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Year : 2021  |  Volume : 30  |  Issue : 2  |  Page : 193-197  Table of Contents     

Well-being and burnout in medical students


1 Department of Mental Health and Cultural Diversity, Institute of Psychiatry, Psychology and Neuroscience, Kings College, London, England
2 Honorary Senior Clinical Lecturer, Oxford Health NHS Foundation Trust, Oxford University, Oxford, England
3 Department of Experimental Medicine, University of Foggia, Foggia, Italy

Date of Submission24-Oct-2021
Date of Acceptance04-Nov-2021
Date of Web Publication23-Nov-2021

Correspondence Address:
Prof. Dinesh Bhugra
Mental Health and Cultural Diversity, IoPPN, Kings College, London SE5 8AF
England
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipj.ipj_224_21

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   Abstract 


There is no doubt that practice of medicine is an extremely stressful profession. Not surprisingly, training and education in medicine also creates a degree of pressure. In the past 50 years, more attention is being paid to the mental health and well-being of doctors. However, recently focus has shifted to the mental health and well-being of medical students. A series of studies have shown that the rates of mental ill-health among doctors and medical students are exceptionally high and appear to be getting worse. In studies across 12 countries with over 3600 responses, it has been shown that rates of burnout among medical students vary and have been reported to be over 90% of respondents in Hong Kong. Explanations for these high rates vary according to cultural factors which include parental expectations, financial and housing problems, and relationship difficulties. It is crucial that institutions make every effort at looking after the mental health needs of medical students and their medical staff.

Keywords: Burnout, medical students, well-being


How to cite this article:
Bhugra D, Molodynski A, Ventriglio A. Well-being and burnout in medical students. Ind Psychiatry J 2021;30:193-7

How to cite this URL:
Bhugra D, Molodynski A, Ventriglio A. Well-being and burnout in medical students. Ind Psychiatry J [serial online] 2021 [cited 2021 Dec 9];30:193-7. Available from: https://www.industrialpsychiatry.org/text.asp?2021/30/2/193/330939



Medical students are the future and are the key to patient care and well-being of the society in decades to come. It is well recognized that a majority of mental illnesses in adulthood start below the age of 24 which corresponds with the age that they are when in medical schools. In addition, like other students who may have left home for the first time due to loneliness, isolation, and other factors, they appear to be prone to developing psychiatric disorders for a number of reasons. The stress of medical education, financial pressures, and rapidly changing advances in medicine which also affect learning and practice are also likely to contribute to burnout and poor mental functioning.

For the past 50 years or so, it has been increasingly recognized that doctors and medical students are prone to higher risk of psychiatric disorders and to burnout. Although increased attention has been paid to the mental health and well-being of doctors and other health professionals, the same has not worked for medical students.


   Definitions Top


Burnout has been defined as a pervasive and debilitating state resulting from a period of overwhelming stress. It has been classically defined as an experience of physical, emotional, and mental exhaustion. In addition to exhaustion, burnout also has other components of depersonalization and feeling an absent sense of personal accomplishment. Emotional exhaustion is the feeling of being emotionally overextended by one's work and its effect on functioning. Depersonalization includes unfeeling unempathetic impersonal response. Absent sense of personal accomplishment in a highly competitive group can add to a sense of disappointment at not achieving what one had set out to achieve leading to a sense of despondency and despair. This needs to be differentiated from day-to-day stress which is to do with over-engagement. In medical practice and medical education, a sense urgency prevails which can lead to physical and psychological symptoms of anxiety. Although burnout itself may show, symptoms of anxiety individuals experiencing burnout are likely to be in despair and depression. Medicine has always been a stressful job related to making life and death decisions 24 h a day with pressures to not being able to form personal relationships with the team or the patients and their carers, increased bureaucracy, and managerialism in the National Health Scheme at least.[1] Stress diathesis hypothesis further confirms that stress can lead to psychiatric disorders. This is further complicated by two additional factors: changing face of medicine and role of doctors but also changing patient expectations which contribute to blame culture. In many countries, the pressure is to involve patients in clinical decision-making, and patients may present with information from the web asking for specific medications or interventions and feeling disappointed and angry that their wishes have been ignored. Potential changes such as artificial intelligence may make life easier in some medical specialties whereas may create more problems in others. Algorithm-based clinical decisions may be attractive, but patients often do not behave like their algorithms, thus creating a further area of tension. Many medical students anecdotally have criticized the use of simulation in their training for a number of reasons. When faced with actors who are “representing” patients, they feel it difficult to express empathy – the argument being that at the back of their minds, they know that these actors are not real patients. Some have mentioned that they did not come into medicine to become technicians.

Burnout creates not only a detached attitude toward others but also a sense of disengagement. Thus, if individuals already feel that they are not part of a team, such further isolation and alienation can be truly damaging. A usual reaction to this experience is low sense of work efficacy.[2] The opposite of burnout is engagement which has been defined as a state of mind with vigor, dedication, and absorption.[3],[4] Burnout affects empathy and other external environmental factors can also play a role in the development of burnout.[5] Burnout leads to individuals working at suboptimal levels which in turn affects self-esteem, thereby setting up a vicious cycle. Burnout can lead to medical errors, impaired professionalism, reduced patient satisfaction, and increased staff turnover.


   Reasons For Burnout Top


As burnout is related to one's job and work performance, a perceived or real lack of control over workload is an important precipitating factor. Monotonous chaotic mundane routine work interspersed with complex urgent tasks can add to the likelihood of burnout. This is more likely when individuals under pressure feel trapped and under constant pressure and they are not able to take breaks or have access to reasonable working conditions. Certain personality types can also contribute to burnout, especially when perfectionism, a need to feel in control, and competitiveness are traits. A sense of entrapment is related to the observations that medical students and doctors alike are expected to be empathic toward their patients but at the same time supposed to maintain professional distance, thus getting mixed messages.


   Stages Of Burnout Top


The first stage of burnout is to do with stress arousal, poor concentration, memory lapses, irritability, and anxiety which may be followed by stage of energy conservation and maladaptive strategies such as avoidance, lateness, and social withdrawal when students do not attend their classes or wards. The third stage is exhaustion which can be associated with anxiety, depression, apathy, and suicidal ideation, results in the disappearing act, low work rate, rage, difficulties with examinations. The consequences of burnout include the “disappearing act” where the individual is not answering calls, unexplained absences during the day; lateness; frequent sick leave and even when they are at work they may show slowness in doing procedures, clerking patients, dictating letters, and making decisions. Even when they are arriving early and leaving late, they do not achieve results in spite of a reasonable workload.[6] Some individuals may show what is described as “Clinic Rage:” bursts of temper, shouting matches, and reacting badly to real or imagined slights. Some individuals when experiencing burnout may demonstrate rigidity with poor tolerance of ambiguity, an inability to compromise, difficulty prioritizing, and inappropriate “whistleblowing.” The team members, junior colleagues, or nurses find ways to avoid seeking the doctor's opinion or help under these circumstances. These doctors may experience career problems when they may have difficulty with assessments. This may, in turn, cause uncertainty about career choice and subsequent disillusionment with medicine.[6] Under these circumstances, individuals may reject constructive criticism and become more defensive.

Burnout has to be differentiated from stress. Burnout may be seen as a result of working conditions and stress that occurs as a result. Most doctors tend to work long hours and worry constantly about the welfare of their patients. Furthermore, a fear of things going wrong puts them under additional pressure. In many countries, there is an increasing “blame culture” in the health-care system which contributes to this stress. On the other hand, being fastidious almost obsessional personality comes with the territory of practicing medicine. So why should the medical students experience bum out? Before we look at that, there are some factors that are to be considered.


   Rates Of Burnout Top


Studies from India,[7] Italy,[8] Portugal,[9] England,[10] Canada,[11] Paraguay,[12] Brazil,[13] Morocco,[14] Jordan,[15] New Zealand,[16] and Nigeria[17] have all shown worrying rates of burnout. Some of these are illustrated in [Table 1].
Table 1: Number of respondents scoring positive on General Health Questionnaire and disengagement and exhaustion

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Stressors in academic field which can apply to all years in the medical school

Some caveats are essential while interpreting these results. The number of respondents varies across countries. As the surveys are online, individuals choosing to respond are self-selected and the sample may not be entirely representative of the medical school or the country. These online anonymous surveys may attract those respondents who are suffering. As noted above, most medical students are at a vulnerable age of developing psychiatric disorders so may be feeling distressed anyhow. In a more recent series of surveys from 25 countries, similar findings have emerged.[18],[19] Interestingly, in a nationwide survey by the British Medical Association with over 4300 usable responses, the pathways for seeking help were reportedly best for medical students and worse for trainees or residents.[20]


   Causative Factors Top


In a subsequent qualitative study from the UK studying reasons for burnout among medical students in the UK, Bhugra et al. identified five key factors:[21]

  1. Systemic factors: Problems with structures and systems. Medical students are often not seen as part of a team and in some situations seen as additional burden that already stretched staff are expected to carry
  2. Occupational: Job itself and nature and support available will influence the likelihood. Repeated and short duration rotations add to stress as well as not getting enough time to be embedded in the team
  3. Interpersonal factors: Working with peers created tensions. Being expected to work in teams and not feeling a part of the teams created a dissonance and was reported as a major stressor
  4. Environmental factors: Practical issues such as lack of workspace, not having quiet places to rest, and limited access to nutritious diet contributed to feelings of being unwanted and uncared for
  5. Sociocultural: Working out of context and not being aware of culture of the organization added to the stress.


The international surveys mentioned earlier have identified four types of stressors which were relationships (with peers and parents), financial pressures, accommodation, and studies.

These include increased scholastic workload, competition to score high which influences subsequent career choice, high stake examinations, too many tests, and expectations of the teachers and parents. In clinical years, the stress is to do with unfamiliar environment, variable type and degree of supervision, poor role models, and poor quality of teaching. Personal stressors would include leaving home for the first time, loss of contact with parents and friends, difficulties forming new friendships and relationships, and loneliness. Unrealistic expectations of self and by others can lead to stress and familial pressure expectations can also add to the vulnerability to burnout. This indicated a particular challenge for educators and universities alike. The use of alcohol and/or cannabis to deal with anxiety and exhaustion appears to vary across countries [Table 2]. The BMA survey also revealed that nearly one-third of doctors who were reporting burnout were using alcohol or self-prescription to manage, especially those who were more senior.[20],[21]
Table 2: Use of alcohol and cannabis in selected sample

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Not surprisingly, management strategies to deal with stress varied according to cultures which also influenced the use of cannabis or alcohol. In countries like Portugal, 79% of medical students reported using cannabis, whereas the use of alcohol was higher in Paraguay [Table 2].


   What is Needed? Top


An important solution is developing resilience. Resilience is defined as an individual's ability to adapt to and manage stress-facing fear, having a moral compass, having good role models to follow and be mentored by, physical and brain fitness, cognitive and emotional flexibility, having meaning, purpose, and growth in life and realistic optimism. The focus on well-being is critical and it is encouraging to see that many universities with departments of education and occupational medicine are working toward improving working and training conditions. Hospitals have led to providing good quality food and better conditions for rest when on call.

Self-care is important as mental health is critical to one's functioning. Physical activity, yoga, meditation, mindfulness, and other activities can help an individual to relax. Individuals often have their own strategies to manage and deflect stress, so space and time must be made available to allow this to happen. It is crucial that within the cultural boundaries, individuals are aware of their own strengths and weaknesses in order to look after their own emotional needs.

Peer support

By recognizing that those whose mental health may be under pressure and recognizing their needs can help and sometimes help may be more acceptable from peers which in turn can strengthen social networks.

Individuals who feel stressed must feel that they can use primary care physicians without feeling stigmatized and can seek help in a confidential manner.

Support organizations must be publicized and easy access made available. Individual medical students must be clear about boundaries and seek help early and feel able to share problems.

Identify and prioritize activities

These include healthy balanced diet and lifestyle. Maintaining good relationships, having a sense of humor, regular breaks, and making time for oneself can help.

Organizations, i.e., medical schools and universities, must offer dedicated space to rest and relax and wellness programs. Easy access to confidential support can be very helpful. Bullying and harassment can cause stress, thus their prevention is a must. Gender, sexual orientation, or religious belief-related bullying must be challenged and zero bullying policies and actions must be implemented.

These are some of the broad principles. Some solutions may well need to be modified according to cultural variations. It is important that medical students are taught to look after themselves so that they can look after their patients. Recognizing one's own vulnerabilities will make an individual a better and more empathic doctor.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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   Definitions
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   Stages Of Burnout
   Rates Of Burnout
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   What is Needed?
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