Lower Likelihood of Burnout Among Family Physicians From Underrepresented Racial-Ethnic Groups

Montgomery Douglas; Emil Coman; Aimee R. Eden; Suleiman Abiola; Kevin Grumbach

doi:10.1370/afm.2696

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RE: Lower Likelihood of Burnout Among Family Physicians From Underrepresented Racial-Ethnic Groups
Ashley B Cremona-Simmons

Published on: 10 August 2021
RE: Lower LIkelihood of Burnout Among Family Physicians From Underrepresented Racial-Ethnic Groups
Jeannette E. South-Paul

Published on: 03 August 2021
RE: Finding the aspects of caring that make family doctors happy
John J Frey

Published on: 14 July 2021

Published on: (10 August 2021)
Page navigation anchor for RE: Lower Likelihood of Burnout Among Family Physicians From Underrepresented Racial-Ethnic Groups
RE: Lower Likelihood of Burnout Among Family Physicians From Underrepresented Racial-Ethnic Groups
Ashley B Cremona-Simmons, Resident Physician, OhioHealth Riverside Family Medicine Residency
In “Lower Likelihood of Burnout Among Family Physicians From Underrepresented Racial-Ethnic Groups'', Douglas et al determined that underrepresented individuals in medicine (UiM) were less likely to experience burnout.1 These findings are in stark contrast to overwhelming evidence of racial discrimination and stereotyping correlating to greater distress and depression scores among UiM. Douglas et al analyzed responses on an examination questionnaire regarding emotional exhaustion and depersonalization. To support their methods, they rationalized that emotional exhaustion and depersonalization are valid predictors of burnout on the Maslach Burnout Inventory (MBI). However, the MBI has multiple shortcomings including a lack of validation in UiM.2 This approach likely resulted in inaccurate findings and grossly under-reported physician burnout in an especially vulnerable and marginalized population.

The MBI assesses burnout using three subscales: emotional exhaustion, depersonalization, and reduced personal accomplishment.3 Several limitations, however, have been previously identified with the MBI. These limitations include using only negative wording to frame emotional exhaustion and depersonalization2 along with an unclear clear relationship between the concept of burnout and how it is measured.3 The MBI defines burnout using all three subscales but also states that each of these must be evaluated independently. The MBI’s most important limitation, however,...
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In “Lower Likelihood of Burnout Among Family Physicians From Underrepresented Racial-Ethnic Groups'', Douglas et al determined that underrepresented individuals in medicine (UiM) were less likely to experience burnout.1 These findings are in stark contrast to overwhelming evidence of racial discrimination and stereotyping correlating to greater distress and depression scores among UiM. Douglas et al analyzed responses on an examination questionnaire regarding emotional exhaustion and depersonalization. To support their methods, they rationalized that emotional exhaustion and depersonalization are valid predictors of burnout on the Maslach Burnout Inventory (MBI). However, the MBI has multiple shortcomings including a lack of validation in UiM.2 This approach likely resulted in inaccurate findings and grossly under-reported physician burnout in an especially vulnerable and marginalized population.

The MBI assesses burnout using three subscales: emotional exhaustion, depersonalization, and reduced personal accomplishment.3 Several limitations, however, have been previously identified with the MBI. These limitations include using only negative wording to frame emotional exhaustion and depersonalization2 along with an unclear clear relationship between the concept of burnout and how it is measured.3 The MBI defines burnout using all three subscales but also states that each of these must be evaluated independently. The MBI’s most important limitation, however, is the exclusion of racism, resilience, and isolation from analysis. Minority physicians are subject to microaggressions, bias, and discrimination creating social exclusion and isolation.2,4 In addition, minorities historically are plagued by stigma when confronting mental health issues.4 Minority physicians may be less likely to disclose symptoms of burnout on the MBI.4 Douglas et al failed to analyze the systemic barriers faced by UiM, to examine the intersectional nature of the minority experience and to account for cultural differences in reporting psychological distress.

To accurately assess physician burnout among underrepresented groups, researchers must work to develop validated culturally sensitive tools. To mitigate physician burnout and to improve public health, researchers must strive for inclusivity. Moreover, research should focus on the eradication of institutionalized racism ultimately creating a more diverse and supportive environment.

References
1.Douglas, M., Coman, E., Eden, A., Abiola, S. and Grumbach, K., 2021. Lower Likelihood of Burnout Among Family Physicians From Underrepresented Racial-Ethnic Groups. The Annals of Family Medicine, 19(4), pp.342-350.
2. Lawrence JA, Davis BA, Corbette T, Hill EV, Williams DR, Reede JY. Racial/Ethnic Differences in Burnout: a Systematic Review [published online ahead of print, 2021 Jan 11]. J Racial Ethn Health Disparities. 2021;1-13. doi:10.1007/s40615-020-00950-0
3. Kristensen, T., Borritz, M., Villadsen, E. and Christensen, K., 2005. The Copenhagen Burnout Inventory: A new tool for the assessment of burnout. Work & Stress, 19(3), pp.192-207.
4.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.2020.12762
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Competing Interests: None declared.
Published on: (3 August 2021)
Page navigation anchor for RE: Lower LIkelihood of Burnout Among Family Physicians From Underrepresented Racial-Ethnic Groups
RE: Lower LIkelihood of Burnout Among Family Physicians From Underrepresented Racial-Ethnic Groups
Jeannette E. South-Paul, Family Physician, Professor and Chair Emeritus, Univerwsity of Pittsburgh; J. South-Paul Academic Consultants, LLC
Lower Likelihood of Burnout Among Racial and Ethnic Minority Family Physicians
A Commentary
Jeannette E. South-Paul, MD, DHL (Hon), FAAFP
8 3 2021

Douglas and colleagues’ recently completed a cross-over observational survey of applicants from the 2017 American Board of Family Medicine recertification exam and those responding to the 2017 National Graduate survey. They noted a lower likelihood of burnout among family physicians from underrepresented racial-ethnic groups. They used structural equation models to test the effects of underrepresented status on measures of emotional exhaustion and depersonalization. Family physicians underrepresented in medicine were significantly less likely than their non-underrepresented counterparts to report emotional exhaustion and depersonalization, to practice in more racially and ethnically diverse counties and to practice obstetrics.
Studies such as this must focus on the data that are available and associated with the study participants. Nonetheless, professional factors influencing individual physician experiences necessarily layer upon personal characteristics and environment as well as historical experiences which are not available in databases. The epidemic of burnout among health care professionals has prompted ongoing analysis of these factors in the hope of interrupting the stressors that have devastated not only individual practitioners but their colleagues and the patients for whom they care....
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Lower Likelihood of Burnout Among Racial and Ethnic Minority Family Physicians
A Commentary
Jeannette E. South-Paul, MD, DHL (Hon), FAAFP
8 3 2021

Douglas and colleagues’ recently completed a cross-over observational survey of applicants from the 2017 American Board of Family Medicine recertification exam and those responding to the 2017 National Graduate survey. They noted a lower likelihood of burnout among family physicians from underrepresented racial-ethnic groups. They used structural equation models to test the effects of underrepresented status on measures of emotional exhaustion and depersonalization. Family physicians underrepresented in medicine were significantly less likely than their non-underrepresented counterparts to report emotional exhaustion and depersonalization, to practice in more racially and ethnically diverse counties and to practice obstetrics.
Studies such as this must focus on the data that are available and associated with the study participants. Nonetheless, professional factors influencing individual physician experiences necessarily layer upon personal characteristics and environment as well as historical experiences which are not available in databases. The epidemic of burnout among health care professionals has prompted ongoing analysis of these factors in the hope of interrupting the stressors that have devastated not only individual practitioners but their colleagues and the patients for whom they care.
Furthermore, the job stress and psychological strain of one individual impacts others in the same social environment. This ‘crossover phenomenon’ was described by Bolger and colleagues in 1989 and amplified by Bakker and colleagues almost 20 years later in relation to the impact of stress on the family partner. They called for further research of this crossover impact (e.g. depression, anxiety, exhaustion) among work partners. Bakker and Demerouti (2007b) later tested Westman and Vinokut’s (1998) hypothesis that empathy moderates the crossover of work engagement – the direct opposite of burnout.
Minorities are more likely to be attracted to and thrive in organizations that have substantial minority representation – a workforce situation that has been difficult to achieve at this time. As a result a number of programs such as those sponsored by the Association of American Medical Colleges have been instituted to bring minorities underrepresented in medicine and science together to nurture a sense of community and empathy while building skills to effectively compete in primarily majority institutions.
Meaning of life
More recent efforts by Hooker and colleagues to identify stressors as well as protective factors against burnout have resulted in the introduction of conceptual models spotlighting awareness of life meaning, or ‘meaning salience’, as anchors to improved stress and coping, and potentially reduced experience of burnout. They note this as another area under-researched with respect to burnout. A study of health care workers laboring during the SARS CoV2 pandemic noted the fear of exposure to the virus that was prevalent among nursing assistants and Black and Latinx workers, while housekeepers and Black and Latinx workers most often experienced enhanced meaning and purpose. In multilevel models, odds of burnout were 40% lower in those feeling valued by their organizations.
Moral resilience
In addition to recognizing the importance of finding meaning in life, health care professionals face a complexity of ethical challenges on a daily basis bringing attention to an awareness of the value of moral resilience in a challenging professional environment. Antonsdottir, Rushton and colleagues examined domains of moral resilience and their contribution to burnout over and above work and demographic variables. Moral resilience is described as the ability to preserve or restore integrity in response to moral adversity. The importance of assessing moral resilience is that it may be modifiable and provide an opportunity to intervene to achieve empowerment and growth.
One’s Journey
Above all, an area not measured in any of the current databases is an assessment of the journey faced by URM physicians as they pursue careers in medicine. Differential experiences of URMs on the journey into medicine have been documented for years but are only now getting more visibility. The well-known 1910 Flexner report (promoted as increasing the quality of medical education) resulted in the closure of all but two black medical schools – Meharry and Howard who educated the majority of black physicians at that time. There was limited access for underrepresented minority (URM) students to majority medical schools up until the last 40 years to include having fewer black males matriculating in medical schools in 2014 than occurred in 1978 and they experienced isolation and stereotypical behaviors.
Furthermore, little research has focused on the impact of faith-based institutions in anchoring success in the black community. Historically black colleges and universities were largely launched by the United Methodist Church and a few by other denominations. Campaigns for freedom, civil and voting rights, and safety and liveable communities were largely led by black and later LatinX clergy. Thus, most black, LatinX, and indigenous citizens were raised with a respect and comfort in a faith anchor for the journey of life. This spiritual lens has allowed many minorities to position the stressors of life – both personal and professional – as stages of a journey that may result in detours but will ultimately result in success. Until these critical factors undergirding the experiences of those racial and ethnic groups underrepresented in medicine are explored further and understood, appropriate steps for reducing burnout will be inadequate.

References
1. Panagioti M, Geraghty K, Johnson J, et al. Association between physician burnout and patient safety, professionalism, and patient satisfaction: A systematic review and metaanalysis. JAMA Intern Med. 2018;178:1
2. Bolger, N., DeLongis, A., Kessler, R., and Wethington, E. (1989). The contagion of stress across multiple roles. Journal of Marriage and the Family, 51, 175-183
3. Westman M, Bakker AB. Crossover of burnout among health care professionals (Ch 9). In Handbook of Stress and Burnout in Health Care ISBN 978-1-60456-500-3 Editor: Jonathon R. B. Halbesleben, pp. © 2008 Nova Science Publishers, Inc.
4. Bakker and Demerouti (2007b). The crossover of work engagement: A closer look at the role of empathy. Manuscript submitted for publication.
5. Westman, M., and Vinokur, A. (1998). Unraveling the relationship of distress levels within couples: Common stressors, emphatic reactions, or crossover via social interactions? Human Relations, 51, 137-156.
6. AAMC Minority Faculty Leadership Program. https://web.cvent.com/event/b207582a-aa58-44d0-b477-1d12b48d0066/summary... 8 3 2021
7. Hooker SA, Post RE, et al. Awareness of meaning in life is protective against burnout among family physicians: a CERA study. Fam Med 2020;52(1):11-16.
8. Prasada K, McLoughlin C, Stillman M, et al. Prevalence and correlates of stress and burnout among US healthcare workers during the COVID-19 pandemic. EClinicalMedicine Published May, 16, 2021. https://doi.org/10.1016/j.eclinm.2021.100879
9. Antonsdottir I, Rushton CH, Nelson KE, et al. Burnout and moral resilience in interdisciplinary healthcare professionals. J Clin Nurs 20321;00:1-13.
10. Sullivan LW, Mittman IS. The state of diversity in the health professions a century after Flexner. Acad Med 2010;85:246-253.
11. Solomon S, Atalay AJ, Osman NY. Diversity is not enough: Advancing a framework for antiracism in medical education. Acad Med doi: 10.1097/ACM.0000000000004251)
12. Gallegos A. AAMC report shows decline of black males in medicine. AAMC News. Published September 27, 2016. Accessed July 1, 2021. https://www.aamc.org/newsinsights/aamc-report-shows-decline-black-males-...
13. Osseo-Asare A, Balasuriya L, Huot SJ, et al. Minority resident physicians’ views on the role of race/ethnicity in their training experiences in the workplace. JAMA Netw Open. 2018;1(5):e182723.
14. Wheeler M, de Bourmont S, Paul-Emile K, et al. Physician and trainee experiences with patient bias. JAMA Intern Med. 2019;179(12):1678-1685.
15. Krupat E, Camargo CA, Espinola JA, et al. A snapshot of underrepresented physicians 15 years after medical school. Adv Health Sci Educ Theory Pract. 2020;25(3):711-730.
16. Bullock JL, Lockspeiser T, del Pino-Jones A, et al. They don’t see a lot of people my color: A mixed methods study of racial/ethnic stereotype threat among medical students on core clerkships. Acad Med. 2020;95(11 Suppl):S58-S66
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Competing Interests: None declared.
Published on: (14 July 2021)
Page navigation anchor for RE: Finding the aspects of caring that make family doctors happy
RE: Finding the aspects of caring that make family doctors happy
John J Frey, Family Doctor, University of Wisconsin School of Medicine and Public Health
The article by Douglas et.al. is an important contribution to what must be an ongoing search in family medicine to identify factors which are likely to contribute to satisfaction and a positive spirit in family physicians.

Medicine is about service - to patients and communities. This study, not surprisingly to many of us, finds that family physicians from underrepresented groups in society have a more positive attitude about their work - and coincidentally, their work is often in more challenging communities. Three quarters of a century ago, the Psychiatrist Robert Coles in his landmark five volume series Children of Crisis (Little Brown and Co Publisher) focused on how children subjected to dire conditions of poverty, racism and general deprivation managed to surmount those challenges and go on to successful adulthood and lives of service. Supportive family members, teachers, and adults were critical to children finding resilience.

My suspicion is that, when the next stage of the research by Montgomery and his colleagues gets underway to find out why and how the family physicians from underrepresented groups in their study find a more positive and satisfying life's work, they may find some of the same factors as Coles did with children. A sense of purpose, service and positive contribution to communities that many family physicians feel will add to that resilience and, I hope, sustain the discipline and inspire more young people to lives caring for th...
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The article by Douglas et.al. is an important contribution to what must be an ongoing search in family medicine to identify factors which are likely to contribute to satisfaction and a positive spirit in family physicians.

Medicine is about service - to patients and communities. This study, not surprisingly to many of us, finds that family physicians from underrepresented groups in society have a more positive attitude about their work - and coincidentally, their work is often in more challenging communities. Three quarters of a century ago, the Psychiatrist Robert Coles in his landmark five volume series Children of Crisis (Little Brown and Co Publisher) focused on how children subjected to dire conditions of poverty, racism and general deprivation managed to surmount those challenges and go on to successful adulthood and lives of service. Supportive family members, teachers, and adults were critical to children finding resilience.

My suspicion is that, when the next stage of the research by Montgomery and his colleagues gets underway to find out why and how the family physicians from underrepresented groups in their study find a more positive and satisfying life's work, they may find some of the same factors as Coles did with children. A sense of purpose, service and positive contribution to communities that many family physicians feel will add to that resilience and, I hope, sustain the discipline and inspire more young people to lives caring for their communities. Coles focused on children who were successful in their lives, despite obstacles, as a way to help other children in the future. We need to do the same with family doctors.
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Competing Interests: None declared.