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

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