Taking Action Against Clinician Burnout A Systems Approach to Professional Well-Being (2019) / Chapter Skim
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8 Student and Trainee Burnout and Professional Well-Being
8 Student and Trainee Burnout and Professional Well-Being
Pages 235-272
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Within these learning environments is a complex array of social interactions, organizational cultures and structures, and physical and virtual spaces that surround and shape participants' experiences, perceptions, and professional development (Gruppen et al., 2019; Josiah Macy Jr. Foundation, 2018)
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allopathic medical students, which reported that 56 percent of medical students had at least one symptom of burnout. In addition, high emotional exhaustion, high depersonalization, and overall burnout were more prevalent among medical students than in a national sample of age-similar college graduates not studying medicine (Dyrbye et al., 2014)
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. In a longitudinal study of medical students in Sweden, emotional exhaustion at the end of medical school, as measured by the Oldenburg Burnout Inventory, independently predicted the students' level of emotional exhaustion during their internships (Dahlin et al., 2007)
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Nonetheless, the data suggest that burnout among non-physician learners is a serious problem. For example, a 2010 study of 436 nursing students at a single institution found emotional exhaustion, depersonalization, and personal accomplishment scores (Maslach Burnout Inventory–Human Services Survey for Medical Personnel [MBI–HSS MP]
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. Similarly, a small study of 150 medical residents from 13 specialties training in two hospitals reported residents who had completed medical school outside of the United States had significantly lower emotional exhaustion and depersonalization on univariate analysis (Eckleberry-Hunt et al., 2009)
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Longitudinal studies of internal medicine residents have similarly found burnout to be an independent predictor of residents perceiving that they committed a medical error over the sub sequent 3 months (West et al., 2006, 2009)
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. In a longitudinal study of internal medicine residents, reduced empathy was an independent predictor of higher odds of self-perceived error in the following 3 months (West et al., 2006)
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For example, one study reported that medical students with high emotional exhaustion were more likely to choose a specialty with a more controllable lifestyle (e.g., dermatology versus internal medicine) and that those with low personal accomplishment were more likely to choose a higher-income specialty (e.g., anesthesiology versus pediatrics)
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For example, burnout was found to be an independent predictor of alcohol abuse and dependence in a multi-institutional study of 4,402 medical students (Jackson et al., 2016) , and higher emotional exhaustion and depersonalization scores were associated with greater alcohol intake in a study of 168 family medicine residents (Lebensohn et al., 2013)
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In addition to these studies, longitudinal data reported in 2010 (Dyrbye et al., 2010b) showed that higher satisfaction with the learning environment was an independent predictor of not having burnout at baseline or 1 year later among medical students.
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. Among medical residents, work hours, excessive workload, and overnight call frequency have been shown to increase the risk of burnout (Sargent et al., 2004; van Vendeloo et al., 2018)
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showed no A significant differences in mean emotional exhaustion or depersonalization scores between cohorts of residents in 63 internal medicine programs who trained under a flexible policy that resembles the 2017 ACGME requirements and those who trained under the 2011 ACGME standard duty-hour policies. The potential impact of a flexible policy for surgical trainees is less clear since studies to date have not included a validated measure of wellbeing (Bilimoria et al., 2016)
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One study of third- and fourth-year medical students reported that lower satisfaction with the organization of clerkship rotations and the variety of medical problems encountered during clinical training were independent predictors of burnout (Dyrbye et al., 2009b)
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One important result from a longitudinal study of internal medicine residents was that perceptions of having com mitted a medical error was an independent predictor of subsequent worsening in all domains of burnout (West et al., 2006)
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. A 2015 study found that perceived stigma likely explains why medical students with burnout do not actively seek help and, in addition, reported that faculty and peer behaviors may also influence a learner's help-seeking (Dyrbye et al., 2015a)
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. Similarly, a longitudinal study of medical students found that greater exposure to a negative medical school diversity climate was associated with an increase in depressive symptoms among students of all races and ethnicities groups (Hardeman et al., 2016)
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. In a qualitative study, medical students identified negative role models as a major stressor in the learning environment and reported that positive role models helped them reframe stressors, making the challenges inherent to professional development seem more worthwhile (Jenkins et al., 2018)
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For example, more favorable ratings of teachers, reported explicit teaching about certain topics, and direct observation of goals-of-care discussions was associated with lower emotional exhaustion scores and better overall teaching quality, while more frequent observation of the residents' skills was associated with lower depersonalization scores
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. Although the direction of the relationship cannot be determined from these cross-sectional studies, one longitudinal study involving 186 final-year medical students in Sweden found that positive perceptions of the first year of residency training environment, driven by supervisors who incorporated residents' needs for education, feedback, and support, was negatively assoiated with the development of emotional exhaustion (measured us c ing Oldenburg Burnout Inventory)
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. Other smaller studies have also reported an association between work–home conflict and higher emotional exhaustion scores, higher depersonalization scores, and overall burnout among residents (Ringrose et al., 2009; Sargent et al., 2004)
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. In a longitudinal study that followed medical students as they transitioned from the Karolinska Institute Medical School into residency, a high degree of worry about the future during the final year of medical school predicted emotional exhaustion (Oldenburg Burnout Inventory)
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Similarly, self-care strategies are important. For example, a study of 4,402 medical students found that being compliant with exercise guidelines from the Centers for Disease Control and Prevention was an independent predictor of a lower risk of burnout (Dyrbye et al., 2017a)
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Although, in a large study of medical students, educational debt has not found to be an independent predictor of burnout (Dyrbye et al., 2010b) , a multi-institutional longitudinal study of 1,701 medical students found that those students who worked for income were significantly less likely to recover from burnout over the course of 1 year than students who were not employed (Dyrbye et al., 2010b)
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or in a 1-year longitudinal study of internal medicine residents (Ripp et al., 2011)
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have demonstrated some effectiveness. As part of their overall well-being strategy, some medical schools and residency programs assess learner well-being (Hill and Smith, 2009; Oladeji et al., 2018)
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and ensure the protection of confidentiality, the consent of learners, transparency and honesty in reporting, and the regular evaluation and improvement of learner well-being as part of broader learning environment assessments. Well-Being Curriculum Medical schools and residency programs have introduced a breath of curricula to raise awareness, promote self-care, and teach positive coping skills and mindfulness-based stress reduction in an effort to help learners promote their well-being.
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, sub-optimal patient care, and medical error; less is known about its prevalence and consequences in other health care professional learners. The main drivers for burnout among learners have their roots in the learning environment and include grading schema, sub-optimal clinical experiences, inadequate preparation and support, supervisor behaviors, peer behaviors, and a lack of autonomy.
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2010. Predictors of persistent burnout in internal medicine residents: A prospective cohort study.
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2009b. The learning environment and medical student burnout: A multicentre study.
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medical students derived from a national, four-year longitudinal study. Academic Medicine 94(2)
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1998. Psychological stress and burnout in medical students: A five-year prospective longitudinal study.
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medical students. Academic Medicine 91(9)
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2004. Stress, burnout and doctors' attitudes to work are determined by personality and learning style: A twelve-year longitudinal study of UK medical graduates.
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2007b. The role of social support in burnout among Dutch medical residents.
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2016. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: A systematic review and meta-analysis.
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2002. Burnout and self-reported patient care in an internal medicine residency program.
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2006. Association of perceived medical errors with resident distress and empathy: A prospective longitudinal study.
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2018. Perceived stress, stressors, and coping mechanisms among PGY1 pharmacy residents.
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