Student

health

Burnout in medical
students: a systematic
review
Waguih IsHak, Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai
Medical Center and David Geffen School of Medicine at UCLA, Los Angeles, California, USA
Rose Nikravesh, University of Nevada School of Medicine, Reno, Nevada, USA
Sara Lederer, Argosy University, Los Angeles, California, USA
Robert Perry, Cedars-Sinai Medical Center, Los Angeles, California, USA
Dotun Ogunyemi, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
Carol Bernstein, Department of Psychiatry, New York University School of Medicine, New
York, USA

Burnout is a SUMMARY line, and PsycInfo search from professional characteristics

prominent force Background Burnout is a state of 1974 to 2011 using the keywords: correlate well with burnout.
challenging mental and physical exhaustion ‘burnout’, ‘stress’, ‘well-being’, Potential interventions include
related to work or care-giving ‘self-care’, ‘psychiatry’ and ‘medi- school-based and individual-
medical activities. Distress during medical cal students’. Three authors based activities to increase over-
students‘ well- school can lead to burnout, with agreed independently on the all student well-being.
being significant consequences, partic- studies to be included in this Discussion Burnout is a promi-
ularly if burnout continues into review. nent force challenging medical
residency and beyond. The Results The literature reveals that students’ well-being, with con-
authors reviewed literature per- burnout is prevalent during cerning implications for the con-
taining to medical student burn- medical school, with major US tinuation of burnout into
out, its prevalence, and its multi-institutional studies esti- residency and beyond. To address
relationship to personal, environ- mating that at least half of all this highly prevalent condition,
mental, demographic and psychi- medical students may be affected educators must first develop
atric factors. We ultimately offer by burnout during their medical greater awareness and under-
some suggestions to address and education. Studies show that standing of burnout, as well as of
potentially ameliorate the current burnout may persist beyond the factors that lead to its devel-
dilemma posed by burnout during medical school, and is, at times, opment. Interventions focusing
medical education. associated with psychiatric on generating wellness during
Methods A literature review was disorders and suicidal ideation. A medical training are highly
conducted using a PubMed ⁄ Med- variety of personal and recommended.

242  2013 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2013; 10: 242–245
INTRODUCTION More attention
needs to be paid

M
edicine is an intrinsically to the burnout
demanding profession,
one that seems likely to phenomenon
leave many practitioners at risk during medical
for burnout. Burnout was origi- school
nally thought to come later in a
medical career, after idealism has
given way to pragmatism, and the
fascination with medical practice
is replaced by routine. However,
despite the fact that doctors are
experiencing an increased
tendency to retire early, citing
work pressures and declining job
satisfaction, burnout seems to be
less prevalent in senior doctors
than in early career doctors.1,2 As
medical students shift from a
mostly didactic-filled schedule to reported prevalence ranging be- ing one or more positive life
one that is focused on patient tween 45 and 71 per cent. We events (OR 0.70; p = 0.02),
care, with a combination of reviewed the studies examining whereas no such relationship was
increased stress, reduced confi- the relationship between burnout found between burnout and neg-
dence and experience, more and personal life factors, work- ative life events.3
attention needs to be paid to the place ⁄ learning environment,
burnout phenomenon during minority ⁄ non-minority status and The above studies are limited
medical school,2,3 as it could lead psychiatric morbidity, and then by response rates of 50–55 per -
to suboptimal (self-reported) explored other dimensions of cent, raising uncertainty about
patient care and decreased per- burnout in relation to these selection bias, i.e. students
sonal health and well-being. variables. experiencing burnout were less
likely to respond to a question-
Burnout is characterised by a Table S1 lists supporting naire. Moreover, the cross-sec-
triad of emotional exhaustion, information and findings relevant tional design limits drawing
depersonalisation and a decreased to burnout. conclusions about causality. The
sense of accomplishment.2 The conflicting results between the
Maslach Burnout Inventory (MBI) Medical student burnout and two studies may also have been
is the gold standard in measuring personal life factors affected by the methods each
burnout. The emotional exhaus- A cross-sectional study from three study used to explore personal life
tion (EE) subscale assesses feel- Minnesota medical schools analy- events, as well as institution
ings of emotional depletion and sed data in 2006 to identify the selection from a single state or
work-related exhaustion, whereas impact personal life events had on multiple states.
the depersonalisation (DP) sub- medical student burnout. The
scale measures an individual’s study showed a 45 per cent Medical student burnout and
detachment or the degree to overall burnout prevalence, and workplace ⁄ learning
which one treats patients with an that experiencing a major illness environment
impersonal response. The personal was the only negative life event The above 2009 multistate study
accomplishment (PA) subscale highly associated with increased of medical students was also
assesses feelings of competence rates of burnout (OR 2.594; analysed to examine the implica-
and achievement towards one’s p = 0.002). Positive life events tions of workplace conditions on
work. Maslach proposed that were seemingly unrelated to burnout.3 Participants completed
burnout is indicated by high sub- burnout, although they were a novel 15-item questionnaire
scale scores for EE and DP, along significantly linked to a lower assessing workplace conditions.
with a low subscale score for PA. prevalence of at-risk alcohol use Results indicated that student
(p = 0.0151) and depression burnout in the first and second
RESULTS (p = 0.0047).4 In contrast, a 2009 year was strongly associated with
cross-sectional multistate study the perceived level of support
We found nine studies on burnout demonstrated that burnout is less from faculty staff, whereas stu-
in medical students, with the prevalent among students report- dent burnout in the third and

 2013 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2013; 10: 242–245 243
 Evidence fourth year was most closely being part of a minority group associated increase in suicidal
suggests an linked to clerkship organisation have either comparable or lower ideation.
and exposure to cynical residents. PA scores.
association Students rotating on hospital Longitudinal data generated
between wards and those required to stay Standardised screening for by following Australian medical
burnout in for overnight call were also more symptoms of depression showed no students, assessed burnout via a
medical likely to experience burnout, significant differences between high score on EE and DP at six
students and possibly because of extended white and minority cohorts in intervals. The resulting data
hours spent at the hospital and either study.5,6 Both studies are revealed burnout rates among this
suicidal the acuity of the cases seen hindered by the possibility of group of anywhere between 28
ideation (OR 1.69 and 1.48, respectively; response bias,5,6 especially in the and 75 per cent.9 Students who
both p = 0.02). No significant smaller sample in which minority were single were significantly
relationship was seen with the students were less prevalent more emotionally exhausted than
frequency of call, number of among those who responded. their classmates in relationships.
patients seen, admissions or con- Participants with psychiatric
sults.3 Psychiatric morbidity morbidity had significantly higher
associated with burnout mean EE scores at most points
Medical student burnout and The 10th revision of the WHO’s during the examination period
minority ⁄ non-minority status International Statistical Classifi- (p < 0.001).9
Differences between minority and cation of Diseases and Related
non-minority cohorts in burnout Health Problems (ICD-10) pro- Additionally, there may be a
and other measures were exam- vides no diagnostic guidelines for connection between personality
ined. In one sample, results reveal burnout, apart from labelling it a factors and certain students’
similar overall burnout rates, as ‘state of vital exhaustion.2 The propensity to develop burnout. A
well as similar mean EE and DP American Psychiatric Associa- study of Swedish medical students
scores, regardless of the students’ tion’s Diagnostic and Statistical suggested that impulsivity might
racial or ethnic backgrounds. The Manual of Mental Disorders, fourth be ‘associated with high risk-
only significant difference was a edition, text revision (DSM-IV- taking and unhealthy behavior’.
lower mean personal accomplish- TR), only describes related Such individuals may be ‘impa-
ment score (p = 0.02) in minority entities, such as adjustment tient’, which may lead to disen-
students.5 disorders. gagement during clinical training
and subsequently burnout.10
In another study, differences in Evidence suggests an associ-
mean burnout measures were not ation between burnout in medi- Potential interventions
detected across minority sub- cal students and suicidal Medical schools are in a position
groups, but burnout was more ideation. Cross-sectional data to promote students’ well-being,
prevalent in the cohort of white from seven medical schools through teaching and promoting
students (39 versus 33%; showed students experiencing self-care skills, instituting
p = 0.03). Overall, non-minority burnout were two to three times wellness interventions, and
students were more often burned- more likely to be among the educating students about
out, with high EE (p = 0.03) and 11.2 per cent of responding preventing and reducing
DP (p = 0.01) scores compared students who had considered burnout.1 The restructuring of
with their minority peers, among suicide in the past.7 Burnout medical student duties, regular
whom low DP scores were the most severity was highly associated performance evaluations and
significant indicator of burnout.6 with suicidal ideation (OR 3.46; mentoring programmes have all
p < 0.001), and this association been reported to be helpful in
Whereas the aforementioned persisted after controlling for reducing medical student
study of Minnesota medical stu- depression within the same burnout.10 In addition, develop-
dents discovered a higher prev- population. DP, EE and PA scores ing a structured mentoring
alence of low PA score amongst significantly predicted suicidal programme for students can help
the minority cohort,5 no signif- ideation, with DP being reduce student burnout. For many
icant differences in PA scores especially predictive. Another students, receiving support
were detected within this larger, study found that burnout was around challenging cases via peer
more diverse sample.6 Taken independently associated with relationships can be validating
together, these two studies both recent suicidal ideation and and stress-reducing.
reveal that, whereas white stu- serious thoughts of dropping out
dents appear to be at greater or of medical school.8 Fortunately, Other interventions, including
the same risk for DP, the PA 26.8 per cent of students who cognitive behavioural training,
subscale data consistently shows had previously reported burnout psychotherapy, counselling,
students who self-indentified as recovered from this state and its adaptive and communication

244  2013 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2013; 10: 242–245
skills training, social support, could promote new standards of medical students. Mayo Clinic Interventions
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Shanafelt TD. Race, ethnicity, and
risk of burnout by reducing stress tion to the next generation of medical student well-being in the
by reducing
and increasing quality of life. medical students. United States. Archives of Internal stress and
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The limitations of wellness Future research would need to 7. Dyrbye LN, Thomas MR, Massie FS,
interventions include the fact that implement randomised controlled
quality of life
Power DV, Eacker A, Harper W,
some students may not find a methodology and longitudinal Durning S, Moutier C, Szydlo DW,
particular wellness programme to studies to examine the impact of Novotny PJ, Sloan JA, Shanafelt TD.
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10.1111/tct.12014 ⁄ suppinfo
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successful burnout prevention Shanafelt TD. A multicenter study of
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burnout in medical students.
and wellness education pro- life in minority and non-minority US
grammes during medical school

Corresponding author’s contact details: Waguih IsHak, MD, FAPA, Cedars-Sinai Medical Center and UCLA, Psychiatry and Behavioral
Neurosciences, 8730 Alden Drive, Thalians W-157, Los Angeles, CA 90048, USA. E-mail: [email protected]

Funding: None.

Conflict of interest: None.

Ethical approval: Not required.

doi: 10.1111/tct.12014

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