Abstract
Introduction: Physician workforce shortages are expected to reach 48,000 primary care physicians by 2034 with burnout, discrimination (gender, race, and others), and harassment as contributors. Physicians experience discrimination and harassment on a daily basis and continue to work with patients who routinely discriminate against them, which can be directly related to burnout.
Methods: The American Academy of Family Physicians (AAFP) created the Leading Physician Well-Being Certificate Program to combat these issues. Surveys were sent to cohorts at multiple time points – beginning, middle, and end. Multiple evaluation instruments were included in these surveys, but for this analysis, we focused on the Everyday Discrimination Scale (EDS). For Cohort 1 (n = 88, 2021), they received the EDS midway through their cohort. For Cohort 2 (n = 62, 2022), they received the EDS at each time point, but received a Privilege Assessment midway through their cohort due to their answers on the EDS.
Results: Cohort 1 consistently rated the questions with higher levels of discrimination than Cohort 2 scholars. In general, Asian women from Cohort 1 experienced the most discrimination of all the groups (7 statements). For the Privilege Assessment, Asian and other women of color were more likely to indicate less privilege than other groups.
Discussion: Physicians taking the AAFP Leading Physician Well-Being Certificate Program reported have experienced discrimination and harassment. Certain physician groups experience higher levels of discrimination and harassment, and concurrent lower levels of privilege. While unfortunate, discrimination and harassment will continue to play a large role in physicians’ lives.
Introduction
US physician workforce shortages are projected to worsen to a shortfall of 33,100–48,000 primary care physicians by 2034.1,2 Multiple institutions/studies have indicated the shortage can be attributed to educational costs,3 discrimination and harassment from employers4–7 and patients,8 burnout,9,10 as well as the number of physicians set to retire soon1 and the primary/specialty care salary disparity.11,12 During the COVID-19 pandemic, primary care physicians reported their burnout at an all-time high,13–16 and burnout continues to be at high levels.17,18 Post-COVID-19 burnout has been attributed to mistreatment,8 employers’ lack of respect,19–21 and poor work-life balance.22,23
Discrimination continues to play a large role in medicine.7,24–31 Physicians experience discrimination on a daily basis32–34 and continue to cope with patients’ discriminatory behaviors.8,35 Unfortunately, discrimination against physicians has been documented in medical and academic literature for decades.27,36–39 Despite efforts to address discrimination, patterns in the experiences of practicing physicians indicate persistent negative effects. Research also indicates female physicians report experiencing multiple instances of prejudice and discrimination from patients and employers due to their gender and race/ethnicity, including sexist jokes, sexual harassment, weaker recommendation letters, lower income, less recognition/recognized as physicians, and stigma associated with pregnancy.40
Physicians experience burnout that can be partially related to the discrimination they receive.1,5,7,8,10,23,32,34 This article’s aim was to analyze survey evaluation data from the well-being and burnout program at the American Academy of Family Physicians (AAFP) to determine rates of discrimination (2 cohorts) and privilege (1 cohort) among diverse scholars and cohorts.
Methods
Leading Physician Well-being Program
AAFP received a UnitedHealth Foundation grant to create a program to address burnout and well-being among family physician members. Leading Physician Well-Being Program was designed to provide a diverse set of family physicians with leadership skills needed to enact workplace change to improve burnout and well-being.41 The program included a Continuing Medical Education certificate, as well as didactic education, in-person sessions, and a quality improvement project. Scholars applied to the program and were selected based on their applications. The first cohort was from January to October 2021 (Cohort 1); the second cohort was from January to October 2022 (Cohort 2).
Evaluation
A survey, with multiple validated instruments, was distributed to the cohorts at 3 times – beginning (January), midpoint (May-June) and end of program (October). The baseline survey contained demographic questions. The focus of this analysis is the Everyday Discrimination Scale.24 The first cohort (2021) completed the Everyday Discrimination Scale at midpoint due to the prevalence of discrimination reported in interviews. The second cohort (2022) received the Everyday Discrimination Scale at each time point. In addition, Cohort 2 also received a Privilege Assessment42–44 (Implicit Bias Tool from the EveryONE project42,43,45) as part of the midpoint evaluation due to baseline responses.
Consent for scholar participation was received when they accepted their position into the program. In addition, all surveys were voluntary, and scholars could decide not to take or complete a survey at any time. If a scholar chose to opt-out of the survey online, they no longer received evaluation surveys. All surveys, distributed through Qualtrics (Provo, UT), and evaluation were approved by the AAFP Institutional Review Board. Only authorized team members were able to access the data.
Statistical Analysis
Descriptive statistics were completed for all survey questions. For a scholar to be included, they had to provide a gender and/or race at baseline and complete at least one question in the Everyday Discrimination Scale from the midpoint. Data were non-normal due to the sample size and the use of Likert scales. For the analyses between cohorts, we used Mann-Whitney U test. For the tests with demographics, we used Quade’s ANCOVA (nonparametric ANCOVA). A two-sided α of 0.05 was used. All analyses were completed using SPSS 29 (Armonk, NY).
Results
Demographics
Cohort 1 scholars (n = 62) were significantly younger (n = 88; P < .001), which translated to more Cohort 1 scholars being considered “new” physicians (<=7 years since residency) than Cohort 2 scholars (P < .001). There were more males in Cohort 2 (P = .002), but both cohorts were majority female. Approximately 10% of scholars identifying as Asian in both cohorts. Private hospital or health system were listed the largest primary employer (Cohort 1: 41.9%; Cohort 2: 45.5%). Significantly more Cohort 2 scholars worked in Primary Care Only offices than Cohort 1 scholars (P = .013; Table 1). As the circumstances in which these physicians practiced continued to evolve (eg, pandemic, other policies), the cohorts were analyzed separately to observe any changes in discrimination.
Demographics
Everyday Discrimination Scale – Midpoint of Both Cohorts
Cohort 1 scholars consistently reported higher levels of discrimination and were more likely to experience discrimination in all settings than Cohort 2 scholars (Table 2). In general, Asian females from Cohort 1 experienced the most discrimination out of all the groups (7 statements), followed by Other POC females from Cohort 1 (5 statements). White males from Cohort 2 experienced the least discrimination (Table 2).
Everyday Discrimination Scale Results for Cohorts 1 and 2
Privilege Assessment in Cohort 2
White males agreed with the privilege assessment statements more than the other race/gender categories. Asian and Other POC females were more likely to significantly disagree with the statements than anyone identifying themselves as White (Table 3).
Results of the Privilege Assessment of Cohort 2 (n = 62)
Discussion
Consistent with previous reports, nonWhite participants reported experiencing more discrimination than White participants25,26 and females reported experiencing more discrimination than males.27,46 We also noted Asian females were the most likely group to experience discrimination (no Asian males in either cohort). These surveys took place during the pandemic, with the first cohort starting less than a year (January 2021) after the beginning of the pandemic, which saw numerous accounts of discrimination toward people of Asian descent.28 The first cohort of Asian females reported more discrimination than the second cohort of Asian females. This could be due to the pandemic being further along and a potential slight attenuation of the fears associated with Asian people.47–49
For the question “At work, when different opinions would be helpful, how often is your opinion not asked for?”, White males in Cohort 1 indicated this happened often. This could be due to a shift in recent years from the focus on White males and the power structure serving them50–52 to a more diverse, inclusive environment.53⇓⇓–56 While the White males from Cohort 1 felt this way, the White males from Cohort 2 did not.
For the questions related to the use of pejorative terms, slurs, or inappropriate jokes from supervisors and coworkers, Asian and Other POC females in Cohorts 1 and 2 were the ones most likely to experience discrimination, in line with current literature on discrimination in the workplace.27,57 In addition, Asian and Other POC females indicated they have to often be careful about their appearance, what they say, what happens around them, and trying to avoid certain situations. Having to be constantly on guard, frequently checking on outward appearance, as well as remaining careful about language use, can lead to reduced well-being and eventually burnout.58,59 Burnout associated with discrimination can compound the burnout associated with the job itself,16,19,60 adding to the stresses and quickening the pace of burnout and of the person leaving their job.
For Cohort 2’s Privilege Assessment, White males, overall, agreed with every statement indicating a higher level of privilege than all other groups (White, Asian, and Other POC females). Asian and Other POC females generally disagreed with the statements, indicating lower levels of privilege. Several statements make note of where workplaces can do better with hiring. Diverse hiring,60,61 recognition of holidays important to employees,62 and food options reflective of their employee base63 are a few places where workplaces can improve and were noted as problem areas. Workplaces can provide micro and macro-aggression identification training to better provide support and decrease/stop discrimination.64⇓–66 Tolerance for workplace discrimination has lessened in recent years,67,68 but there is still a long way to go to meaningfully abate workplace discrimination, particularly in medicine.69 Providing diverse offerings, as well as correct training and policies, will help propel equity forward.70,71
In addition, the Cohort 2 scholars noted safety issues where improvements could be made, such as a garage at night.72,73 Workplaces can also provide updated facilities/lighting on their campus to improve safety and the feeling of security.74 Asian and Other POC females also indicated the difficulties in receiving medical care. They did not agree family members would receive proper care and that their race would not work against them if they needed care, in line with previous literature on medical discrimination.75
Limitations
We do recognize this is a limited sample; however, it is a specific group (physicians) experiencing discrimination in their everyday lives, and it does affect how they are perceived and how others perceive them. In addition, the sample is split over 2 years, which could affect the circumstances under which the groups responded. However, this did allow for changes to the questions (ie, addition of the privilege assessment).
Conclusion
Discrimination is an important aspect of physicians’ lives, not just in how it affects their patients, but in how it affects their job. While physicians are at the forefront of working with community resources to help their patients in all aspects including discrimination, they still experience discrimination themselves and have to navigate a system working against them.
Acknowledgments
The authors thank the LPW participants for completing the surveys and the project staff for their support.
Notes
This article was externally peer reviewed.
Funding: The AAFP Leading Physician Well-Being Certificate Program is made possible through funding by the UnitedHealth Foundation.
Conflict of interest: The authors have no conflicts to declare.
To see this article online, please go to: http://jabfm.org/content/38/3/566.full.
- Received for publication October 28, 2024.
- Revision received January 15, 2025.
- Accepted for publication January 21, 2025.
