Are Hispanic, Black, and Asian Physicians Truly Less Burned Out Than White Physicians? Individual and Institutional Considerations | Depressive Disorders | JAMA Network Open | JAMA Network
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Invited Commentary
Health Policy
August 7, 2020

Are Hispanic, Black, and Asian Physicians Truly Less Burned Out Than White Physicians?Individual and Institutional Considerations

Author Affiliations
  • 1Center for State Health Policy, Rutgers, The State University of New Jersey, New Brunswick
  • 2Edward J. Bloustein School of Planning and Public Policy, Rutgers, The State University of New Jersey. New Brunswick
JAMA Netw Open. 2020;3(8):e2013099. doi:10.1001/jamanetworkopen.2020.13099

Garcia and colleagues1 delve into an understudied but vitally important physician workforce concern: professional burnout. Their work draws on a national survey of physicians with a sample large enough to examine differences in important metrics by race/ethnicity. Given the long-standing struggle to improve the diversity of the medical profession, examining the extent of burnout among physicians of minority racial/ethnic groups is imperative.

As Garcia and colleagues1 note, their findings may be counterintuitive to some. Multivariable models adjusting for specialty, workload, practice setting, age, and sex show that physicians in minority racial/ethnic groups (ie, Hispanic/Latinx, non-Hispanic Black, and non-Hispanic Asian physicians) had considerably lower rates of burnout than their White counterparts. Given the literature on experiences of discrimination and career pressures among Hispanic/Latinx, Black, and Asian physicians,2 one might expect more, not less, burnout. How can this be?

We need first to consider the possibility that this result may not truly reflect better practice circumstances or more resilient personal characteristics of these physicians. Although the data used by Garcia and colleagues1 have strength in their national scope and detailed measures, the sample sizes are not large enough to enable full disentangling of the association between race/ethnicity and burnout.

Garcia and colleagues1 use multivariable models to control for key cofactors to isolate the independent association between race/ethnicity and burnout, but such modeling can also mask important associations. We believe that controls for practice specialty are especially suspect in this regard. Prior work has shown that primary care physicians experience more burnout than specialists3 and that physicians of minority racial/ethnic groups are more likely to practice primary care.4 Therefore, it could be that controlling for specialty in the multivariate model masks the extent of burnout experienced by physicians from underrepresented groups compared with their White counterparts. If this is so, the findings of the study by Garcia and colleagues1 are less comforting. It is critical that future studies use large data sets with modeling approaches like nesting, stratification, or interaction terms to disentangle these and possibly other critical associations.

Although nationally representative surveys are important tools for understanding workforce dynamics, studies relying on survey research must be carefully scrutinized. Survey research has become extraordinarily challenging, particularly because response rates have steadily declined. One cannot automatically infer bias from low response rates, and surveys remain important tools for assessing workforce stress; however, going forward, research techniques that include analysis of administrative records and in-depth qualitative methods should be used to complement surveys.

Methodological issues aside, if we accept that physicians in minority racial/ethnic groups demonstrate less burnout than White physicians, the search for protective factors is important. Drawing on a cross-sectional study at a single point in time, Garcia and colleagues1 note that their research can serve only to raise hypotheses that may explain these differences. For example, they suggest that their finding of more favorable reports of work-life balance among Black physicians supports the idea that Black physician resilience is bolstered by stronger family support. They also posit that workforce dynamics, possibly stemming from greater early attrition among medical students and physicians of minority racial/ethnic groups, selects for more resilient physicians from underrepresented groups over time. These hypotheses deserve testing in future research using large representative surveys, longitudinal designs, and other strategies.

We believe that there may be other factors in play. First, graduating medical students from underrepresented groups are disproportionately more likely to express interest in working with underserved populations,5 suggesting that physicians of minority racial/ethnic groups have different expectations about the realities of practice (and perhaps greater intrinsic motivation to address the needs of patients with complex social and health challenges). Those from more privileged backgrounds may lament that medicine is “not your father’s profession” more than the slowly growing diverse new generation of physicians.

Organizational trends and regional variations may also be factors. Although Garcia and colleagues1 were able to control for broad categories of practice setting (eg, private practice vs academic medical center), substantial changes are afoot in the organization and ownership of medical practice that are not captured in their data. For instance, there is a distinct pattern toward physician employment in hospitals and health system acquisition of physician practices.6 Private equity firms have also aggressively acquired practices in high-revenue specialties.7 How pressures from new ownership relationships may drive levels and disparities in physician burnout is an area ripe for future research.

Market-level differences affecting medical practice, with concomitant variations in forces promoting burnout, are likely large. The organization of medical practice varies across markets, and certainly the legacy of discrimination and integration of people of minority racial/ethnic groups in medicine, however gradual, varies regionally. Examining these factors, at the very least studying regional differences, can shed light on the dynamics of burnout and other practice outcomes and should be incorporated into future research.

Future work must also examine the implications of the COVID-19 pandemic on stress, trauma, and burnout among physicians. The pandemic has brought inequalities and flaws of US health care into sharp focus. Communities in minority racial/ethnic areas are being disproportionately affected by SARS-CoV-2, and the extraordinary stresses of the pandemic are having outsized consequences on physicians caring for underserved populations. These are disproportionately physicians of minority racial/ethnic groups.5

The work by Garcia and colleagues1 raises important questions. As the nation grows more diverse, identifying forces undermining the vitality of the physician workforce is as important now as ever, particularly so for physicians from groups underrepresented in medicine. Fairness dictates that we strive for equal opportunities in health care careers for persons of minority racial/ethnic groups. Improving accessibility and effectiveness of care for underserved patients, especially in these most dire of times, depends on it.

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Article Information

Published: August 7, 2020. doi:10.1001/jamanetworkopen.2020.13099

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Cantor JC et al. JAMA Network Open.

Corresponding Author: Joel C. Cantor, ScD, Center for State Health Policy, Rutgers, The State University of New Jersey, 112 Paterson St, Fifth Floor, New Brunswick, NJ 08901 (jcantor@ifh.rutgers.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Garcia  LC, Shanafelt  TD, West  CP,  et al.  Burnout, depression, career satisfaction, and work-life integration by physician race/ethnicity.   JAMA Netw Open. 2020;3(8):e2012762. doi:10.1001/jamanetworkopen.2020.12762Google Scholar
2.
Nunez-Smith  M, Pilgrim  N, Wynia  M,  et al.  Race/ethnicity and workplace discrimination: results of a national survey of physicians.   J Gen Intern Med. 2009;24(11):1198-1204. doi:10.1007/s11606-009-1103-9 PubMedGoogle ScholarCrossref
3.
Shanafelt  TD, Boone  S, Tan  L,  et al.  Burnout and satisfaction with work-life balance among US physicians relative to the general US population.   Arch Intern Med. 2012;172(18):1377-1385. doi:10.1001/archinternmed.2012.3199 PubMedGoogle ScholarCrossref
4.
Xierali  IM, Nivet  MA.  The racial and ethnic composition and distribution of primary care physicians.   J Health Care Poor Underserved. 2018;29(1):556-570. doi:10.1353/hpu.2018.0036 PubMedGoogle ScholarCrossref
5.
Garcia  AN, Kuo  T, Arangua  L, Pérez-Stable  EJ.  Factors associated with medical school graduates’ intention to work with underserved populations: policy implications for advancing workforce diversity.   Acad Med. 2018;93(1):82-89. doi:10.1097/ACM.0000000000001917 PubMedGoogle ScholarCrossref
6.
Inserro  A. Hospital acquisitions of physician practices continue. Published February 26, 2019. Accessed May 7, 2020. https://www.ajmc.com/newsroom/hospital-acquisitions-of-physician-practices-continue
7.
Casalino  LP, Saiani  R, Bhidya  S, Khullar  D, O’Donnell  E.  Private equity acquisition of physician practices.   Ann Intern Med. 2019;170(2):114-115. doi:10.7326/M18-2363 PubMedGoogle ScholarCrossref
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