Burnout among resident doctors can make them more susceptible to racial bias and negatively impact care

The study found that resident physicians, who had symptoms of burnout, were more likely to have both explicit and implicit bias

                            Burnout among resident doctors can make them more susceptible to racial bias and negatively impact care

While physician burnout can lead to medical errors, researchers have now found that resident doctors experiencing burnout are also likely to suffer from greater bias toward black patients. In a study that involved 3,392 non-black, second-year resident physicians in the US, Mayo Clinic researchers found that as symptoms of burnout increased among the medical residents, they became more susceptible to racial bias.

According to Dr. Liselotte Dyrbye, who led the study, the findings are significant as bias impacts one’s decision-making. She further explains that burnout among physicians increases the risk that patients do not receive the best care, and contributes to disparities in care.

Burnout is a condition marked by emotional exhaustion, cynicism, and negative feelings toward one’s job. According to the World Health Organization (WHO), burnout is characterized by three dimensions: “feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and reduced professional efficacy.”

The study, published in JAMA Network Open, concludes that burnout was associated with increased implicit and explicit bias among US resident physicians. The research team says as burnout among resident physicians and physicians in practice is high - over 40% - the implications for the quality of care provided to black Americans, as well as to other disadvantaged groups, are significant and could explain some of the health disparities between ethnic groups in the US.

“Resident physicians with burnout are more likely to have bias than resident physicians without burnout. When physicians are not operating in an optimal mental and emotional state, they may find it harder to push back against their own biases. Having bias impacts decision-making. So, this means that burnout increases the chance the physician has a bias and ultimately delivers the worse quality of care to black patients than physicians without bias. For example, a physician who has a bias may be less likely to order a test that a patient needs,” Dr. Dyrbye from Mayo Clinic told MEA WorldWide (MEAWW).

According to Dr. Dyrbye, health disparities between ethnic groups in the US are well documented. For example, black Americans are more likely to experience a stroke, heart disease, infant mortality, obesity, and diabetes – even after one adjusts for their level of education and income. She further explains that some of this disparity in health outcomes is due to physicians’ biases – biases that physicians are both aware they have (explicit bias) and bias that they are not aware they have (implicit bias or unconscious bias).

“In our study, we found that resident physicians who had symptoms of burnout were more likely to have both explicit and implicit bias. That means physician burnout may explain at least part of the disparities in health we see between black and non-black Americans. As burnout among resident physicians and physicians in practice is high (over 40%) the implications to the health of black Americans may be substantial,” she told MEAWW.

She further says, “Physicians with burnout are more likely to commit medical errors, be involved in medical malpractice litigation, and have a bias toward black patients. Additionally, physicians with burnout are more likely to reduce their clinical hours and leave their current job, both of which reduces access for patients. Substantial data exists demonstrating that burnout is a threat to the quality and safety of care. Additionally, burnout is costing the US approximately 4.6 billion dollars every year due to physicians leaving their jobs or reducing the amount of time they spent taking care of patients. It is important that organizations effectively address the factors that are contributing to burnout among physicians. Doing so is critical for all patients to receive compassionate care from competent physicians.”

The research team says as burnout among resident physicians and physicians in practice is high - over 40% - the implications for the quality of care provided to black Americans, as well as to other disadvantaged groups, could be substantial. (Getty Images)

While many studies have investigated how differences in physician care contribute to a higher incidence of many health conditions among black Americans, there is very little information on how a physician’s mental state can trigger these disparities. Accordingly, the researchers wanted to know if burnout affects the manifestation of bias in medical residents. They measured explicit bias on a “feeling thermometer” with the lowest score implying cold or unfavorable toward black people and the highest score indicating warm or favorable. Further, implicit bias was measured on a test that involved sorting pictures of white and black people and words to describe them, including ‘good’ and ‘bad.’ 

Data analysis was conducted from March 1, 2018, through December 21, 2018, and then again from April 30, 2019, to May 7, 2019. Among those studied, 1,529 of 3,380 resident physicians (45.2%) had symptoms of burnout, and 1,394 of 3,377 resident physicians (41.3%) had depression. The team - which also included researchers from Yale University, the University of Minnesota, Syracuse University, and Oregon Health & Science University - looked at the relationship between burnout and bias at the same point in time, and then they examined how burnout related to explicit bias a year later. Even after taking into account physicians’ age, gender, ethnicity, race, and specialty, the researchers found that symptoms of burnout were strongly associated with bias.

“Among resident physicians, symptoms of burnout appeared to be associated with greater explicit and implicit racial biases. Given the high prevalence of burnout among physicians and the negative implications of bias for medical care, symptoms of burnout may be factors in racial disparities in healthcare,” says the study.

Researchers conducted these surveys in the second and third years of residency to assess changes over time. Physicians experiencing high symptoms of burnout in the second year tended to respond with more racial bias, explicit and implicit, says the team. Significantly, the researchers found that treating burnout could make a tangible improvement in racial bias in the clinic. The reason: their findings show that while racial bias decreased across the board in the follow-up years, the most significant reduction in bias was in those physicians who could recover from their burnout by the third year.

“When we looked over the course of one year, we saw that as symptoms of burnout worsened, the physician’s explicit bias also worsened. In contrast, for physicians who recovered from burnout over the course of the year, their explicit bias also became lower. This finding suggests that a possible strategy to reducing disparity in care between white and blacks Americans is to implement strategies that reduce prevalence among physicians,” Dr. Dyrbye told MEAWW. 

The researchers suggest that treating burnout can make a big difference. They found that there was reduction in bias in those physicians who experienced burnout in the second year but had recovered from burnout by the third year. (Getty Images)

In an invited commentary on the study, experts state that given the strength of the study, it may be easy to conclude that burnout leads to bias among our resident physicians. However, they add, it is important to recognize that a causal association cannot be assumed on the basis of this study alone. “For example, it is possible that physicians with an underlying implicit or explicit bias are subject to greater moral distress when they are forced to reconcile their bias with the fact that they must treat all patients the same, regardless of the color of their skin. In this case, the root cause of the bias is not burnout. Rather, burnout is unmasking an underlying bias that had always existed," say the experts.
They add, “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. This is why addressing both burnout and bias together will be key to breaking the cycle,” say the experts.

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