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Medical School Burnout - Reaching Out to Students at Risk

—By Kim Krisberg, special to AAMCNEWS

Marly Francois wanted to be a doctor ever since she was a little girl. So when she moved to Southern California in 2011 to begin medical school at Loma Linda University, it was a dream come true.

But the transition from New Jersey to California was difficult. Without any friends or family nearby, she felt isolated. Still, she was determined to succeed. Francois immersed herself in her medical texts until she started to have feelings of burnout by the end of her first year and forced herself to cut back on study hours.

Then, in the first half of her second year, Francois failed three courses. The shock pushed her to resume her extreme study schedule. She began studying all day, every day, only stopping to eat. She even skipped classes to fit in more study time. But despite all the hours of study, she said the stress and anxiety made it difficult to actually absorb the material.

A quick look at the statistics reveals that Francois is hardly alone. Liselotte Dyrbye, MD, MHPE, associate director of research applications for the Program on Physician Well-Being at the Mayo Clinic Department of Medicine, coauthored a 2008 study in Annals of Internal Medicine that found approximately 50 percent of students experienced burnout among more than 2,000 medical student respondents across seven schools.

Today, burnout is increasing among physicians in all specialties, and there seems to be an upward if less conclusive trend, in medical students reporting burnout, Dyrbye said. Burnout is often defined and measured by three indicators: emotional exhaustion associated with work-related stress, feelings of detachment toward patients, and a low sense of personal accomplishment.

Students are struggling because there’s no incentive to take care of themselves. And even when we do have a supportive administration saying ‘take care of yourself,’ the larger culture of medicine is focused on sucking up and pushing through.” —Rachel Stones, third-year student, University of Chicago Pritzker School of Medicine

Francois was lucky—she realized her study habits had spun out of control and sought help through a mentoring program offered at Loma Linda University School of Medicine. She connected with a mentor who helped her put together a sustainable study schedule that worked.

“It’s easy to feel like you’re alone,” said Francois, now a fourth-year student. “But just talking about it helped so much—it helped normalize the experience.”

Dyrbye said medical students tend to begin their studies with mental health profiles that are better than their peers in other fields. But for many students that profile worsens from the effects of myriad factors: large workloads, increased competition for residency slots, competitiveness, and first-time exposure to human suffering and death. In 2014, Dyrbye coauthored a study in Academic Medicine that found medical students, residents, and early career physicians experience more burnout than their peers outside the medical field.

“[Medical schools] play an enormous role in addressing this … but teaching students self-care strategies can’t be the entire message,” said Dyrbye, who is also a professor in the Division of Primary Care Internal Medicine at Mayo Clinic. “The institution also has to do the right thing and step up to create an environment where students can thrive and be challenged and learn.”

There can be serious consequences if student burnout is not addressed. Dyrbye coauthored another Academic Medicine study published March 2016 that explored the relationship between medical student burnout and alcohol abuse, for example. In a national survey of 12,500 students, more than 32 percent of the 4,400 who responded met the diagnostic criteria for alcohol abuse or dependence—a rate about twice as high as the general U.S. college-educated population aged 22 to 34. And students who were burned out, depressed, or reported low mental health were more likely to abuse alcohol.

Medical schools are stepping up

Although the literature is slim on evidence-based interventions for medical student burnout, Dyrbye said awareness of the problem is growing.

The University of Nebraska Medical Center (UNMC), for example, is tackling burnout on several fronts. On the academic side, the institution is planning to switch to a pass/fail grading system for the first two years of medical school, with the intention of reducing student competition and isolation and fostering collaboration, said Rowen Zetterman, MD, director of faculty mentorship development at UNMC. On the services side, the university debuted a mobile phone app in 2015 that any student can download to assess personal symptoms of burnout and navigate available services. Also in late 2015, UNMC hired a psychologist to develop stress management programming for students, residents, faculty, and staff.

“We must figure out how to ameliorate this problem, particularly if you believe that the problem will carry forward (into their careers),” Zetterman said. “If you believe that, then solving the problem of burnout in medical school is crucial to the future of health care.”

“There’s not going to be one thing that will be the panacea for all burnout,” Ludwig said. “It’s a lot more nuanced than that.”
—Allison Ludwig, MD, Albert Einstein College of Medicine

At the University of Chicago Pritzker School of Medicine, a survey taken earlier this year by third- and fourth-year students found that up to half reported at least one symptom of burnout, said Wei Wei Lee, MD, MPH, who directs student wellness programs in her role as assistant dean of students. Lee and her colleagues, including medical students who serve on the school’s Wellness Committee, are now developing a resiliency curriculum, with a particular focus on supporting students as they transition into their clinical years and begin caring for patients. The curriculum, which will eventually be integrated into the third year of school, will focus on skills such as setting realistic goals, managing expectations, and recovering from setbacks.

“From day one [of medical school], we signal to students that their wellness is a priority,” Lee said. “We want to have an open discourse around wellness and burnout—we want students to know they’re not alone.”

Students on Pritzker’s Wellness Committee include four representatives from each class. They are elected to serve by a vote of their peers. The process helps build confidence among students that when it comes to wellness, their voices will be heard, said Rachel Stones, a third-year representative on the committee.

 “By and large, [student burnout is a] national systemic issue with the way we do training,” Stones said. “Students are struggling because there’s no incentive to take care of themselves. And even when we do have a supportive administration saying ‘take care of yourself,’ the larger culture of medicine is focused on sucking up and pushing through … and ultimately, that’s not good for patients.”

Reaching students at risk

One of the great challenges of resiliency training is how to reach those most at risk for burnout, said Allison Ludwig, MD, assistant dean for student affairs at Albert Einstein College of Medicine in the Bronx, N.Y. Making such training a requirement can add to an already daunting workload, but if it is optional, she noted, it’s often the students who need it least who participate. The key, but also the challenge, is striking the right balance, Ludwig said.

For example, the school recently instituted a resiliency intervention among third-year clerks, providing them with biofeedback gadgets so they could monitor their stress indicators. But, according to Ludwig, the timing wasn’t good—students were already too nervous about their new third-year responsibilities to really engage in the process.

“There’s not going to be one thing that will be the panacea for all burnout,” Ludwig said. “It’s a lot more nuanced than that.” —Allison Ludwig, MD, Albert Einstein College of Medicine

Einstein already has in place a number of academic features that can help with stress and burnout, including pass/fail grading in the first two years and a tuition-free extended academic schedule for those who need it. Among its student wellness offerings is the Peer Mentor Network, where students can turn for confidential support and advice.

Arthie Jeyakumar, a mentor in the Einstein program, is a fourth-year medical student who experienced her own struggles with not meeting personal expectations and feeling overwhelmed in her third year. At the time, she said it felt like she was losing all balance in her life. Her diet and sleeping began to suffer, and she had a difficult time talking about it without being overcome by emotion.

Fortunately, with support from fellow students and faculty, Jeyakumar persevered and now she uses the experience to mentor others.

“We’re all very hard on ourselves,” she said. “But we’re not all perfect; we’re just human. I try to help other students realize that too—that they’ll get past this and there’s something greater waiting on the other side.”