Association of Racial Bias with Burnout among Resident Physicians

Liselotte Dyrbye, Jeph Herrin, Colin P. West, Natalie M. Wittlin, John F. Dovidio, Rachel Hardeman, Sara Emily Burke, Sean Phelan, Ivuoma Ngozi Onyeador, Brooke Cunningham, Michelle van Ryn

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Abstract

Importance: 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. Objective: To assess the association between burnout and explicit and implicit racial biases toward black people in resident physicians. Design, Setting, and Participants: 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. Main Outcomes and Measures: 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). Results: 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. Conclusions and Relevance: 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.

Original languageEnglish (US)
Article numbere197457
JournalJAMA Network Open
Volume2
Issue number7
DOIs
StatePublished - Jul 26 2019

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Racism
Physicians
Healthcare Disparities
Depersonalization
Depression
Thermometers
Surveys and Questionnaires
Internship and Residency
Medical Schools
Medical Students
Radiology
Information Systems
Habits
Emotions
Cohort Studies

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Dyrbye, L., Herrin, J., West, C. P., Wittlin, N. M., Dovidio, J. F., Hardeman, R., ... van Ryn, M. (2019). Association of Racial Bias with Burnout among Resident Physicians. JAMA Network Open, 2(7), [e197457]. https://doi.org/10.1001/jamanetworkopen.2019.7457

Association of Racial Bias with Burnout among Resident Physicians. / Dyrbye, Liselotte; Herrin, Jeph; West, Colin P.; Wittlin, Natalie M.; Dovidio, John F.; Hardeman, Rachel; Burke, Sara Emily; Phelan, Sean; Onyeador, Ivuoma Ngozi; Cunningham, Brooke; van Ryn, Michelle.

In: JAMA Network Open, Vol. 2, No. 7, e197457, 26.07.2019.

Research output: Contribution to journalArticle

Dyrbye, L, Herrin, J, West, CP, Wittlin, NM, Dovidio, JF, Hardeman, R, Burke, SE, Phelan, S, Onyeador, IN, Cunningham, B & van Ryn, M 2019, 'Association of Racial Bias with Burnout among Resident Physicians', JAMA Network Open, vol. 2, no. 7, e197457. https://doi.org/10.1001/jamanetworkopen.2019.7457
Dyrbye L, Herrin J, West CP, Wittlin NM, Dovidio JF, Hardeman R et al. Association of Racial Bias with Burnout among Resident Physicians. JAMA Network Open. 2019 Jul 26;2(7). e197457. https://doi.org/10.1001/jamanetworkopen.2019.7457
Dyrbye, Liselotte ; Herrin, Jeph ; West, Colin P. ; Wittlin, Natalie M. ; Dovidio, John F. ; Hardeman, Rachel ; Burke, Sara Emily ; Phelan, Sean ; Onyeador, Ivuoma Ngozi ; Cunningham, Brooke ; van Ryn, Michelle. / Association of Racial Bias with Burnout among Resident Physicians. In: JAMA Network Open. 2019 ; Vol. 2, No. 7.
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abstract = "Importance: 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. Objective: To assess the association between burnout and explicit and implicit racial biases toward black people in resident physicians. Design, Setting, and Participants: 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. Main Outcomes and Measures: 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). Results: 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. Conclusions and Relevance: 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.",
author = "Liselotte Dyrbye and Jeph Herrin and West, {Colin P.} and Wittlin, {Natalie M.} and Dovidio, {John F.} and Rachel Hardeman and Burke, {Sara Emily} and Sean Phelan and Onyeador, {Ivuoma Ngozi} and Brooke Cunningham and {van Ryn}, Michelle",
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T1 - Association of Racial Bias with Burnout among Resident Physicians

AU - Dyrbye, Liselotte

AU - Herrin, Jeph

AU - West, Colin P.

AU - Wittlin, Natalie M.

AU - Dovidio, John F.

AU - Hardeman, Rachel

AU - Burke, Sara Emily

AU - Phelan, Sean

AU - Onyeador, Ivuoma Ngozi

AU - Cunningham, Brooke

AU - van Ryn, Michelle

PY - 2019/7/26

Y1 - 2019/7/26

N2 - Importance: 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. Objective: To assess the association between burnout and explicit and implicit racial biases toward black people in resident physicians. Design, Setting, and Participants: 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. Main Outcomes and Measures: 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). Results: 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. Conclusions and Relevance: 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.

AB - Importance: 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. Objective: To assess the association between burnout and explicit and implicit racial biases toward black people in resident physicians. Design, Setting, and Participants: 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. Main Outcomes and Measures: 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). Results: 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. Conclusions and Relevance: 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.

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