By: Aquila Lesko
As physician burn-out has mainstreamed in medicine, it is only natural that researchers have turned their attention to analyzing the mental well-being of the youngest members of the healer sector: residents and medical students. Burnout describes a work-associated syndrome characterized by emotional exhaustion, cynicism and a low sense of personal accomplishment[1]. The origin of burnout for medical students is directly correlated to high levels of stress throughout training[2]. Common stressors include moving away from the student’s hometown, learning new study habits, maintaining passing grades in classes, competitiveness and comparison to classmates, minimizing social networks and activities, decreasing contact with friends and family, harmfully high pressure to score above-average on board examinations, exposure to death and illness, financial difficulty, ethical conflict between personal morals and protected medical practices and potential belittlement and berating at the hands of a preceptor. Without proper coping mechanisms these stressors transform stress into distress, a state of extreme anxiety, and eventually burnout. Students who experience burnout are characterized by emotional exhaustion, depersonalization and low personal accomplishment[2]. Stress and performance have an indirect relationship, meaning that students experiencing burnout have both impaired academic and clinic performance. These students experience a decrease in empathy and humanitarianism, which is harmful to them personally and to their prospective patients[2]. Burnout fosters dishonesty, as an increase in academic plagiarism and cheating is seen among students suffering burnout. Also linked to medical students experiencing burnout is substance abuse: 20% of medical students report problematic drinking due to stress and anxiety[2]. The most serious result of burnout is suicide.
The results of the research have been daunting. One study found that a resounding 12% of medical students had probable major depression disorder, 30% if residence were included, and 9.2% of fourth year medical students admitted to suicidal ideations during the previous week [2]. The American Foundation for Suicide Prevention reports that medical students are three times more likely to commit suicide compared to their same-aged peers [3]. The progression of this mental deterioration can even be demonstrated on a timeline: one study found that students first enrolled in medical school have equal, or potentially better, mental health as their peers[4] but by the end of their second year displayed significant signs of burnout and stress[5]. By the time a student became a resident, 60% met the criteria for burnout and over 50% screened positive for depression[6]. These figures only represent the direst polar end of the burnout spectrum, leaving one to infer that the number of medical trainees that experience burnout is alarmingly high.
Since the issue of burnout has become a hot-topic in medical publications there have been multiple initiatives started to diffuse and alleviate its causes. One such initiative, Taking Action Against Clinician Burnout: A Systems Approach to Supporting Professional Well-Being, is aimed at “leaders in health care organizations and health professions, educational institutions as well as within the government and industry” with the goal of prioritizing major improvements in clinical work and learning environments[6]. Initiatives like this are highly appreciated and necessary, but for medical students and residents it is a matter of the luck of the draw to be accepted into a program that implements one. Until such initiatives become required regulations within medical schools and residency programs, students must rely on a personal development of resiliency to beat the statistical odds of suffering burnout.
The term resiliency is understood as how an individual overcomes adversity to achieve desirable and optimal outcomes[7]. By definition, a more resilient person is better able to properly manage and apply stresses for future developments than a less resilient one. As resiliency is an aspect of personal development in all individuals, it is an effective point of intervention in attempts to defend against burnout. Yet to achieve an effective intervention, a clinical definition is needed for the commonly known abstract trait. Doctor Carl Bell provides such a definition by understanding resiliency in terms of characteristics that can be strengthened through emotional exercise [8].
Accordingly, there are 14 characteristics of resiliency: (a) having curiosity and intellectual mastery; (b) having compassion – with detachment; (c) having the ability to conceptualize; (d) obtaining the conviction of one’s own right to survive; (e) possessing the ability to remember and invoke images of good and sustaining figures; (f) having the ability to be in touch with affects, not denying or suppressing major affects as they rise; (g) having a goal to live for; (h) having the ability to attract and use support; (i) possessing the vision of the possibility and desirability of restoration civilized moral order; (j) having the need and ability to help others; (k) having an effective repertory; (l) being resourceful; (m) being altruistic towards others and (n) having the capacity to turn traumatic helplessness into learned helpfulness[8]. These characteristics provide a working definition for emotional resiliency which, just like physical muscle, require exercising to build and maintain.
Exercising emotional resiliency is the primary intervention that all medical students can practice to protect against burnout. There are several ways to build emotional strength. One is to develop and expand community partnerships (faith institutions, outreach-programs, volunteer programs, etc.)[8]. By doing so the characteristics (h), (l) and (m) are strengthened. Another is to aggressively manage physical health, which builds characteristics (a) and (c). To manage physical health, medical students should have an active discussion with their own medical providers about suitable diet and exercise regimes. Improving bonding and connectedness with family and friends is the third and helps to exercise the characteristics (e), (h) and (i)[8]. If personal attempts to accomplish connectedness are difficult for a student, undergoing therapy to identify causes and learn alternative methods can be a solution. Self-esteem plays a large role in developing emotional resiliency and can be sub-categorized to help better build it by facilitating: connectedness (gaining satisfaction from connecting with people or events of value); a sense of model (models that help make sense of the world); a sense of uniqueness (respecting and honoring individual, unique characteristics) and a sense of power (feeling competent to do what must be done)[8]. Strong self-esteem builds on characteristics (a), (c), (i) and (l). Learning and improving social skills (leadership, problem solving, planning, communication, etc.) promotes further development of characteristics (b), (h), (j), (k) and (m) and can be accomplished through secondary programs and classes[8]. The final area of practice is minimizing the effects of trauma [8], which can be accomplished through recognition of stress inducing events and proper management of associated feelings and thoughts. The use of therapy to learn and practice this method would be very useful to a student. Minimizing trauma improves characteristics (d), (f), (m) and (n). Continuously indulging in these proactive exercises of emotional resilience can strengthen resiliency and diminish the potential for burnout.
The need for a suitable and effective program that transforms these emotional exercises into an accessible application for students is necessary, but until one is created it is the responsibility of the student alone to cultivate resiliency. It can be obtained by strengthening the characteristics of resiliency through disciplined practice and cooperation with therapists, physicians, educators and close-connections. The statistical data regarding student burnout is disheartening and there are no regulations enforcing educational institutions to directly address the problem, therefore primary prevention aimed at building and maintaining individual resiliency is highly recommended.
References:
- (2019). Taking Action Against Clinician Burnout a systems approach to professional well-being. S.l.: NATIONAL ACADEMIES PRESS.
- Dyrbye L.N., Thomas M.R., Shanafelt T.D. (2005) Medical student distress: Causes, consequences, and proposed solutions.Mayo Clinic Proceedings, 80 (12) , pp. 1613-1622.
- Goebert, D., Thompson, D., Takeshita, J., Beach, C., Bryson, P., Ephgrave, K., … Tate, J. (2009). Depressive Symptoms in Medical Students and Residents: A Multischool Study. Academic Medicine, 84(2), 236–241. doi: 10.1097/acm.0b013e31819391bb
- Physician and Medical Student Suicide Prevention. (2020, January 21). Retrieved from https://afsp.org/our-work/education/healthcare-professional-burnout-depression-suicide-prevention/
- Dyrbye, L. N., West, C. P., Satele, D., Boone, S., Tan, L., Sloan, J., & Shanafelt, T. D. (2014). Burnout Among U.S. Medical Students, Residents, and Early Career Physicians Relative to the General U.S. Population. Academic Medicine, 89(3), 443–451. doi: 10.1097/acm.0000000000000134
- Brazeau, C. M., Shanafelt, T., Durning, S. J., Massie, F. S., Eacker, A., Moutier, C., … Dyrbye, L. N. (2014). Distress Among Matriculating Medical Students Relative to the General Population. Academic Medicine, 89(11), 1520–1525. doi: 10.1097/acm.0000000000000482
- Masten AS, Coatsworth JD. (1998). The development of competence in favorable and unfavorable environments. Am Psychol, 52,205–20.
- Bell, C. C. (2001). Cultivating resiliency in youth. Journal of Adolescent Health, 29(5), 375–381. doi: 10.1016/s1054-139x(01)00306-8
