previously, Dyrbye and colleagues write.

To investigate a possible link, they analyzed longitudinal and cross-sectional data from a national sample of 3392 nonblack resident physicians who had been followed since their first year of medical school as participants in the Cognitive Habits and Growth Evaluation Study (CHANGES). Participants had provided baseline data at medical school enrollment in 2010 and 2011, and completed questionnaires at year 4 of medical school, and years 2 and 3 of residency, answering questions about demographics, medical specialty, burnout, depression, and attitudes about black and white people.

The researchers assessed residents' burnout symptoms using two measures (one question each on emotional exhaustion and depersonalization) adapted from the full Maslach Burnout Inventory that have previously been shown to effectively stratify the risk of burnout. Symptoms of depression were measured using the depression short form 4a of the Patient-Reported Outcomes Measurement Information System (PROMIS).

To evaluate respondents' explicit and implicit racial attitudes, the researchers compared participants "feeling thermometer" ratings (on a 1–100 scale) of self-reported "warm" or "cold" feelings toward blacks and whites, as well as their scores on the race Implicit Association Test (IAT), which is designed to measure the strength of automatic associations in peoples' minds and uncover their unconscious racial bias.

Of the 3392 resident physicians included in the analysis of the second-year resident questionnaire, more than half were younger than age 30 (57.9%) and two thirds self-identified as white (69.6%). Based on the two burnout indicators, 1203 of the residents (35.6%) had high emotional exhaustion and 1179 (34.9%) had high depersonalization, and 1529 (45.2%) had burnout. Approximately 41% of the cohort reported depressive symptoms, and the mean PROMIS score was 7.1 (SD 3.3).

The results of the racial bias measures showed mean feeling thermometer (FT) scores of 77.9 toward black people (SD 21.0)  and 81.1 toward white people (20.1). The mean racial IAT score was 0.4 (SD 0.4), all of which, according to the authors, "indicate a preference for white people over black people."

In the analyses of racial attitudes and burnout and depression symptoms, significant relationships were observed. Higher scores on the emotional exhaustion and depersonalization measures were associated with lower FT scores and thus more unfavorable attitudes toward black people, the authors write.

Specifically, residents with high emotional exhaustion had lower mean FT scores toward black people compared with resident physicians without high emotional exhaustion (75.9 [SD 21.9] vs 78.9 [20.4]; difference, –3.0; 95% confidence interval [CI], –4.5 to –1.5; P < .001). Residents with high depersonalization had lower mean FT scores toward black people compared with resident physicians without high depersonalization (74.8 [SD 22.3] vs 79.5 [20.1]; difference, –4.7; 95% CI, –6.2 to –3.2; P < .001).

In addition, residents with at least 1 symptom of burnout had lower mean FT scores toward black people compared with those without symptoms of burnout (75.9 [SD 21.9] vs 79.5 [20.1]; difference, –3.6; 95% CI, –5.0 to –2.2; P < .001).

Implicit bias toward black people was also greater among resident physicians with high depersonalization (racial IAT mean [SD] scores, 0.48 [0.41] vs 0.42 [0.42]; difference, 0.05; 95% CI, 0.02 - 0.09; P < .001) and overall burnout (mean [SD], 0.47 [0.42] vs 0.42 [0.42]; difference, 0.05; 95% CI, 0.02 - 0.07; P = .002). There was no significant association between implicit bias and emotional exhaustion or between implicit bias and depressive symptoms.

In multivariable analysis, burnout and depersonalization were independently associated with lower FT score toward black people and with racial IAT scores, the authors report.

The relationship between implicit racial bias and symptoms of burnout is especially concerning given the existing body of research indicating suboptimal clinical interactions between physicians with higher implicit bias and their black patients, the authors write. "[I]n turn, their black patients have greater distrust, have lower level of adherence to treatment recommendations, and are less likely to follow up."

A Moving Target

Of 2744 non-black resident physicians who completed both the second-year and third-year residency questionnaire, which excluded those training in radiology or pathology, 884 (33.3%) reported symptoms of chronic burnout, 381 (13.9%) had recovered from symptoms of burnout, 346 (10.2%) reported new symptoms of burnout, and 1122 (41.1%) never had symptoms of burnout.

Among these residents, those who never had burnout had higher mean FT scores toward black people at both second-year and third-year time points than those who recovered from burnout, had new burnout, and had chronic burnout. But the scores generally improved, the authors report.

"These findings suggest that resident physicians' feelings toward black people can become more favorable over the course of 1 year," the authors write.

The highest gain (4.8) in meant FT scores toward black people was observed among residents who recovered from burnout. The gains observed among those who never had burnout, had new burnout, and had chronic burnout, respectively, were 2.8, 1.6, and 2.9, the authors report.

No significant differences in change patterns in burnout and FT score toward black people between both time points were observed in multivariate analyses, "[H]owever, a dose-response association was found between change in depersonalization from R2 to R3 Questionnaires and R3 Questionnaire explicit bias," the authors write. Specifically, for each 1-point increase in depersonalization, the difference in R3 FT score was –0.73 (95% CI, –1.23 to –0.23; P = .004).

Cause or Effect?

It is unclear whether the association between burnout and bias is causal, the authors write. However, they note, "these findings are consistent with those of other studies, which reported that positive emotions are associated with decreases in bias, suggesting that successful efforts to reduce symptoms of burnout among resident physicians may be useful in reducing health care inequalities."

"The findings of this study are interesting to say the least. However, we should exercise caution in how we interpret them," according to Alexa M. Mieses, MD, MPH, a board-certified family physician and member of the Racial Equity Task Force of the Durham, North Carolina, Public Health Department System and Payer Advocacy Committee. Mieses was not associated with the study.

"Burnout lowers a person's ability to navigate complex psychological situations. People tend to revert to their instincts and rely on routines in this state. Therefore, it is possible that burnout exploits a vulnerability, that is implicit bias against a particular group, and thus it may manifest more egregiously, as in the explicit bias testing used in the study," she said in an interview with Medscape Medical News. "It's important to realize that everyone has implicit bias against various groups of people, and burnout likely only makes it worse."

While burnout should never be used as an excuse for bias or other negative or harmful behaviors, "we would be naive to believe that burnout doesn't affect one's ability to relate to others, empathize, and process socially complex issues," Mieses said.

"However, it is important to remember that racial bias and burnout are two different issues," she emphasized. "They may interplay with one another, but they need to be treated separately when looking for a solution. First and foremost, people need to accept and realize that everyone has bias against someone or something. The sooner we discover what our natural biases are, the better we can modify our behavior to not act on them."

In this regard, she said, "medical education specifically needs to ensure that groups of people are not stereotyped or stigmatized via the way we teach about disease and epidemiology."

The authors of an invited commentary, Vineet M. Arora, MD, and Anita Blanchard, MD, of University of Chicago Medicine in Illinois, also warn against concluding that burnout leads to bias among resident physicians. "[I]t is important to recognize that a causal association cannot be assumed on the basis of this study alone," they write. "In this case, mitigating burnout may reduce the perception of bias in the moment, but it will not actually address the underlying bias that continues to linger and can emerge when a physician faces another external stressor." They key to breaking the cycle, they stress, is to address both burnout and bias together.

The findings should be used as a springboard to future work to better understand what's happening and how best to mitigate the effects of burnout and bias. But change can't wait for research, they say. "[T]here are more than 135,000 resident physicians in training who are treating patients at any given time," Arora and Blanchard write. "The time is now to break the cycle of burnout and bias in our nation's graduate medical education programs. Our nation is depending on us."

The study was supported by National Heart, Blood and Lung Institute and the Mayo Clinic. Dyrbye reports receiving royalties for the Well-Being Index licensed by the Mayo Clinic to CWS Inc. Coauthor Michelle van Ryn is the founder and president of Diversity Science and Principal Investigator of the study that provided the data for this report. Coauthor Rachel Hardeman reports receiving funding from the National Heart, Lung and Blood Institute through a Research Supplement to Promote Diversity in Health-Related Research.

Arora and Blanchard report receiving a grant from the Accreditation Council of Graduate Medical Education Pursuing Excellence. Arora reports serving on the board of directors for the American Board of Internal Medicine. Blanchard reports serving on the Accreditation Council of Graduate Medical Education review committee for obstetrics and gynecology and as vice president of the board of directors of the American Board of OBGYN.

Mieses has disclosed no relevant financial relationships.

JAMA Network Open. Published online July 26, 2019. Full text, Editorial

For more news, follow Medscape on FacebookTwitter, Instagram, and YouTube


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: