Much research has gone into studying patient race and ethnicity and their effect on the care received. Medscape's Oncologist Lifestyle Survey asked oncologists how they racially and ethnically self-identify in order to explore associations with patient care, personal choices, and levels of happiness. The survey also posed questions from previous years about burnout, bias, and other lifestyle factors. More than 14,000 physicians from over 27 specialties responded and provided some surprising results.

Note: Values in charts have been rounded and may not match the sums described in the captions.

The Medscape survey once again asked physicians about burnout, which is defined in this and other major studies as a loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.^[1] Burnout rates for all respondents have been trending up since 2013, the first year that Medscape examined them, when the overall rate was 40%. This year, it is 51%, more than a 25% increase over just 4 years. The results of another recent, major survey support this unfortunate trend, finding that burnout had worsened between 2011 and 2014, with more than half of physicians reporting it.^[2]

In this year's Medscape report, 47% of oncologists reported burnout, seventh from the bottom among all physicians. The highest percentage occurred among those practicing emergency medicine (59%), followed by ob/gyns (56%) and family physicians, internists, and infectious disease physicians, all at 55%. These groups all deal directly with patients, often in exigent circumstances. Emergency medicine physicians, family physicians, and internists ranked in the top five in Medscape's 2015 and 2016 reports as well. Not surprisingly, other research has found high burnout rates in these groups.^[3-6]

Oncologists were asked to rate the severity of their burnout on a scale of 1 to 7, where 1 equals "It does not interfere with my life" and 7 equals "It is so severe that I am thinking of leaving medicine altogether." Of the oncologists who reported burnout, the average severity rating was 4.5, third highest among all physicians.

Of note, although relatively high percentages of emergency and family physicians said that they experienced burnout, their average severity ratings fell below the middle, at 4.2. Urologists' rating was the highest, at 4.6, followed by otolaryngologists' and oncologists', both 4.5. Surprisingly, while infectious disease physicians were fifth most likely to be experiencing burnout, their severity rating was the lowest: 3.9.

Oncologists were asked to rate the causes of their burnout on a scale of 1 to 7, where 1 equals "Does not contribute at all" and 7 equals "Significantly contributes." Topping the list was "too many bureaucratic tasks," followed by "spending too many hours at work" (both rounding to 5.2). "Increasing computerization," at 4.6, was third highest.

In an October 2016 Medscape roundtable discussing electronic health records (EHRs) and burnout, one of the panelists, Robert W. Brenner, MD, said, "If [EHR requirements are] implemented without a change in the workflow in the office, too much data entry falls on the physician. That is what is adding to the huge burden."

Three options were added to this year's survey because they were mentioned frequently as important contributions to burnout in write-in responses last year. They are "insurance issues," which oncologists rated at 4.2, and "threat of malpractice" and "family stress," both rated 3.4.

In this year's Medscape Lifestyle Report, a higher percentage of female oncologists (53%) reported burnout than their male peers (44%). Percentages have trended sharply up for men and down for women since this question was first asked in Medscape's 2013 survey. That year, 36% of men and 56% of women reported burnout.

Using US Census Bureau criteria,^[7] we asked physicians about their race or ethnicity. Because such classifications are not necessarily straightforward, respondents could choose more than one option, and about 5% did so. That being considered, the majority (59%) of oncologists identified as white/Caucasian. Following in prevalence were those describing themselves as Asian Indian (12%), other Asian (6%), and Chinese (5%).

A 2015 Kaiser Family Foundation report on medical school graduates' race, based on data from the Association of American Medical Colleges,^[8] found 7% of respondents self-identifying as multiracial, 58.8% white/Caucasian, 19.8% Asian, 5.7% black/African American, and 4.6% Hispanic/Latino.^[9] These findings may suggest a decline in the percentage of all physicians who are white/Caucasian and a slight increase in those who are black/African American.

In this year's Medscape report, among racial/ethnic groups that comprised more than 4% of oncologists, the percentage of female relative to male respondents was generally low. The highest percentage of women occurred among those who described themselves as other Asian (50%). The lowest was among those who identify as Asian Indian (32%). Among white/Caucasian oncologists, 65% are men and 35% are women.

The highest percentage of women (63%) among all physicians in this year's report occurred among black/African American respondents, and the lowest (38%) among whites/Caucasians. This finding mirrored a survey by the American Association of Medical Colleges, which concluded that among physicians of all ages, female black/African American physicians were the only non-white group in which there is currently a higher percentage of women than men. Among physicians age 29 and younger, however, there are also more female than male Asians and Hispanics/Latinos. Furthermore, the survey concluded that among black/African American medical school applicants, fully two thirds are female.^[10]

This year's responses indicated some association between race/ethnicity and burnout in oncologists. Among groups comprising more than 4% of respondents, the highest percentages occurred in those who identified themselves as Chinese (62%) or other Asian (50%). Asian Indian oncologists, at 38%, were least likely to report burnout among these racial and ethnic groups.

A 2007 study of medical students found that 47% experienced burnout, and the rate was lower among non-whites than whites.^[11] Notably, however, non-white students who had experienced adverse treatment due to their race had a higher burnout rate than their non-white peers. (There was no difference, though, in the percentages of those who reported that they were depressed.) A study on race and work-related stress found that, in general, non-white physicians face a more demanding patient base than do their white peers. Nevertheless, Hispanic/Latino and black/African American physicians reported no difference in stress from their white peers, although Asians and Pacific Islanders reported higher average stress than white physicians.^[12]

In this year's Medscape report, oncologists were asked if they believed that they had biases toward specific types or groups of patients, and respondents could choose more than one option. Keeping in mind that these results include only groups that comprise more than 4% of respondents, self-identified Chinese oncologists most frequently admitted to biases toward certain patient populations, at 77%. Among white/Caucasian respondents, the largest racial/ethnic group, 35% acknowledged biases.

In addition to small sample sizes, a limiting factor in the Medscape survey and other studies involving race and ethnicity is implicit bias, which occurs without conscious awareness. Implicit bias is frequently at odds with one's reported feelings and beliefs, and it is more likely that attitudes toward whites will be more positive while negative biases are more often found directed towards non-whites.^[13,14]

When oncologists who admitted biases toward patients with specific characteristics were asked to identify them, half (50% of women, 49% of men) chose emotional problems. More male than female oncologists cited perceived low intelligence (49% vs 39%, respectively) and heavier weight (42% vs 32%).

Ten percent of oncologists who admitted bias said that it affects their treatment. This places them fifth from the bottom among all respondents. Critical care physicians ranked highest at 24% and psychiatrists and nephrologists were second and third at 23%. Pathologists were least likely to report that bias affected their patient care, at 6%.

Some research suggests that implicit bias might affect physicians' judgment.^[13] In one study, although implicit bias did not have an effect on treatment recommendations, physicians were more likely to view white patients as "cooperative" than black patients, which, they admitted, could have influenced their decisions.^[15]

Medscape asked whether the effect of bias on treatment was positive (eg, extra time spent, friendlier manner) or negative (eg, less time spent, less friendly manner), and respondents could answer "yes" to both. Of the 10% of oncologists who acknowledged an effect, the highest percentages admitted to negative treatment of patients lacking insurance coverage (67%) and those with perceived low intelligence or language differences (50% for each). The highest percentage of positive treatment triggered by bias was toward older patients (60%).

Twenty percent of oncologists who answered this question acknowledged negative treatment of patients whose race or ethnicity differed from their own. Of note, one analysis of studies on the relationship between patients' race/ethnicity and care found that there was greater overuse of care among white patients, though the reasons for this are unclear.^[16]

In general, higher percentages of oncologists age 45 and under acknowledged biases than did those over age 45. More than half (54%) of younger respondents expressed bias toward patients with emotional problems, compared with only 26% of their older peers. And 49% of younger oncologists, compared with 32% of older ones, admitted bias toward patients with perceived low intelligence. The only patient characteristic implicated more often by older respondents was heavier weight.

In this survey, there appeared to be some relationship between spiritual or religious belief and bias among oncologists. Of those who report that they have a spiritual belief, 33% admit to being biased. Of those with no belief, a larger 48% admit to bias.

Oncologists' political leanings on social issues may have some relationship to their reported bias, with more socially liberal respondents admitting to bias than their socially conservative peers (43% vs 28%).

The lifestyle survey, like in previous years, asked physicians to rate their happiness at work and outside of work on a scale of 1 to 7, with 1 equaling "extremely unhappy" and 7 equaling "extremely happy." Among oncologists, 62% of women compared with 56% of men said they are very to extremely happy outside of work; 36% of both men and women reported high happiness levels at work. Both male and female oncologists, however, are far happier outside of work.

Among all physicians reporting that they are very or extremely happy outside of work, oncologists ranked seventh from the bottom, at 58%. They ranked seventh from the top among those reporting that they are happy at work, at 36%. In this year's report, dermatologists (43%) and ophthalmologists (42%) ranked first and second for happiness at work, which was also the case in the 2016 and 2014 reports. The happiest physicians outside of work this year were urologists, at 69%, followed by ophthalmologists and dermatologists, both at 67%.

Burnout appears to have a marked effect on oncologists' non-work lives. Only 43% of burned-out respondents are very or extremely happy outside the workplace compared with 71% of those who are not burned out.

Burnout seems to have an even more pronounced negative effect on oncologists' happiness at work. Sixty-one percent of respondents with no burnout claimed to be very or extremely happy at work compared with a dismal 8% of their burned-out peers.

There appears to be little relationship between oncologists' burnout and getting regular exercise. Sixty-six percent of non-burned-out compared with 61% of burned-out respondents reported exercising at least twice a week.

According to the most recent report on the topic from the Centers for Disease Control and Prevention, the prevalence of obesity among American adults in 2011-2014 was 36.5%, a rate that has remained relatively unchanged since 2003.^[17] The 2013 JAMA Internal Medicine study of lifestyle behaviors in healthcare workers^[18] showed little difference in rates of overweight or obesity between the healthcare professionals studied and their patients.

Oncologists who reported their body mass index in the Medscape survey do better than the general public, but a significant number are overweight or obese. Burnout may play a small role, with 41% of burned-out oncologists acknowledging that they are overweight to obese compared with 36% of those who are not burned out.

According to the latest government statistics on alcohol use, 71% of American adults said they drank within the past year and 57% in the past month.^[19] Medscape oncologist respondents report very light to moderate drinking habits, but burnout does appear to play a role. Twenty-four percent of those reporting burnout had at least one drink per day compared with 19% of those who were not burned out.

Among oncologists responding to the Medscape survey, 61% of men and 60% of women reported having adequate savings or more, while 35% of men and 38% of women said they have minimal or no savings.

Among oncologists, only slightly more men have no debt than their female peers (33% vs 30%). When they did report having debt, 61% of female and 57% of male oncologists said it is manageable, and only 9% of men and 7% of women reported unmanageable debt.

In spite of the ongoing income disparity between all male and female physicians, as reported in this year's Medscape Compensation Report, fewer male (47%) than female oncologists (53%) believe that their current income and assets are sufficient to meet their needs. Thirty-nine percent of men and 34% of women said that their income and assets are not sufficient right now but that they expect them to improve, while 14% of men and 13% of women have no hope of seeing improvement.

Debt appears to have a marked relationship to burnout for nearly every specialty. With the exception of neurologists, more non–burned-out physicians are debt-free compared with their burned-out peers. There are some interesting surprises, however. Urologists reported the highest severity rating of burnout (4.6) and are the specialists with the largest disparity between burned-out and non–burned-out physicians with regard to debt; almost one half (42%) of non–burned-out urologists are debt-free, double the percentage (20%) of their burned-out peers in the same position. In contrast, emergency medicine physicians had the highest frequency of burnout, but there was little difference in percentages of burned-out and non–burned-out emergency medicine physicians reporting that they were debt-free (23% vs 28%). Between 19% and 31% of all burned-out specialists have no debt; the corresponding range for non–burned-out specialists was 27%-42%. At 19%, family physicians with burnout were the least likely group to report that they were debt-free.