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Medical Student Burnout: Interdisciplinary Exploration and Analysis

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Abstract

Burnout—a stress-related syndrome characterized by exhaustion, depersonalization, and a diminished sense of accomplishment—is a common phenomenon among medical students with significant potential consequences for student health, professionalism, and patient care. This essay proposes that the epidemic of medical student burnout can be attributed to a technocratic paradigm that fails to value medical students as persons with human needs and limitations. After briefly reviewing the literature on medical student burnout, the author uses two theories to elucidate potential causes: unsatisfactory aspects of the learning environment and a feeling one’s efforts are meaningless or irrelevant. Cultural factors also facilitate burnout in medical students immersed in a clinical environment that cultivates excessive detachment from patient and self, impairing self-care, damaging a sense of self, and impeding the development of a mature, well-integrated professional identity. The ethical implications of medical student burnout are also addressed. Finally, this paper suggests possible preventive and remediative strategies such as optimizing the learning environment as well as narrative approaches that promise enhancement of both individual and institutional well-being.

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Notes

  1. Drybye et al, “Burnout and Suicidal Ideation among U.S. Medical Students.” Annals of Internal Medicine, 149(2008): 334.

  2. Cole and Carlin, “Faculty Health as a Crisis of Meaning: Humanistic Diagnosis and Treatment,” In Faculty Health and Academic Medicine: Physicians, Scientists, and the Pressures of Success, ed. T Cole, T Goodrich, and T Gritz. (New York, NY: Humana Press, 2009), 153.

  3. Davis-Floyd and St. John, From Doctor to Healer: The Transformative Journey. (Piscataway, NJ: Rutgers University Press, 1998): 15–77.

  4. Maslach, Schaufeli, and Leiter, “Job Burnout.” Annual Review of Psychology, 52(2001): 397–422.

  5. Pines and Keinan, “Stress and burnout: The significant difference,” Personality and Individual Differences 39 (2005): 626.

  6. See Cole and Carlin, 147–156, for a discussion of meaning and identity in the distress of academic faculty.

  7. Irvine, “The Ethics of Self-Care,” In Faculty Health and Academic Medicine: Physicians, Scientists, and the Pressures of Success, ed. T Cole, T Goodrich, and T Gritz. (New York, NY: Humana Press, 2009): 127–131.

  8. Davis-Floyd and St. John, 52.

  9. Kaiser, “Fixing Identity By Denying Uniqueness: An Analysis of Professional Identity in Medicine,” Journal of Medical Humanities, 23(2): 95–101.

  10. Maslach and Leiter, The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It. (San Francisco, CA: Jossey-Bass, 1997): 38.

  11. Dyrbye et al, “Burnout and Suicidal Ideation,” 334.

  12. Thomas et al, “How Do Distress and Well-being Relate to Medical Student Empathy? A Multicenter Study.” Journal of General Internal Medicine 22(2007): 177.

  13. Shanafelt et al. “Burnout and Self-Reported Patient Care in an Internal Medicine Residency Program.” Annals of Internal Medicine 136(2002): 358.

  14. Maslach, Schaufeli, and Leiter, 419–420.

  15. Shapiro, Kasman, and Shafer, “Words and Wards: A Model of Reflective Writing and Its Uses in Medical Education,” Journal of Medical Humanities 27(2006): 231–244.

  16. Suchman et al, “Toward an Informal Curriculum that Teaches Professionalism: Transforming the Social Environment of a Medical School,” Journal of General Internal Medicine 19(2004): 501–504.

  17. Dyrbye, Thomas, and Shanafelt, “Systematic Review of Depression, Anxiety, and Other Indicators of Psychological Distress Among U.S. and Canadian Medical Students,” Academic Medicine. 81(2006): 354.

  18. Ibid.

  19. Dyrbye et al, “Burnout and Suicidal Ideation,” 339.

  20. Ibid, 334.

  21. Dyrbye et al, “Personal Life Events and Medical Student Burnout: A Multicenter Study,” Academic Medicine, 81 (2006): 374.

  22. Dahlin and Runeson, “Burnout and Psychiatric Morbidity among medical students entering clinical training: a three year prospective questionnaire and interview-based study.” BMC Medical Education, 7(6).

  23. Van Rooyen, “Professor, I’m tired and stressed!” Medical Education, 42(5): 516.

  24. Dyrbye et al, “Burnout and Suicidal Ideation,” 334.

  25. Ibid.

  26. Dahlin and Runeson.

  27. Ibid.

  28. Dyrbye et al, “The Learning Environment and Medical Student Burnout: A Multicentre Study.” Medical Education 2009 43: 274–282

  29. Dyrbye et al, “Personal Life Events,” 374.

  30. Dyrbye et al, “Race, Ethnicity, and Medical Student Well-Being in the United States.” Archives of Internal Medicine, 167(19): 2103–2109.

  31. Dyrbye et al, “The Learning Environment,” 276.

  32. Ibid.

  33. Ibid.

  34. Dahlin and Runeson.

  35. Dyrbye et al. “Burnout and Suicidal Ideation,” 336.

  36. Thomas et al., 177.

  37. Shanafelt et al., 358.

  38. Maslach, Schaufeli, and Leiter, 406.

  39. Drybye, Thomas, and Shanafelt, “Systematic Review,” 354.

  40. Maslach, Schaufeli, and Leiter, 399.

  41. Ibid.

  42. Ibid, 403.

  43. Ibid.

  44. Ibid.

  45. Ibid, 416.

  46. Maslach and Leiter, 27–28.

  47. Maslach, Schaufeli, and Leiter, 409–411.

  48. Maslach and Leiter, 38.

  49. The next two paragraphs are summarized from Maslach and Leiter, 38–59, and Maslach, Schaufeli, and Leiter, 414–415.

  50. Maslach, Schaufeli, and Leiter, 414.

  51. Ibid.

  52. Ibid.

  53. Maslach and Leiter, 17.

  54. Cole and Carlin, 152–153.

  55. Maslach and Leiter, 148.

  56. Pines and Keinan, 626.

  57. Ibid.

  58. Ibid, 627.

  59. Ibid, 625.

  60. Dunn, Iglewicz, and Moutier, “A Conceptual Model of Medical Student Well-Being: Promoting Resilience and Preventing Burnout,” Academic Psychiatry, 21(1), 46.

  61. Dyrbye, Thomas, and Shanafelt, “Medical Student Distress: Causes, Consequences, and Proposed Solutions,” Mayo Clinic Proceedings, 80(12): 1615.

  62. Davis-Floyd and St. John, 55.

  63. Irvine, 129.

  64. Parker-Pope, The Misery of the Med Student” Well Blog. New York Times (October 30, 2008). Accessed from: http://well.blogs.nytimes.com/2008/10/30/the-misery-of-the-med-student/?scp=2&sq=medical%20student%20burnout&st=cse. Reader comment #4.

  65. Dyrbye, Thomas, and Shanafelt, “Medical Student Distress,”1614.

  66. Ibid, 1614–1615.

  67. In one study, only half of third and fourth-year students felt they received appropriate feedback and that faculty helped them identify weaknesses. Dyrbye et al, “The Learning Environment,” 276.

  68. Kaiser, 101.

  69. Parker-Pope, reader comment #48.

  70. Silver and Glicken, “Medical Student Abuse: Incidence, Severity, and Significance,” Journal of the American Medical Association 263, (1990): 527–532.

  71. Association of American Medical Colleges, 2008 Medical School Graduate Questionnaire. Program Evaluation Survey: All Schools Summary Report. Available at: http://www.aamc.org/data/gq/allschoolsreports/2008_pe.pdf

  72. Ibid.

  73. Ibid.

  74. Wilhelm, “The Student and Junior Doctor in Distress,” Medical Journal of Australia, 177 (2002): S5.

  75. Dunn, Iglewicz, and Moutier, 46.

  76. Ibid.

  77. Dyrbye, Thomas, and Shanafelt, “Medical Student Distress,” 1614.

  78. Hafferty and Franks, “The Hidden Curriculum, Ethics Teaching, and the Structure of Medical Education.” Academic Medicine 69(11): 865.

  79. Dyrbye, Thomas, and Shanafelt, “Medical Student Distress,” 1614–1615.

  80. Irvine, 129–131.

  81. Ibid.

  82. Davis-Floyd and St. John, 52 and 57.

  83. See the comments written in response to Parker-Pope, “The Misery of the Med Student” Well Blog.

  84. Dunn, Iglewicz, and Moutier, 46.

  85. Parker-Pope, reader comment #48.

  86. Irvine, 129.

  87. Davis-Floyd and St. John, 55.

  88. Ibid, 15–16.

  89. Hafferty and Franks, 861–871.

  90. Dyrbye, Thomas, and Shanafelt, “Medical Student Distress,”1615.

  91. Hafferty and Franks, 865.

  92. Ibid.

  93. Irvine, 128–131.

  94. Ibid.

  95. Ibid, 131.

  96. Ibid, 128–131.

  97. Bereiter, “Crying For My Grandmother.” Journal of the American Medical Association, 299 (18): 2129–2130.

  98. Ibid, 2130.

  99. Ibid.

  100. Davis-Floyd and St. John, 55.

  101. Remen, Kitchen Table Wisdom: Stories That Heal. (New York, NY: The Berkley Publishing Group, 1996): 52.

  102. Ibid.

  103. Irvine, 128–131.

  104. Remen, 52.

  105. Irvine, 132–144.

  106. Ibid, 130.

  107. Bereiter, 2129.

  108. Ibid.

  109. Charon, Narrative Medicine: Honoring the Stories of Illness. (New York, NY: Oxford University Press, 2006): 155–156.

  110. Shapiro, Kasman, and Shafer, 234–235.

  111. See Davis-Floyd and St. John, 49–77, for more on the medical student’s socialization process.

  112. Kaiser, 95–101.

  113. Ibid.

  114. Ibid, 98–100.

  115. Ibid, 95–101.

  116. Irvine, 131.

  117. See Davis-Floyd and St. John, page 53, for further discussion of this issue.

  118. Hafferty and Franks, 862.

  119. Davis-Floyd and St. John, 55.

  120. Maslach and Leiter, 1–22.

  121. Cole and Carlin, 150–152.

  122. See Davis-Floyd and St. John, 15–48.

  123. Cole and Carlin, 147–148.

  124. See Hafferty and Franks, 861 for the medical school’s role in “moral enculturation”.

  125. Shapiro, Kasman, and Shafer, 232.

  126. Hafferty and Franks, 862.

  127. Irvine, 127–131.

  128. Irvine, 127–128.

  129. Thomas et al, 177.

  130. Shanafelt et al, 358.

  131. Hafferty and Franks, 868.

  132. “The medical school, including faculty, staff, students, and residents, and its affiliated clinical teaching sites, share responsibility for creating an appropriate learning environment.” Liasion Committee on Medical Education, “ Accreditation Standards,” MS-31-A. Available at: http://www.lcme.org/ functionslist.htm#learning%20environment

  133. Maslach, Schaufeli, and Leiter, 419.

  134. Ibid, 419–420.

  135. Maslach and Leiter, 102–154.

  136. Dyrbye, Thomas, and Shanafelt, “Medical Student Distress,” 1618.

  137. Maslach and Leiter, 102–154. Employees contributing to burnout interventions often experience improved fairness and more community.

  138. Ibid.

  139. Maslach, Schaufeli, and Leiter, 419–420.

  140. “All the information we want to share with them is not necessarily what they really need to learn,” suggests burnout researcher Dyrbye in an interview. Chen, PW. “Medical Student Burnout and the Challenge to Patient Care.” New York Times (October 30, 2008). Available at: http://www.nytimes.com/2008/10/31/health/chen10-30.html?_r=1

  141. Cole and Carlin, 127-146.

  142. Dyrbye, Thomas, and Shanafelt, “Medical Student Distress,” 1618.

  143. Dunn, Iglewicz, and Moutier, 47.

  144. Dyrbye, Thomas, and Shanafelt, “Medical Student Distress,” 1616–1619.

  145. Dunn, Iglewicz, and Moutier, 49.

  146. Dyrbye et al, “Burnout and Suicidal Ideation,” 340.

  147. Suchman et al, 501–504.

  148. Ibid, 501–503.

  149. Cole and Carlin, 154–155.

  150. Shapiro, Kasman, and Shafer, 231–244.

  151. Irvine, 133.

  152. Ibid, 134.

  153. Ibid, 135–137.

  154. Cole and Carlin, 147–156.

  155. Ibid.

  156. Hafferty, “Beyond Curriculum Reform: Confronting Medicine’s Hidden Curriculum.” Academic Medicine 73(1998): 404.

  157. Ibid.

  158. Parker-Pope, reader comment #18.

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With special thanks to the many persons who made this essay possible.

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Jennings, M.L. Medical Student Burnout: Interdisciplinary Exploration and Analysis. J Med Humanit 30, 253–269 (2009). https://doi.org/10.1007/s10912-009-9093-5

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