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    Original Investigation
    Medical Education
    July 26, 2019

    Association of Racial Bias With Burnout Among Resident Physicians

    Author Affiliations
    • 1Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
    • 2Department of Internal Medicine, Yale School of Medicine, Charlottesville, Virginia
    • 3Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
    • 4Department of Psychology, Yale University, New Haven, Connecticut
    • 5School of Public Health, Division of Health Policy and Management, University of Minnesota, Minneapolis
    • 6Department of Psychology, Syracuse University, Syracuse, New York
    • 7Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
    • 8Department of Family Medicine and Community Health, University of Minnesota, Minneapolis
    • 9School of Nursing, Oregon Health and Science University, Portland
    JAMA Netw Open. 2019;2(7):e197457. doi:10.1001/jamanetworkopen.2019.7457
    Key Points español 中文 (chinese)

    Question  Are symptoms of burnout associated with resident physicians’ implicit and explicit biases toward black people?

    Findings  In this cohort study of 3392 second-year resident physicians who self-identified as nonblack, symptoms of burnout were associated with greater explicit and implicit racial biases. Recovery from burnout in the third year of residency was associated with the greatest reduction in explicit bias toward black people.

    Meaning  Given the high prevalence of burnout among resident physicians and the negative association between bias and suboptimal medical care, symptoms of burnout may be factors in disparities in care; the implications for the quality of care provided to black people and other disadvantaged groups could be substantial.


    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.