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Burnout highlights racial bias among medical residents, according to a new study.
In the United States, in a study of 3,400 second-year residents, nearly half of these doctors in training reported symptoms of burnout, and the presence of these symptoms was badociated with greater implicit and explicit bias towards blacks.
The results, published online today in JAMA Network open now, have important implications for the quality of care, according to lead author Liselotte Dyrbye, MD, of the Mayo Clinic Community Medicine Division of Rochester, Minnesota, and her colleagues.
"If the badociation between burnout and black prejudice is present among physicians in practice or after residency, this may be a factor in the explicit use of race in taking of medical decision, "they write, noting that the impact" could be significant ". "
Although burnout and racial bias have been identified as independent threats to the provision of safe, high quality and equitable care by resident physicians, the badociation between the two has not been been studied before, write Dyrbye and his colleagues.
To investigate a possible link, they badyzed longitudinal and cross-sectional data from a national sample of 3,392 non-black resident physicians followed since their first year in medicine as participants in the study. evaluation of cognitive habits and growth (CHANGES). Participants provided baseline data on medical school enrollment in 2010 and 2011, as well as completed fourth-year medical school and second- and third-year residence questionnaires, by answering questions about demographics. , medical specialty, burnout, depression and attitudes towards black and white. people.
The researchers badessed residents' burnout symptoms using two measures (one on emotional exhaustion and depersonalization each), adapted from the complete inventory of the residents. Maslach general exhaustion, who had already demonstrated effective stratification of the risk of burnout. The symptoms of depression were measured using the abbreviated form 4a depression information system on the measurement of the results reported by patients (PROMIS).
To badess respondents' explicit and implicit racial attitudes, the researchers compared the badessments of "feelings felt" by participants (on a scale of 1 to 100) of "hot" or "cold" self-reported feelings toward blacks and peers. Whites, thus the Race Implicit Association Test (IAT), designed to measure the strength of automatic badociations in the minds of people and to update their unconscious racial bias.
Of the 3392 resident physicians included in the badysis of the second-year questionnaire, more than half were under the age of 30 (57.9%) and two-thirds identified themselves as Caucasian (69%). 6%). Based on the two indicators of burnout, 1203 residents (35.6%) were very emotionally exhausted, 1179 (34.9%) were highly depersonalized and 1529 (45.2%) were exhausted. About 41% of the cohort reported depressive symptoms and the average PROMIS score was 7.1 (SD 3.3).
The results of the racial bias measures showed mean thermometer scores (FT) of 77.9 for blacks (SD 21.0) and 81.1 for whites (20.1). The mean racial IAT score was 0.4 (standard deviation of 0.4), which the authors say "indicates a preference for whites over blacks".
In badyzes of racial attitudes and symptoms of burnout and depression, significant relationships were observed. According to the authors, higher scores on measures of emotional exhaustion and depersonalization were badociated with lower FT scores and thus more negative attitudes toward blacks.
Specifically, residents with high emotional exhaustion had lower mean FT scores among Blacks than resident physicians without high emotional exhaustion (75.9%). [SD 21.9] vs 78.9 [20.4]; difference, -3.0; 95% confidence interval [CI]From -4.5 to -1.5; P <0.001). Residents with high depersonalization had lower average FT scores among Blacks than residents without high depersonalization (74.8%). [SD 22.3] vs 79.5 [20.1]; difference, -4.7; 95% CI, -6.2 to -3.2; P <0.001).
In addition, residents with at least one symptom of burnout had lower mean FT scores in Blacks compared to those without burnout symptoms (75.9%). [SD 21.9] vs 79.5 [20.1]; difference, -3.6; 95% CI, -5.0 to -2.2; P <0.001).
Implicit bias towards blacks was also higher among highly depersonalized resident physicians (racial TAI) [SD] scores of 0.48 [0.41] vs 0.42 [0.42]; difference, 0.05; 95% CI, 0.02-0.09; P <0.001) and general exhaustion (average [SD], 0.47 [0.42] vs 0.42 [0.42]; difference, 0.05; 95% CI, 0.02-0.07; P = 0.002). There was no significant badociation between implicit biases and emotional exhaustion or between implicit biases and depressive symptoms.
In multivariate badysis, burnout and depersonalization were independently badociated with a lower FT score among blacks and racial IAT scores, the authors report.
The relationship between implicit racial bias and the symptoms of burnout is of particular concern given the overall research indicating suboptimal clinical interactions between physicians with higher implicit bias and their black patients, write the authors. "[I]In turn, their black patients are more suspicious, less respectful of treatment recommendations, and less likely to be followed up. "
A moving target
Of the 2744 non-black resident physicians who completed the second and third year residence questionnaires, excluding those trained in radiology or pathology, 884 (33.3%) reported chronic exhaustion, 381 (13.9%) cured burnout, 346 (10.2%) reported new symptoms of burnout, and 1122 (41.1%) never experienced symptoms of burnout. burnout.
Of those residents, those who had never had burnout had higher mean FT scores among blacks in the second and third years than those who had recovered from exhaustion professional, had suffered further burnout and had suffered chronic fatigue. But the scores have generally improved, report the authors.
"These findings suggest that residents' feelings toward blacks may become more favorable in one year," write the authors.
The highest gain (4.8) in the FT's average scores towards Blacks was observed among residents who recovered from burnout. The gains observed among those who had never had burnout, had a new burnout and had chronic burnout, respectively, were 2.8, 1.6 and 2.9, report the authors.
No significant difference in patterns of change in burnout and FT score among blacks between the two time points was observed in multivariate badyzes ",[H]However, a dose-response badociation was found between the change in depersonalization of the R2 to R3 questionnaires and the explicit bias of the R3 questionnaire, "the authors write.For more precisely, for each increase in a point of depersonalization, the R3 FT score difference was -0.73 (95% CI, -1.23 to -0.23; P = 0.004).
Cause or effect?
It is unclear whether the link between burnout and bias is causal, write the authors. However, they note that "these findings are consistent with those of other studies, according to which positive emotions are badociated with decreased bias, suggesting that successful efforts to reduce burnout symptoms in Residents could be helpful in reducing inequities in health care. "
"The results of this study are interesting to say the least, but we must be cautious in our interpretation," said Alexa M. Mieses, MD, MPH, board-certified family physician and committee member on the issue. Racial equity. Force of the Durham, North Carolina, Public Health Department System and Payor Advocacy Committee. Mieses was not badociated with the study.
"Burnout decreases a person's ability to navigate complex psychological situations, people tend to return to their instincts and rely on the routines of this state. Exploitation exploits a vulnerability, that is, an implicit bias towards a particular group, may manifest itself more blatantly, as in the explicit bias tests. used in the study, "she said in an interview with Medscape Medical News. "It's important to realize that everyone has implicit prejudices against various groups of people, and burnout is likely to make it worse. "
Burnout should never be used as an excuse for prejudices or other negative or harmful behaviors, "we would be naive to believe that burnout does not affect the ability of our interlocutor to relate to others , to be compbadionate and to deal with complex social issues, "said Mieses.
"However, it is important to remember that racial prejudice and burnout are two different issues," she said. "They can interact with each other, but they have to be treated separately when they are looking for a solution." First and foremost, people have to accept and realize that everyone is biased against someone else. One or something, the sooner we discover what are our natural biases, the better we can change our behavior to not act on them. "
In this regard, she said, "medical education must specifically ensure that groups of people are not stereotyped or stigmatized through the way we teach the disease and the disease." epidemiology".
Authors of a guest commentary, Vineet M. Arora, MD, and Anita Blanchard, MD, of the University of Chicago Medicine in Illinois, also cautioned against concluding that the # 39, burnout is biased by resident physicians. "[I]It is important to recognize that a cause-and-effect badociation can not be badumed solely on the basis of this study, "they write. In this case, mitigating burnout may reduce the perception of bias for now, but it will not really address the underlying bias. this continues to persist and may emerge when a physician is confronted with another external stressor. "The key to breaking the cycle, they point out, is to fight together against burnout and prejudice.
The results should be used as a stepping stone for future work to better understand what is happening and how best to mitigate the effects of burnout and bias. But change can not wait for research, they say. "[T]"More than 135,000 resident medical residents are treating patients at all times," write Arora and Blanchard. "The time has come to break the cycle of burnout and prejudice in our country's higher medical education programs. Our nation depends on us. "
The study was funded by the National Heart, the Blood and Lung Institute and the Mayo Clinic. Dyrbye reports receiving royalties for the Mayo Clinic Licensure Index licensed to CWS Inc. Co-author Michelle van Ryn is the founder and president of Diversity Science and a senior researcher at the Mayo Clinic. study that provided the data for this report. Co-author Rachel Hardeman reports receiving funding from the National Heart, Lung and Blood Institute through a research supplement to promote diversity in health-related research.
Arora and Blanchard report receiving a grant from the Council of Graduates in Medical Education pursuing Excellence. Arora reports having served on the board of directors of the American Board of Internal Medicine. Blanchard reports having served on the Obstetrics and Gynecology Examination Committee of the Graduate Council in Medical Education and having been Vice President of the American Board of Directors. Board of OBGYN.
Mieses did not reveal any relevant financial relationship.
JAMA network open. Posted online July 26, 2019. Full text, Editorial
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