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A new survey of nearly 6000 physicians has found higher levels of burnout among physicians with disabilities (PWDs) than among those without disabilities. PWDs also were more likely to report depersonalization and emotional exhaustion than their nondisabled peers.

"There are major factors contributing to burnout, which tie back to systemic ableism and widely variable policies and resources that institutions and employers have regarding disability in physicians," coauthor Christopher Moreland, MD, MPH, associate program director, internal medicine residency and interim chief, Division of Hospital Medicine, Dell Medical School, The University of Texas at Austin, told Medscape Medical News.

"We've seen signals in our research across medical students, residents, and practicing physicians that the experiences of struggles to obtain access…does take a toll on mental health," said Moreland, a board member of the advocacy group Docs with Disabilities Initiative.

The study was published online on May 9 in JAMA Network Open.

Navigating Disclosure and Access

Moreland said his own experience drew him to this area of research.

"I've been deaf all my life and have had a successful career as a deaf physician, but being deaf has actually influenced my experiences all along that path," said Moreland, past president of the Association of Medical Professionals With Hearing Losses.

Moreland was diagnosed at age 2. Today, he wears a cochlear implant and works with a sign language interpreter, treating patients and teaching students using both sign language and spoken English.

"For each stage in my career — for example, applying to medical school or residency training or interviewing for positions after completing my training — I've had to navigate the disclosure of my deafness and figure out how to access different forms of interpreting services within those different situations," he continued.

Having to "innovate and create strategies is part of the educational and employment experience of people with disabilities, and it adds onto the already heavy load of what is required to work in the medical field."

Moreland and his colleagues became interested in whether this increased "load" contributed to burnout, a condition that affects many physicians, even those without disabilities.

Moreland and colleagues' previous research on medical students with disabilities showed a higher risk for burnout, in particular emotional exhaustion and disengagement. That work, along with other data on disabled residents' mental health risks, led them to pursue the current study, he said.

The researchers analyzed the Association of American College's 2022 National Sample Survey of Physicians data.

Participants were asked if they had a disability and, if so, what their disability was. They were also asked about two dimensions of burnout, taken from the Maslach Burnout Inventory: Depersonalization and emotional exhaustion.

The researchers controlled for demographic variables, workplace characteristics, and international medical graduate status in their analysis.

Institutions Should Bear the Burden

The survey was completed by 5917 physicians (62.9% men; mean [SD] age, 51.98 [11.78] years), of whom 3.1% reported having a disability.

The most commonly reported disabilities were related to chronic health and mobility (32.4% and 24.9%, respectively).

PWDs had higher odds of reporting depersonalization than their non-PWD counterparts (adjusted odds ratio [aOR], 1.45; 95% CI, 1.11-1.91; P = .007). PWDs also reported emotional exhaustion more frequently than non-PWDs, but the difference was not statistically significant (aOR, 1.19; 95% CI, 0.91-1.57; P = .21).

According to Moreland, too much of the burden of mitigating burnout falls on the individual PWD, while the true onus should lie with the institution. "Physicians with disabilities need to be able to safely communicate their access needs and identify their disability to the right people at their institution, which requires a clear policy and procedure," he said.

Safe communication and a safe environment are essential because PWDs face higher rates of mistreatment, both by patients and colleagues, as demonstrated in previous research conducted by Moreland and colleagues. This mistreatment ranges from offensive remarks to threats of physical harm, and even physical harm itself.

Inequitable pay is another common problem faced by PWDs. One study reported that annual earned income was 10.8% lower and hourly earned income was 13.3% lower among employed PWDs than among non-disabled physician peers.

Moreland added that PWDs face cognitive and practical burdens that fellow physicians without disabilities don't face.

"From my experience and what I've seen among my colleagues, I think physicians with disabilities often feel they need to do more than those without disabilities to be perceived as being of equal worth," Moreland observed.

"Like others from underrepresented backgrounds, we have to think two and three times about how we're perceived and how our work is perceived, and how to phrase something we say, or how address certain situations more carefully — which is a lot of cognitive effort."

And there is also a great deal of practical planning PWDs need to do. "For example, some institutions might have more effective universal designs for access available to faculty and staff, but accommodations available at one site — even in the same institution — might not be available for the same physician at another site or setting," Moreland said.

Taken together, these factors suggest that institutions "need to develop disability-specific policies to address and support disability disclosure, accommodation and access processes, unconscious bias training, mistreatment support and intervention, and equitable pay structure," he emphasized.

Moreover, PWDs should be "invited to the table when diversity, equity, and inclusion discussions are taking place to engage in these discussions about developing those policies and realistic work that can be done, based on their experiences and perspectives."

Study limitations include the "self-reported nature of survey data" and "potential underreporting of disability due to fear of stigma." Moreover, the authors noted, physicians with high levels of burnout may opt not to participate in surveys.

Moreland added that future research should investigate the difference between lifelong and acquired disability. "I've been deaf all my life, so my disability wasn't acquired while I was already practicing medicine," he pointed out. Navigating a disability may be very different for physicians who developed the disability while already involved in their medical career.

Ableism as a Social Injustice

Commenting for Medscape Medical News, Rex Marco, MD, professor of reconstructive spine surgery and musculoskeletal oncology and program director of the spine fellowship, Department of Orthopedic Surgery, McGovern Medical School, UTHealth Houston, Houston, called the study "interesting and accurate," noting that burnout is "common in many physicians nowadays."

"Ableism should be addressed, and there should be a better mechanism to report ableism and mistreatment," said Marco, who has quadriplegia from an accident and serves as the chief medical ambassador of the Christopher & Dana Reeve Foundation.

Marco, who was not involved with the current study, believes that the risk for repercussions in bringing these issues up to the administration in the work environment are often greater than the potential benefits the physician might accrue. "It's relatively easy for organizations to allow this type of mistreatment to go on and not address it, from what I've seen," he said.

Marco said he has experienced ableism in his professional career. Prior to his accident, he had been a spinal surgeon and musculoskeletal oncologist at a different institution. After his accident, he was no longer able to perform surgery, but he still had an array of other abilities and skills that were unaffected by his disability, such as conducting research, teaching residents, and seeing patients for evaluation and treatment. Yet he felt that there was very little support and acknowledgement of the capacities he retained.

"I could have worked many more hours than I was given the opportunity to work, and I lost leadership positions or had leadership positions taken away from me," he recounted.

He described a colleague who had sustained a stroke and whose institution didn't allow him to return to work as a physician but only as a research nurse — although the colleague's post-stroke function would not have precluded him from practicing in his original specialty. "I've come to realize that ableism is a social injustice, and it's not okay," Marco said.

Fortunately, Marco reported feeling "greatly supported" in all of his abilities and capabilities in his current position.

Antidotes to Burnout

Several years prior to his accident, the crisis of a close family member propelled Marco to enter a recovery program. "I didn't realize until I entered recovery that I had actually been experiencing burnout," he recounted. "I had no emotional intelligence, and I depersonalized my patients. I was also pretty depersonalized myself."

For example, "I tried to 'fix' my patients' emotions instead of showing sympathy and empathy for their anger, grief, fear, or denial. This led me to judgmental thinking and depersonalization and a decreased sense of personal achievement."

After entering the recovery program, "I learned to be more emotionally intelligent, to listen and understand rather than needing to be understood, and to be okay with being okay just as I was."

Marco also learned the practice of mindfulness meditation, which he describes as "one of the best ways to decrease stress." He noted that "when there's less stress, there's less likelihood of burnout and a greater likelihood of finding meaning and purpose, which is the antidote to burnout." Today, Marco is a certified mindfulness meditation teacher.

"Without my recovery tools and mindfulness practice, I would have fallen prey to burnout and discouragement after my accident, given the professional challenges and ableism I encountered," he said. "Those tools helped minimize the potential mental health impact of my disability."

This study was supported, in part, by a grant from the Ford Foundation; a Rehabilitation Research and Training Centers Equity grant from the National Institute on Disability, Independent Living, and Rehabilitation Research; and a grant from the Robert Wood Johnson Foundation. Moreland and coauthors and Marco declared no relevant financial relationships.

Batya Swift Yasgur, MA, LSW, is a freelance writer with a counseling practice in Teaneck, New Jersey. She is a regular contributor to numerous medical publications, including Medscape Medical News and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom(the memoir of two brave Afghan sisters who told her their story).