Medical Student Well-BeingMinimize Burnout and Improve Mental Health Among Medical Students

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.

1. Describes the drivers and importance of medical student well-being

2. Provides ways to create a culture of well-being among medical students

3. 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

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.

1. Recognize Shared Responsibility

2. Measure Student Well-Being

3. Optimize the Curriculum

4. Help Control Medical Student Debt

5. Optimize the Learning Environment and Cultivate Community

6. Promote Self-Care and Resiliency

7. Provide Adequate Services for Those Already Affected by Burnout or Distress

8. 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.

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.

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.

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

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.

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.

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.

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.

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.