Abstract
Burnout, a syndrome characterized by emotional exhaustion, depersonalization, and a decreased sense of efficacy, is common among resident physicians, and negative emotional states may increase the expression of prejudices, which are associated with racial disparities in health care. Whether racial bias varies by symptoms of burnout among resident physicians is unknown. To assess the association between burnout and explicit and implicit racial biases toward black people in resident physicians. This cohort study obtained data from surveys completed by first-year medical students and resident physicians in the United States as part of the Cognitive Habits and Growth Evaluation Study. Participants were followed up from enrollment in 2010 to 2011 through 2017. Participants completed questionnaires at year 4 of medical school as well as at the second and third years of residency. Only data from resident physicians who self-identified as belonging to a racial group other than black (n = 3392) were included in the analyses because of scarce evidence of racial bias in the care provided to black patients by black physicians. Resident physicians training in radiology or pathology were excluded because they provided less direct patient interaction. Burnout symptoms were measured by 2 single-item measures from the Maslach Burnout Inventory. Explicit attitudes about white and black people were measured by a feeling thermometer (FT, from 0 to 100 points, ranging from very cold or unfavorable [lowest score] to very warm or favorable [highest score]; included in the second-year [R2] and third-year [R3] questionnaires). The R2 Questionnaire included a racial Implicit Association Test (IAT; range: -2 to 2). Among the 3392 nonblack resident physician respondents, 1693 (49.9%) were male, 1964 (57.9%) were younger than 30 years, and 2362 (69.6%) self-identified as belonging to the white race. In this cohort, 1529 of 3380 resident physicians (45.2%) had symptoms of burnout and 1394 of 3377 resident physicians (41.3%) had depression. From this group, 12 did not complete the burnout items and 15 did not complete the Patient-Reported Outcomes Measurement Information System (PROMIS) items. The mean (SD) FT score toward black people was 77.9 (21.0) and toward white people was 81.1 (20.1), and the mean (SD) racial IAT score was 0.4 (0.4). Burnout at the R2 Questionnaire time point was associated with greater explicit and implicit racial biases. In multivariable analyses adjusting for demographics, specialty, depression, and FT scores toward white people, resident physicians with burnout had greater explicit racial bias (difference in FT score, -2.40; 95% CI, -3.42 to -1.37; P < .001) and implicit racial bias (difference in IAT score, 0.05; 95% CI, 0.02-0.08; P = .002). A dose-response association was found between change in depersonalization from R2 to R3 Questionnaire and R3 Questionnaire explicit bias (for each 1-point increase the difference in R3 FT score decreased, -0.73; 95% CI, -1.23 to -0.23; P = .004) and change in explicit bias. Among resident physicians, symptoms of burnout appeared to be associated with greater explicit and implicit racial biases; given the high prevalence of burnout and the negative implications of bias for medical care, symptoms of burnout may be factors in racial disparities in health care.
Highlights
In multivariable analyses adjusting for demographics, specialty, depression, and feeling thermometer (FT) scores toward white people, resident physicians with burnout had greater explicit racial bias and implicit racial bias
A dose-response association was found between change in depersonalization from R2 to R3 Questionnaire and R3 Questionnaire explicit bias and change in explicit bias
Multiple complex factors are associated with this racial disparity in health status, the difference in medical care provided by physicians to black patients compared with white patients is a substantial aspect.[6,7,8,9,10,11]
Summary
Despite efforts on multiple fronts, substantial morbidity and mortality differences persist between white and black patients, regardless of their socioeconomic status and level of education.[1,2,3,4,5] multiple complex factors are associated with this racial disparity in health status, the difference in medical care provided by physicians to black patients compared with white patients is a substantial aspect.[6,7,8,9,10,11] Previous studies have found that, physicians consciously value equitable care,[12,13] their directly expressed (explicit) and unconscious (implicit) biases are factors in their behaviors and decisions that are associated with the medical care they provide.[14,15,16,17,18,19,20,21,22] These data, coupled with evidence of racial bias among trainees,[23,24,25] have led to calls for graduate medical education to include curricula focused on understanding and addressing racial health disparities.[26,27,28]Burnout is prevalent among resident physicians[29,30,31] and is an underrecognized threat to the success of curricular interventions. A substantial body of literature has documented a high prevalence of burnout and depression among resident physicians.[32,33] Burnout, a syndrome characterized by emotional exhaustion, depersonalization (ie, cynicism), and a decreased sense of efficacy, is job related, situation specific, and largely driven by work-related factors.[34] Among resident physicians, the primary drivers of burnout include work intensity, suboptimal supervisor behaviors, lack of flexibility and control, educational debt, and work-home conflict.[33] Physicians’ negative emotional states have been shown to be associated with greater explicit racial bias in medical decision-making.[35] Negative emotions, like those characterized by burnout and depression, can impede cognitive performance,[36,37,38] making implicit biases more likely to play a role in behaviors and decision-making.[39] Burnout, as a negative emotional state, could activate bias, reduce cognitive capacity leading to inappropriate application of heuristics, or have negative consequences in mindful decision making in other ways
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