What is the problem?
The burnout triad of emotional exhaustion, interpersonal disengagement, and a low sense of personal accomplishment1, impacts half of all medical students2, and persists in residents and practicing physicians3. Interpersonal disengagement interferes with social support and hinders proper treatment of patients4–6.
Burnout correlates with alcohol and substance use problems7,8. Overall use of alcohol in medical students (91%9) is substantially higher than that seen in the general population (56%) as measured by the 2017 National Survey on Drug Use and Health (NSDUH) data on young adults aged 18 to 25 with past month alcohol use10. In a 2016 study by Jackson et al., ⅓ of medical students had symptoms of alcohol abuse/dependence and that use correlated with the burnout domains of emotional exhaustion and depersonalization2. A separate study found that ⅓ of medical students fit criteria for binge drinking and over ¼ used cannabis in the past year9.
Burnout and depressive symptoms overlap11. In a cross-sectional analysis of studies by Rotenstein et al., the rate of depression in medical students averaged 27%12. Burnout continues to be a problem into medical practice. A similar cross-sectional analysis of depression in residents found an average of 29%; the rate of depression increased as training progressed13. The linkage of depression and suicide is well-established including in general as well as in physicians14. The 2016 study by Rotenstein et al. also found that 11% of medical students expressed suicidal ideation and ~16% sought psychiatric treatment12. Given the common reluctance of individuals to admit to symptoms of suicide or seek psychiatric treatment these figures are likely even higher.
Burnout also correlates with higher BMI15,16, poor sleep17,18, and increased motor vehicle accidents19. In addition to the common use of alcohol as a coping mechanism, medical students often utilize ineffective coping responses to stress, such as unhealthy self-indulgence or self-criticism20–22.
Women and minority medical students face unique challenges. Physicians have known implicit bias with minority patients; physician colleagues and supervisors are also like to have implicit bias toward minority medical students as well23,24. Despite much progress recently, gender-based assumptions and stereotypes affect mentoring relationships and gender-based power dynamics can influence actual mentoring25.
Institutional change is an important means to address the problem of burnout since organizational factors are a major cause of burnout3,26. Unfortunately, the individual cannot modify the challenge of clinical medicine; nor is it prudent, given the above statistics, to wait for changes that can only occur at an institutional level.
Individual focused solutions empower the student to enhance or modify a student’s coping strategies, pursue well-being, and enhance resilency27–32. Such interventions include:
- Improving interpersonal communication skills, using mindfulness, focusing on increased self-care, or expanding meaningful social connections27,33–39.
- Recognizing factors causing stress40, developing assertiveness, self-reflection, using cognitive restructuring to think about problems in a productive way, focusing on the quality of life, and learning new interests21,37,41,42.
- Self-reflection such as identifying self-imposed social isolation or acknowledging financial or relational concerns8.
- Enhancing resilience via skills training 26–29 including emphasis on work-life balance30 and focusing on positives in life (gratitude, and awe28), self compassion, taking an optimistic perspective, focusing on others31,32, or taking advantage of supportive factors such as a wellness culture1.
- Bohman B, Dyrbye, L, Sinsky, CA, et al. Physician Well-Being: The Reciprocity of Efficiency, Resilience, Wellness Culture. NEJM Catal. August 2017. https://catalyst.nejm.org/physician-well-being-efficiency-wellness-resilience/. Accessed October 15, 2018.
- Peckham C. Medscape National Physician Burnout & Depression Report 2018. MedScape. January 2018. https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235. Accessed August 6, 2018.
- West CP, Dyrbye LN, Shanafelt TD. Physician Burnout: Contributors, Consequences and Solutions J Intern Med. 2018;283(6):516-529. doi:10.1111/joim.12752.
- Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and Medical Errors among American Surgeons Ann Surg. 2010;251(6):995-1000. doi:10.1097/SLA.0b013e3181bfdab3.
- Klein J, Grosse Frie K, Blum K, von dem Knesebeck O. Burnout and Perceived Quality of Care among German Clinicians in Surgery Int J Qual Health Care J Int Soc Qual Health Care. 2010;22(6):525-530. doi:10.1093/intqhc/mzq056.
- Williams ES, Manwell LB, Konrad TR, Linzer M. The Relationship of Organizational Culture, Stress, Satisfaction, and Burnout with Physician-Reported Error and Suboptimal Patient Care: Results from the MEMO Study Health Care Manage Rev. 2007;32(3):203-212. doi:10.1097/01.HMR.0000281626.28363.59.
- Oreskovich MR, Shanafelt T, Dyrbye LN, et al. The Prevalence of Substance Use Disorders in American Physicians Am J Addict. 2015;24(1):30-38. doi:10.1111/ajad.12173.
- Jackson ER, Shanafelt TD, Hasan O, Satele DV, Dyrbye LN. Burnout and Alcohol Abuse/Dependence Among U.S. Medical Students Acad Med J Assoc Am Med Coll. March 2016. doi:10.1097/ACM.0000000000001138.
- Ayala EE, Roseman D, Winseman JS, Mason HRC. Prevalence, perceptions, and consequences of substance use in medical students. Med Educ Online. 2017;22(1). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5678442/. Accessed October 7, 2018 doi:10.1080/10872981.2017.1392824.
- Center for Behavioral Health Statistics and Quality. Reports and Detailed Tables From the 2017 National Survey on Drug Use and Health (NSDUH) | CBHSQ. United States Department of Health and Human Services. Substance Abuse and Mental Health Services Administration.; 2018. https://www.samhsa.gov/data/nsduh/reports-detailed-tables-2017-NSDUH. Accessed November 7, 2018.
- Wurm W, Vogel K, Holl A, et al. Depression-Burnout Overlap in Physicians. PLoS ONE. 2016;11(3). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773131/. Accessed January 2, 2019 doi:10.1371/journal.pone.0149913.
- Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis JAMA. 2016;316(21):2214-2236. doi:10.1001/jama.2016.17324.
- Mata DA, Ramos MA, Bansal N, et al. Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-Analysis JAMA. 2015;314(22):2373. doi:10.1001/jama.2015.15845.
- Loas G, Lefebvre G, Rotsaert M, Englert Y. Relationships between anhedonia, suicidal ideation and suicide attempts in a large sample of physicians. PLoS ONE. 2018;13(3). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5870971/. Accessed January 2, 2019 doi:10.1371/journal.pone.0193619.
- Peckham C. Physician Burnout and Weight. Medscape Physician Lifestyle Rep. 2015. http://www.medscape.com/features/slideshow/lifestyle/2015/public/overview#12. Accessed March 10, 2016.
- Mota MC, De-Souza DA, Rossato LT, et al. Dietary Patterns, Metabolic Markers and Subjective Sleep Measures in Resident Physicians Chronobiol Int. 2013;30(8):1032-1041. doi:10.3109/07420528.2013.796966.
- McLuckie A, Matheson KM, Landers AL, et al. The Relationship Between Psychological Distress and Perception of Emotional Support in Medical Students and Residents and Implications for Educational Institutions Acad Psychiatry J Am Assoc Dir Psychiatr Resid Train Assoc Acad Psychiatry. 2018;42(1):41-47. doi:10.1007/s40596-017-0800-7.
- Johnson KM, Simon N, Wicks M, Barr K, O’Connor K, Schaad D. Amount of Sleep, Daytime Sleepiness, Hazardous Driving, and Quality of Life of Second Year Medical Students Acad Psychiatry J Am Assoc Dir Psychiatr Resid Train Assoc Acad Psychiatry. 2017;41(5):669-673. doi:10.1007/s40596-017-0668-6.
- West CP, Tan AD, Shanafelt TD. Association of Resident Fatigue and Distress with Occupational Blood and Body Fluid Exposures and Motor Vehicle Incidents Mayo Clin Proc. 2012;87(12):1138-1144. doi:10.1016/j.mayocp.2012.07.021.
- Bamuhair SS, Al Farhan AI, Althubaiti A, Agha S, Rahman S ur, Ibrahim NO. Sources of Stress and Coping Strategies among Undergraduate Medical Students Enrolled in a Problem-Based Learning Curriculum. September 2015. https://www.hindawi.com/journals/jbe/2015/575139/. Accessed May 16, 2018.
- Pereira M, Barbosa M. Teaching Strategies for Coping with Stress – the Perceptions of Medical Students BMC Med Educ. 2013;13:50.
- Fares J, Al Tabosh H, Saadeddin Z, El Mouhayyar C, Aridi H. Stress, Burnout and Coping Strategies in Preclinical Medical Students North Am J Med Sci. 2016;8(2):75-81. doi:10.4103/1947-2714.177299.
- Dehon E, Weiss N, Jones J, Faulconer W, Hinton E, Sterling S. A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making Acad Emerg Med Off J Soc Acad Emerg Med. 2017;24(8):895-904. doi:10.1111/acem.13214.
- van Ryn M, Hardeman R, Phelan SM, et al. Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report J Gen Intern Med. 2015;30(12):1748-1756. doi:10.1007/s11606-015-3447-7.
- Levine RB, Mechaber HF, Reddy ST, Cayea D, Harrison RA. “A Good Career Choice for Women”: Female Medical Students’ Mentoring Experiences: A Multi-Institutional Qualitative Study Acad Med J Assoc Am Med Coll. 2013;88(4):527-534. doi:10.1097/ACM.0b013e31828578bb.
- Tawfik DS, Phibbs CS, Sexton JB, et al. Factors Associated With Provider Burnout in the NICU. Pediatrics. 2017;139(5). http://pediatrics.aappublications.org/content/139/5/e20164134. Accessed December 11, 2018 doi:10.1542/peds.2016-4134.
- West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to Prevent and Reduce Physician Burnout: A Systematic Review and Meta-Analysis The Lancet. 2016;388(10057):2272-2281. doi:10.1016/S0140-6736(16)31279-X.
- Tawfik DS, Sexton JB, Adair KC, Kaplan HC, Profit J. Context in Quality of Care: Improving Teamwork and Resilience Clin Perinatol. 2017;44(3):541-552. doi:10.1016/j.clp.2017.04.004.
- Profit J. Web-based Implementation for the Science of Enhancing Resilience Study (WISER). ; 2018. https://clinicaltrials.gov/ct2/show/NCT02603133. Accessed December 11, 2018.
- Sexton JB, Schwartz SP, Chadwick WA, et al. The Associations between Work–Life Balance Behaviours, Teamwork Climate and Safety Climate: Cross-Sectional Survey Introducing the Work–Life Climate Scale, Psychometric Properties, Benchmarking Data and Future Directions BMJ Qual Saf. 2017;26(8):632-640. doi:10.1136/bmjqs-2016-006032.
- Neff KD, Pommier E. The Relationship between Self-Compassion and Other-Focused Concern among College Undergraduates, Community Adults, and Practicing Meditators Self Identity. 2013;12(2):160-176. doi:10.1080/15298868.2011.649546.
- Shapira LB, Mongrain M. The Benefits of Self-Compassion and Optimism Exercises for Individuals Vulnerable to Depression J Posit Psychol. 2010;5(5):377-389. doi:10.1080/17439760.2010.516763.
- Regehr C, Glancy D, Pitts A, LeBlanc VR. Interventions to Reduce the Consequences of Stress in Physicians: A Review and Meta-Analysis J Nerv Ment Dis. 2014;202(5):353-359. doi:10.1097/NMD.0000000000000130.
- Marine A, Ruotsalainen JH, Serra C, Verbeek JH. Preventing occupational stress in healthcare workers. Cochrane Database Syst Rev. 2006;(4). https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002892.pub2/abstract. Accessed November 20, 2018 doi:10.1002/14651858.CD002892.pub2.
- Panagioti M, Panagopoulou E, Bower P, et al. Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-Analysis JAMA Intern Med. 2017;177(2):195-205. doi:10.1001/jamainternmed.2016.7674.
- Vaillant G. Harvard Second Generation Grant and Glueck Study. Harv Second Gener Study. 2015. http://www.adultdevelopmentstudy.org/grantandglueckstudy. Accessed October 8, 2018.
- Sirois FM, Kitner R, Hirsch JK. Self-Compassion, Affect, and Health-Promoting Behaviors Health Psychol Off J Div Health Psychol Am Psychol Assoc. 2015;34(6):661-669. doi:10.1037/hea0000158.
- Longe O, Maratos FA, Gilbert P, et al. Having a Word with Yourself: Neural Correlates of Self-Criticism and Self-Reassurance NeuroImage. 2010;49(2):1849-1856. doi:10.1016/j.neuroimage.2009.09.019.
- Ayala EE, Winseman JS, Johnsen RD, Mason HRC. U.S. Medical Students Who Engage in Self-Care Report Less Stress and Higher Quality of Life BMC Med Educ. 2018;18(1):189. doi:10.1186/s12909-018-1296-x.
- Marksberry K. Take a Deep Breath. Am Inst Stress. August 2012. https://www.stress.org/take-a-deep-breath/. Accessed October 22, 2018.
- Kok BE, Coffey KA, Cohn MA, et al. How Positive Emotions Build Physical Health: Perceived Positive Social Connections Account for the Upward Spiral between Positive Emotions and Vagal Tone Psychol Sci. 2013;24(7):1123-1132. doi:10.1177/0956797612470827.
- Sonnentag S. Psychological Detachment From Work During Leisure Time: The Benefits of Mentally Disengaging From Work Curr Dir Psychol Sci. 2012;21(2):114-118. doi:10.1177/0963721411434979.
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