Medical students are at a heightened risk for burnout and depression, and this elevated risk persists into residency. Burnout among medical students has a negative impact on medical student individual well-being and on patient care. Learn how to address burnout locally.
Describes the drivers and importance of medical student well-being
Provides ways to create a culture of well-being among medical students
Shares examples of successful medical school programs for student well-being
Becoming and being a physician is arduous, challenging, and a privilege. Physicians are nearly twice as likely to experience burnout as other US workers, after controlling for work hours and other factors.1- 3 Burnout is a syndrome of emotional exhaustion, depersonalization (eg, decreased empathy towards patients), and low sense of personal accomplishment that is primarily attributed to work-related stressors. It is important to understand that the high prevalence of burnout among physicians in practice is not reflective of a problem with admissions or defective personal characteristics. National studies have found that matriculating medical students have better mental health profiles than other similarly aged college graduates who pursue other careers.4
Once in medical school, however, medical students are more likely to experience burnout and depression than other similarly aged individuals pursuing different careers, and this elevated risk persists into residency.4 Burnout among medical students predicts developing thoughts of suicide over the course of one year and seriously considering dropping out of medical school. Additionally, burnout among medical students is associated with a 20% increased risk of alcohol abuse or dependence.9 It is also associated with lower performance on standardized assessments, medical errors, and sub-optimal patient care and professionalism. Burnout and depression prevent medical students from reaching their potential and threaten their professional development.Quiz Ref ID
Dyrbye 201014, Thomas 200715, Dyrbye 201516
Medical students also experience other forms of distress, such as profound levels of stress, poor quality of life, and high degrees of fatigue. In fact, most medical students experience multiple forms of distress simultaneously, and the more forms of distress they experience the higher their risk is for thoughts of suicide and dropping out of medical school.
In addition to accreditation standards, there is a moral and ethical imperative for medical schools to address medical student well-being. Medical schools should take steps to reduce the risk of burnout and depression among their students and make an effort to promote a culture of well-being. This module provides a detailed approach to how this can be accomplished.
Recognize Shared Responsibility
Measure Student Well-Being
Optimize the Curriculum
Help Control Medical Student Debt
Optimize the Learning Environment and Cultivate Community
Promote Self-Care and Resiliency
Provide Adequate Services for Those Already Affected by Burnout or Distress
Fund Organizational Science Around Well-Being
Student well-being is a shared responsibility of the individual learner, the school, and course and site faculty where students have clinical experiences. Within the constraints of a demanding schedule and multiple, competing priorities, individual medical students have responsibility for self-care, including engaging in healthy activities, eating nutritiously, sleeping adequately, managing their time, spending time with family and friends, and reaching out for help.
From a medical school perspective this responsibility includes implementing and evaluating primary and secondary prevention strategies with appropriate investment in well-being related infrastructure and resources, as well as organizational efforts to reduce drivers of distress. Typically, these strategies include having a dedicated individual (or group) charged with overseeing student well-being who is resourced and empowered to make school-level changes, such as the Assistant Dean of Students, Associate Director of Student Affairs, or Director of Student Well-Being.
Medical student well-being should be a routine performance metric for a medical school. Best approaches include using a standardized instrument with national benchmarks to allow for comparison between how medical students are doing locally versus nationally.
What are the best instruments to measure student well-being?
Brief, anonymous surveys using validated instruments are best. Several examples of such tools to assess dimensions of well-being can be found here.
Such data can be supplemented with information provided by the Association of American Medical Colleges (AAMC) national surveys: the Medical School Year Two Questionnaire (Y2Q) and the Medical School Graduation Questionnaire (GQ). The AAMC administers the Medical School Year Two Questionnaire (Y2Q) each year to all active, second-year students across the United States. The survey assesses students on topics ranging from their adjustment to medical school to future career plans, culminating in a national report illustrating the climate and culture of medical schools across the nation. The Medical School Graduation Questionnaire (GQ) is available to medical students eligible for graduation and is voluntary to complete. The survey assesses the medical student experience on topics, such as pre-clinical, clinical, and elective experiences, general medical education, student services, and experiences of negative behaviors.
How should results be shared?
Aggregate, de-identified results should be shared with students during town halls, in communications (eg, letters), and during face-to-face meetings with medical school leadership. Analyzing data by demographic and school related factors (year in school, site) can allow for identification of “hot spots” for local intervention.
The relationship of many curricular elements to well-being have been examined to date, including hours spent in small lecture and clinical experiences, amount of vacation allocated, number and time devoted to testing, and grading. Of these factors only pass-fail grading was independently associated with reduced risk of burnout. Additionally, research has found that among first and second year (pre-clinical) medical students there is no relationship between hours spent in lectures and small groups, hours of clinical experiences, hours and number of exams, weeks of vacation, and any measure of student well- being, including burnout, quality of life, or depressive symptoms.
Quiz Ref IDIn particular, a pass/fail grading system is key for decreasing burnout, stress, and serious thoughts of dropping out. In a large multi-institutional study of first- and second-year medical students, those NOT in a pass/fail curriculum had nearly double rates of burnout, higher stress levels, and were 60% more likely to consider dropping out.23 Switching to pass/fail grading during the non-clinical years does not have a detrimental impact on learning as measured by the United States Medical Licensing Examination (USMLE) Step 1 score or clerkship grades.
Sources: Rohe 200623, Bloodgood 200924
An excessive workload (curriculomegaly) adds enormous stress to medical students and contributes to limited time for self-care. In addition, required attendance and lack of flexible schedules contribute to their sense of lack of control over their daily lives. Clinical experiences involving excessive administrative tasks or work inefficiencies are also likely to contribute.
Sources: Mazurkiewicz 201249, Santen 201050
Traditionally, efforts to improve medical student mental health have been focused on enhancing access to mental health providers, reducing the stigma of mental health services to encourage utilization, and implementing ancillary wellness programs. These well-intended efforts do not typically address the root causes of stress and a multi-faceted curricular change is needed.
Approximately 76% of medical students graduate with educational debt.29 A 2018 analysis from AAMC reported that the median educational debt for medical students graduating in 2017 was $192,000. Educational debt can have a significant impact on a student's overall well-being. In fact, medical school debt is an independent predictor of burnout and increases medical students' risk of alcohol dependence and abuse.9 In addition, a multi-institutional longitudinal study of 1,701 medical students found that students who worked for income were significantly less likely to recover from burnout over the course of one year than students who were not employed.6
Source: AAMC Graduation Questionnaire (GQ)
The Liaison Committee on Medical Education requires that a “medical school provide its medical students with effective financial aid and debt management counseling and has mechanisms in place to minimize the impact of direct educational expenses (ie, tuition, fees, books, supplies) on medical student indebtedness.” Some medical schools are offering full tuition scholarships to assist students, based on the perspective that student debt may adversely affect and re-shape the healthcare industry and drive students towards more lucrative specialties and careers, leaving care gaps in less lucrative areas. Other universities are helping students manage debt by reducing tuition costs, offering a more digitized curriculum, or offering loan repayment assistance programs.
Where can students find additional tuition information?
There is a range of expected tuition fees based on the individual institution. AAMC provides information across academic years in their Tuition and Student Fees Workbook. This workbook contains tuition and fees reported by accredited medical education programs and contains aggregate information organized by academic year, cost type (eg, tuition), medical school ownership (ie, public or private), and medical student residence status (ie, in-state or out-of- state).
Where can students learn more about debt repayment programs?
Resources on managing medical school debt can be found through various organizations. For example, the American Academy of Family Physicians (AAFP) offers a number of resources for medical students searching for educational financing and debt repayment programs. This resource provides students with everything from basic financing information to exploring service in health provider shortage areas (HPSAs) for loan forgiveness.
The AAMC also provides a robust resource covering information on loans, grants, financial literacy education and more. Students can find a list of state and federal loan resources, covering information on debt repayment and forgiveness programs, as well as, scholarships. In addition, AAMC offers the MedLoans® Organizer and Calculator tool to aid students in budgeting and managing their debt.
Refinancing is important as well to reduce the burden of medical school debt. Learn about refinancing to obtain favorable interest rates through the AMA Career Planning Resource.
Medical students expect to and desire to work hard. It is typically not work hours or clinical workload that lead to burnout, but rather a poor learning environment. This may include inadequate support from faculty, lack of supervision from residents, cynical residents, lack of variety of medical problems seen, and harassment/mistreatment. Therefore, it is essential that students can learn in an organized and supportive environment that promotes their personal and professional development.
Part of creating and supporting an optimal learning environment is understanding how students can be empowered in the clinic setting. To learn more, check out the AMA Medical Student Documentation Myth resource.
What can be done to optimize the learning environment?
Program evaluations should be performed regularly and include an assessment of students' perceptions of the learning environment, including the adequacy of emotional support, supervision, and faculty role modeling.
Social support buffers stress and helps to build resiliency. Medical schools should take steps to build community between students, and between students and faculty. For example:
Learning communities such as organized study groups may reduce stress, anxiety, and depression.
Longitudinal clerkships have the potential to build help students build meaningful relationships, support, and substantial involvement in patient care—all factors that should buffer against burnout.
Enhanced social engagement, such as medical student lounges, mentorship families, and social events can help by reducing feelings of isolation and enhancing collegiality.
Deliberate strategies are needed to counter forces that erode connections with friends and colleagues, particularly during away rotations.
What is the role of faculty development?
It is a worthwhile investment to help faculty become more effective at delivering timely feedback and fostering a positive learning climate and effective relationships with medical students. Other positive supervisor behaviors include holding career development conversations, inspiring others to do their best, seeking opinions, treating others with respect and dignity, fostering a positive culture, keeping others informed of changes taking place, and encouraging others to develop their talents and skills.
Sources: Prins 200933, Prins 200834, Dyrbye 201043, Thompson 201052, Dyrbye 200953
What can be done to minimize student mistreatment?
Unfortunately, medical student mistreatment does occur in various forms, and has a negative impact on well-being and leads to an increased risk of burnout. New and accelerated efforts to more effectively address trainee harassment, discrimination, and belittlement are needed. While this is still an area of opportunity and improvement, many programs are working diligently on culture change, specifically focusing on promoting reliability and professional accountability among teaching faculty. Faculty training programs may include resources on how to help affected staff and patients, multi-level professional leadership training, and clear processes on how to capture, report, and address inappropriate behavior.
Providing resources to promote self-care and resiliency should be part of every medical school's strategy to promote student well-being. Unfortunately, students have limited time for self-care and this creates a new tension for them as they become role models for patients. Students should be educated to strive for healthy self-improvement and to avoid the self-destructive and exhausting road of perfectionism.
Other common experiences include feeling of inadequacy and feeling like an imposter. Dealing with such feelings by having faculty talk about their own experience tends to be helpful. Many schools are trying to emphasize the need for self-care by providing personal days during the clerkship year.
How can students recognize the need for self-care?
Recognizing a level of distress that leads to a high risk of detrimental impact on one's medical training and personal life is difficult; in fact, most physicians are unable to accurately recognize their own distress. Many may find the feedback from the 7-Item May Clinic Physician Well-Being Index helpful, and nearly half have been found to make a lifestyle change as a direct result of the feedback.38,39
What can students do on an individual level?
Although the matter of how best to promote self-care strategies and adaptive coping strategies remains understudied, a cognitive behavioral approach may be one strategy to make the information practical. For example, Kushner et al developed a curriculum in which students were asked to identify an area of personal wellness they wished to improve and subsequently monitored their personal behavior in this area, developed cognitive expertise in the recommended behavior, devised a strategy and set a personal goal for improvement, implemented a plan, and self-assessed their efficacy.59
Sources: Dyrbye 20146, West 201110, Shanafelt 200211, Prins 200834, Ripp 201140, Campbell 201041, Dahlin 200742, Dyrbye 200953, Dyrbye 201054, Dyrbye 201755, Thompson 201656, Haglund 200957, Lapinski 201658
Despite these prevention efforts, approximately half of medical students experience symptoms of burnout and nearly a third have symptoms of depression. Therefore, medical schools need to take proactive steps to identify students in need of individualized services and provide barrier-free access to mental health care. The Liaison Committee on Medical Education (LCME) has also assessed the need for addressing medical student mental health and has issued specific requirements on standards for accreditation to medical schools.
For example, LCME standards state that diagnostic, preventive, and therapeutic health services must be accessible to medical school students near the site of their required educational experiences, which may include classroom facilities, rotation sites, etc. Policies should be in place that allow students to be excused to seek necessary health care.
Furthermore, LCME standards require that medical students seeking health services are not penalized within the program or in their careers for doing so. Health professionals providing any services, including psychiatric or psychological counseling, should not be involved in the academic assessment or promotion of students in a medical school program. Legal requirements for security, privacy, confidentiality, and accessibility should be met when maintaining medical student health records.
How can we support student access to resources in order to prevent absenteeism?
Being proactive includes monitoring and responding to absences. Negative life events increase risk of depression and burnout. Although such events are outside the control of medical schools, knowing about them, and reaching out to the student offering support and reasonable accommodations can be helpful.
How can we help reduce the stigma relating to mental health?
Historically, the professional culture discouraged discussing “weaknesses,” neglected self-care, and was indifferent to personal wellness. Medical students are less willing to seek professional help for a serious mental health problem than both the general US population and age-matched peers.45 Stigma toward mental health care is fueled both by what medical students observe in their learning environment and by what they personally believe. Strategies are needed to combat both sources of stigma.
Source: Dyrbye 201516
Encourage help-seeking by providing:
Absentee policy that allows time-off for personal medical appointments during clinical hours
Access to mental health providers not involved in academic assessment or advancement process
Care available at sites in reasonable proximity to required educational experiences
“In network” options for off-campus/external mental health providers
Having faculty, residents, and students share their personal struggles and paths to overcome them can also help reduce stigma and encourage help-seeking. A video entitled “Make the Difference: Preventing Medical Trainee Suicide,” developed by Mayo Clinic and the American Foundation for Suicide Prevention, explains how medical students and residents can help prevent suicide by being alert of the signs of depression and how to be most helpful.
What can be done if the worst happens?
If a student suicide occurs, it is important to respond swiftly and appropriately. A suicide response toolkit has been developed by the American Foundation for Suicide Prevention to help schools deal with a student death by suicide in a manner that supports the community and lessens the risk of contagion.
Research to date has primarily studied the prevalence and factors associated with medical student well- being. Few intervention studies have been conducted, and most of these have focused on individual strategies rather than organizational/medical school level interventions. Although each medical student has a responsibility to engage in self-care, it is system-level factors that are the greatest contributors to medical student distress. Solutions are needed, and for well-designed studies to occur, local investment in novel interventions focused on how to best promote individual healthy choices and improve the learning environment are needed. Vanguard institutions should leverage their faculty to develop evidence-based strategies that other organizations/medical schools can implement. The creation of new knowledge on how best to reduce medical student burnout and enhance their well-being and professional competency development can be achieved through organizational science. Investment is critical to change and to the short and long-term health of medical students.
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