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Abstract

This scoping review explores factors that contribute to medical students’ burnout and identifies the barriers hindering efforts to address burnout and interventions implemented to improve well-being. This scoping review was conducted using the Arksey and O’Malley York methodology. The Joanna Briggs Institute (JBI) guidelines guided the processes of data extraction, evaluation, and reporting of findings. The most common interventions included peer-mentorship programs (n = 6), well-being curriculum interventions (n = 5), virtual wellness programs (n = 1), exercise-based events (n = 1), fireside chats (n = 1), reflective writing courses (n = 1), and faculty-led life coaching (n = 1). Commonly identified risk factors consisted of failure to nurture personal relationships that support emotional resilience (n = 4), the academic rigors of medical education (n = 4), poor time management (n = 3), and poor financial planning or a high debt burden (n = 3). In summary, these studies demonstrate a diverse range of approaches to improving student wellness as influenced through peer and faculty mentoring, highlighting the importance of intervention frequency, continuity across all stages of medical training, and the value of intimate, informal settings in enhancing faculty and student engagement. Our findings will inform future efforts in improving medical student burnout through the design and implementation of various types of wellness programming and systemic changes in medical education.

Keywords

medical students burnout wellness well-being mental health

“Peer-directed approaches not only foster a sense of community but also are easy and cost-effective for institutions to implement.”

Introduction

Burnout is a psychological phenomenon which typically occurs in response to sustained stress.^1,2 Symptoms associated with burnout include depersonalization, loss of a sense of personal accomplishment and a high degree of emotional exhaustion as defined by the National Academy of Medicine, all of which have the potential to carry forward throughout training.³ In the 1990s, burnout was formally recognized in the medical field following research studies showing significant associations between physician burnout and medical errors.⁴ Subsequent research revealed that burnout actually started earlier in medical training, with reported accidents and medical errors starting in medical school and lasting throughout residency.⁵ In medical school, burnout has been noted to occur in stages as the student progresses in training, starting with inattention, lapses in memory, irritability which can progress to maladaptive habits including issues with professionalism along the lines of absenteeism, and finally landing at exhaustion which may result in depression.⁶ It is important to note that burnout has further reaching effects such as the potential to create a sense of detachment and lack of engagement which can negatively impact empathy.^1,6 Multi-institutional studies reveal that half, if not more, of medical students experience burnout.⁷ A study by Rotenstein et al found that the prevalence of U.S. medical students experiencing symptoms of depression is three times higher than the prevalence of this mental health issue in their age-matched peers.^8,9 As for residency, long resident training hours and higher incidence of mental health issues were some of the reported adverse consequences of reported burnout rates in the medical field.^5,10 A meta-analysis of over 22, 000 residents showed an alarming burnout rate of 51%, which varied individually across specialties and led to worsening manifestations of mental health illnesses such as anxiety, depression, and PTSD.¹¹ Since burnout evolves on a continuum starting as early as medical school, continuing through residency, and worsens in clinical practice, it is important to start treating this potential epidemic as early as possible to not only equip students with the skills and strategies needed for building a career centered around wellness and well-being which can be maintained longitudinally into their practice years but also to reduce its severity both of which will be beneficial in future clinical settings.¹²

Challenges in addressing burnout stem from its multilevel and complex etiology, with influential factors ranging from the individual to the interpersonal, organizational, community, and social levels.^13,14 To address such barriers, the American Association of Medical Colleges (AAMC), the governing agency of medical schools in the United States, highly emphasizes the need of wellness integration into medical school curriculums.¹⁵ Some US medical schools have begun implementing wellness programs to not only assess the stressors affecting medical student performance but also evaluate the extent of stress experienced in medical students.¹⁵

Wellness interventions that have shown improvements in medical student well-being have been achieved at the college level including curricular revamping, changes in grading systems, and faculty training in mindfulness.^1,16,17 Another main theme in reported program outcomes is that students should be involved in the implementation of wellness programs as these are not a one-size-fits-all approach but rather individualized interventions tailored to the needs of medical students and the type of burnout they are experiencing.¹⁸ A recent systematic review exploring wellness interventions and their efficacy revealed that some components such as less competitive grading, mental health access, and mindfulness may improve student well-being.¹⁹ However, the evidence on the impact of such programs, peer and mentor involvement, and sustainability of such crucial efforts is still limited in scope.¹⁹ Additional studies are needed to further delineate the long-term sequalae of such interventions as well as to determine the most effective implementation strategies for sustainability of positive student wellness outcomes.

In this scoping review, our goal is to explore factors that contribute to burnout in medical students as well as to identify the barriers that hinder efforts to address medical student burnout and improve well-being. Our findings will inform future efforts in improving medical student burnout through the design and implementation of various types of wellness programming and systemic changes in medical education.

Methods

The review team comprised medical students, one public health expert, and one academic physician with expertise and firsthand experience in medical student wellness programs and student well-being. This scoping review was conducted using the Arksey and O’Malley York methodology, which provides guidance to the authors through a five-step process: (1) defining the research questions; (2) completing a comprehensive literature search for relevant studies; (3) excluding studies that do not align with the predetermined criteria; (4) categorizing and mapping the data; and (5) synthesizing findings, summarizing key data, and reporting the key insights.²⁰ The Joanna Briggs Institute (JBI) guidelines guided the processes of data extraction, evaluation, and reporting of findings.²¹ This approach ensured transparency, reproducibility, and enhanced the credibility of the review’s conclusions.²¹ The study sections were developed with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist as a reference framework.²²

Step 1: Defining the Research Questions

Four research questions were formulated for this scoping review: (1) What are the risk factors associated and/or increasing the risk of medical burnout during medical school? (2) What are the barriers encountered by U.S. medical school programs in addressing medical student burnouts? (3) What is the role of faculty mentorship and peer social support in improving burnout and well-being in medical students? (4) What are future recommendations for the development and implementation of effective wellness programs in U.S. medical schools for improved medical student overall performance and mental well-being?

Step 2: Conducting a Search for Relevant Studies

In collaboration with an expert research librarian (TF) with extensive experience in scoping review methodologies, a comprehensive set of keywords and Medical Subject Headings (MeSH) terms were developed to guide the search process. The search terms included: medical students, wellness, depression, burnout, medical education, mentoring, and mental health. Using these terms, three electronic databases (PubMed, Scopus, and Cochrane Library) were searched to identify relevant peer-reviewed literature, including primary data sources, secondary data sources, and case reports. The screening process was completed by all authors over a 3-month period (May 2024 to August 2024), ensuring a thorough scoping review that addresses all research questions.

Inclusion Criteria

Included in this review were peer-reviewed studies published in English between 2014 and 2024, conducted in the United States, that addressed factors associated with or increasing the risk of medical burnout during medical school. These studies explored the impact of wellness programs in medical schools, the role of faculty mentorship, and peer support in enhancing student well-being. The focus was specifically on medical students during their four years enrolled in a medical school program.

Exclusion Criteria

Excluded from this review were studies that did not focus on the role of faculty mentorship, peer social support, or wellness programs in improving medical student burnout rates. Studies conducted outside the United States, those not based on a pre-existing psychological diagnosis for burnout (e.g., anxiety, depression), or those published in a language other than English were also excluded. Additionally, review studies, editorials, case series, case reports, and published abstracts were not included. Conflicts were resolved through collaborative discussions between co-authors.

Step 3: Selecting Studies that Align with the Research Questions

All co-authors (KB, CS, NL, MR) were responsible for extracting data, tabulating results, and summarizing information. The primary author (PP) and senior author (LS) reviewed all tabulated data to resolve any discrepancies and ensure accuracy of extracted data. Summary tables included one evidence table describing study characteristics such as study design, sample size, study population, age range, study purpose, outcome of interest, risk factors identified associated with medical student burnout, intervention implemented, major intervention outcome (Table 1). Table 2 provides insights on the barriers encountered by U.S. medical school programs in addressing medical student burnout. Table 3 highlights the role of faculty mentorship and peer social support on measured medical student well-being and mental health outcomes. Table 4 lists future recommendations for the development and implementation of effective wellness programs in U.S. medical schools to ensure improved medical student overall performance and mental well-being. A basic qualitative content analysis was conducted to identify recurring themes in future directions across studies. The final table applies the Critical Appraisal Skills Programme (CASP) Checklist to evaluate the rigor and quality of the studies selected (Table 5).²³ Inter-rater reliability was conducted in two rounds across three pairs of reviewers with discrepancies resolved by consensus discussion. Resulting inter-rater reliability was 80% for title and abstract screening and 90% for full-text screening conducted by co-author (PP) and senior author (LS).

Table 1.

Study Characteristics.

Article #	Primary Author/Year	Study Design	Sample Size	Study Population	Study Purpose	Outcome of Interest	Risk Factors Associated with medical student burnout	Type of Intervention/Program Developed/Implemented	Major Intervention Outcomes
1	Abrams et al. (2022)	Pre-post quasi-experimental study	N = 38	Medical students who were actively enrolled peer supporters in their second through fourth years of allopathic medical school during the 2020-2021 year	To examine the impact that involvement in a medical student peer-support program has on the peer supporters themselves	Empathy, self-efficacy, mental health stigma, and the likelihood to assist peers with mental health problems	Lack of empathy	Medical student peer-support program	Peer-support programs present a low-cost, sustainable modality to promote well-being in medical students
							Lack of self-efficacy		Being a peer supporter increased students' self-reported empathy and self-efficacy to help others
							Mental health stigma		Self-efficacy increased the most among male peer supporters, but their post-study survey self-efficacy scores were still lower than those of females
							Mental health stigma		Serving as a peer supporter may not be an effective means to promote self-efficacy amongst women
2	Ahlers et al. (2021)	Descriptive study (Survey)	N = 53	Medical students attending Vanderbilt University in June 2020, including both those who participated in VWLC events and those who did not	To assess the efficacy of the VWLC program on promoting medical student well-being, community, and mental health during the COVID-19 pandemic	Impact of the pandemic and VWLC programming on students' sense of connectivity to peers and students' sense of wellness	The COVID-19 pandemic and social distancing / reduced interpersonal attachments	Virtual Wellness and Learning Communities (VWLC) program	Of the respondents that attended a VLWC event, 79% reported an increased sense of peer connectivity and 61% reported improved wellness after attending
									55% of respondents who attended a VLWC event believed that the events should continue post pandemic to supplement in-person programming
									Those who did not attend a virtual event stated that the main barriers to attending were unfamiliarity with attendees and screen fatigue
3	Arenas & Brisson (2020)	Prospective longitudinal study	N = 168	All M1s and M2s enrolled at Northwestern Feinberg School of Medicine with a bit or little sib, respectively	To improve the transition to medical school for M1s by reducing burnout risk and to improve the mentoring skills of M2s	M1s' anxiety, prioritization skills, and importance for maintaining a work-life balance	Anxiety	Structured peer-mentoring program between M2 and M1 students	Compared to an unstructured peer-mentorship program, introducing guidance via talking points and prompting regular mentoring sessions significantly reduced anxiety, improved prioritization skills, and raised awareness of the importance of striving to maintain work-life balance
						M2s' comfort in giving advice and guidance, motivation to help their sib, capabilities with referring sibs to additional resources, and identification to areas for growth in their little sib	Poor prioritization skills		Having a big sib reduced the anxiety of M1s even prior to their arrival at school or meeting with their big sib
							Lack of work-life balance		Participation in the program augmented the professional development of many M2s
4	Briggs et al. (2021)	Descriptive study (Survey)	N = 1182	Medical students attending medical schools at Boston University, Dartmouth College, Harvard University, Tufts University, UCSF, UMass, University of Rochester, Wayne State, and Cornell University	To assess the effectiveness of various factors at increasing participation in exercise events	Likelihood of the following to increase one's interest in participating in wellness / exercise events	Lack of physical exercise	Exercise events	Strategies most likely to increase student participation in wellness exercise events are those that save them time and money
						Logistics (transportation, food, registration) for an event organized for them			Healthcare institutions and organizations targeting burnout may increase event participation by providing financial discounts, coordinating all event and equipment logistics to allow for seamless participation, and fostering informal mentorship by incorporating social events and colleagues
						Opportunity to find mentors on a formal basis
						Institutional support of an event
						post-event socials			Interventions combining several tactics may be more successful than those incorporating only one or few
						Registration fees being donated to medical research/charity
						Opportunity to participate alongside colleagues from various departments
5	Cameron et al. (2019)	Prospectively designed single-arm intervention study	N = 37	Volunteers from second semester M1 students from the Class of 2019 at Georgetown University School of Medicine	To explore whether a theory-based, structured executive life coaching tailored to the needs of M1 medical students could provide useful tools and approaches to manage the high demands and psychosocial stress of medical training	Safety, feasibility, and tolerability of a structured, theory-based executive/life coaching program	Limited insight into career and life goals	Life Coaching Program with 2 sessions on Vision and Goals (one in group format and one individual) and 2 sessions on Managing stressors (also one in group format and one as an individual session)	There were significant increases in self-efficacy regarding stress management following the program
							Inability to balance work and other priorities		There were not significant improvements in time management and energy for relationships and school after the coaching
							Failure to nurture personal relationships that support emotional resilience		A tailored executive/life coaching program for first-year medical students in the United States is feasible, tolerable, and safe
							Inability to structure time to accomplish specific tasks
6	Dyrbye et al. (2019)	Descriptive study (Survey)	N = 32	Medical schools participating in the AMA's Accelerating Change in Medical Education Initiative	To describe the breadth of strategies U.S. medical schools use to promote medical student well-being	Types of well-being curricula and activities at U.S. medical schools	Lack of physical activity	Well-being curricula and activities, particularly in domains of emotional/spiritual, physical, financial, and social well-being	Schools have implemented a broad range of well-being curricula and activities intended to promote self-care, reduce stress, and build social support for medical students, with variable resources, infrastructure, and evaluation
							Poor financial planning/circumstances
							Poor diet
							Poor sleep		More than half of the responding schools had a student well-being curriculum, most with content scheduled during regular curricular hours and with a combination of optional and mandatory attendance
							Lack of emotional/spiritual awareness		Although 59% of schools reported assessing student well-being, only 26% of schools provided students access to self-assessment tools that would provide them with insight into their own level of well-being
							Lack of social support		Most schools relied on participation rates and student satisfaction to evaluate program effectiveness
7	Flickinger et al. (2022)	Randomized controlled experimental study	N = 29	Pre-clerkship students beginning their clerkship year in February 2017 at the University of Virginia medical school	To pilot the new Flourish curriculum and evaluate students' attitudes and experiences	Student ratings of the program's value in:	Lack of practical wisdom	The Flourish curriculum	Students rated the Flourish curriculum highly, felt it addressed common concerns about clerkships, and were able to apply techniques from the curriculum to their clinical work
						Managing stress and difficult emotions
						Providing a place to process clerkship experiences
						Faculty mentors
						Peer group support			The Flourish framework can help students process their experiences and benefit from peer support, mentorship, and reflection
						Monthly small group sessions			Fostering medical students' wisdom capacities for reflection and compassion may be protective against burnout during their training
8	Langness et al. (2022)	Prospective Observational Study	N = 2984	Medical students from 45 unique medical schools throughout the US	To evaluate individual and institutional drivers of medical student distress and identify the impact of well-being resources on student well-being.	Increase awareness of burnout rates in medical school and improve burnout rates	Low faculty support	N/A	N/A
							Lack of mentorship programs ∙Absence of community-building events
							High debt burden
							Clinical phase or gap year students
							Non-male gender
9	Lee et al. (2022)	Descriptive Cross-Sectional Study	N = 55	Surgery clerkship students at Vanderbilt University	To examine the impact of Fireside Chats in reducing stress and anxiety levels among medical students.	Increase awareness of burnout rates in medical school and improve burnout rates	COVID-19 pandemic isolation	Fireside Chats (small-group, off-campus)	Lowered stress and anxiety levels in medical students
									Provided mental respite and decompression
									Fostered mutualistic mentor-student relationships
									Positive reception and willingness to continue attending Fireside Chats sessions
10	Ludwig et al. (2015)	Mixed-Methods Study	N=332 (Year 1) N=336 (Year 3)	Medical students at Albert Einstein College of Medicine	To identify changes in stress and depressive symptoms over time among medical students.	Improve burnout rates	Increased perceived stress	WellMed Program (comprehensive wellness program)	Significant increase in stress and depressive symptoms between Year 1 and Year 3 students
10	Ludwig et al. (2015)	Mixed-Methods Study	N=332 (Year 1) N=336 (Year 3)	Medical students at Albert Einstein College of Medicine		Improve burnout rates	Risk of depression	WellMed Program (comprehensive wellness program)	Developed WellMed to address wellness across multiple dimensions (mental, physical, spiritual, and financial health)
11	Lynch et al. (2022)	Pilot Study	N=125 (Little Sibs) N=75 (Big Sibs)	Medical students at Larner College of Medicine	To evaluate the impact of a peer-mentorship wellness program on reducing stress during Step 1 preparation.	Improve burnout rates	∙Step 1 preparation stress	Step Siblings (Peer-Mentorship Program)	Reduced stress for the majority of students
							Isolation during study period		Encouraged wellness and peer support during Step 1 preparation
							Isolation during study period		Improved perceived mental health and community support
12	MacArthur et al. (2021)	Qualitative Study	N=97	First-year medical students at a Midwestern U.S. medical school	To evaluate medical students' perceptions of a reflective writing-based wellness course.	Increase awareness of burnout rates in medical school	Academic stress	Reflective Writing Wellness Course	Students appreciated the wellness initiative’s intent but criticized its implementation
							Overburdened schedules		Helped prioritize wellness and relieve guilt for self-care
							Isolation		Fostered connection and reduced feelings of loneliness
13	Nakashima et al. (2020)	Quasi-Experimental Study	N = 108	Third-year medical students during pediatric clerkship	To evaluate the impact of a wellness curriculum on medical student well-being during pediatric clerkship.	Improve burnout rates	∙Academic workload	Wellness Curriculum (Meditation and Chair Yoga)	Significant improvement in mental, physical, emotional, social, and spiritual well-being
							Fatigue
							Limited time for wellness		No improvement in fatigue and social support
14	Pipas et al. (2020)	Quai-Experimental Study	N=21 (Students: 10, Faculty: 11)	First-year medical students and faculty volunteers at Geisel School of Medicine	To evaluate a collaborative wellness curriculum’s impact on stress, burnout, mindfulness, and quality of life	Improve burnout rates	Burnout	A Culture of Wellness Program	28% reduction in burnout
							Perceived stress		Significant decrease in perceived stress
							Limited mindfulness		Significant increase in mindfulness and quality of life
							Limited mindfulness		Participants valued permission and time for self-care
15	Real et al. (2015)	Cohort study	N = 234	Vanderbilt University School of Medicine students enrolled in the wellness program	To measure the level of medical student participation in the wellness program and conduct an exploratory study to look for potential correlations between participation in the wellness program and measured levels of burnout using the Maslach Burnout Inventory (MBI)	Assess medical students' perceived levels of burnout and compare this to measured burnout scores	High Levels of Emotional Exhaustion	N/A	49% of students met criteria for burnout based on criteria of high Emotional Exhaustion and high Depersonalization score
							High Levels of Emotional Exhaustion		Emotional Exhaustion was associated with stressors including grades, lack of time for self, feelings of inadequacy and peer interactions
							High levels of Depersonalization		Depersonalization was associated with clinical year status and lack of feedback
									No significant difference in Emotional Exhaustion or Depersonalization based on lack of support
									Scatter plot of perceived burnout with measured burnout components showed a statistically significant correlation with all three Maslach burnout components
16	Robledo-Gil et al. (2018)	Descriptive study	N = 54	Yale School of Medicine medical students	To examine the utilization and effectiveness of the Peer Advocate (PA) program for medical students at Yale School of Medicine, focusing on how it addresses mental health concerns, academic challenges, and other personal struggles, as well as identifying barriers to its use.	Evaluate the effectiveness of the Peer Advocate (PA) program in addressing medical students' mental health concerns, academic challenges, and personal struggles, while reducing barriers to help-seeking behaviors	Anxiety about academics	Peer Advocate (PA) Program	77% of students contacting a PA found the encounter to be extremely or very helpful
							Dealing with the financial pressures of medical school		Most common reasons for contacting a peer advocate were relationship problems (42.6%), mental health concerns (35.8%) and academic issues (35.8%)
							Adapting to the stress of caring for patients and being part of a hospital team		73% of survey respondents thought the program was “extremely,” “very,” or “somewhat” successful in accomplishing its goal
17	Sathe et al. (2023)	Mixed-methods prospective cohort study	N = 46	Oregon Health & Science University students	To foster improved self-efficacy and well-being during the process of studying for and taking the Step-1 exam	Improve medical students’ self-efficacy	N/A	Nourish Program	Learner self-efficacy improved from mean = 24.9 at baseline to 27.7 post program (P < .001)
								Community building
								Peer Tutoring
								Affirmation/Gratitude
								Wellness Support	Mean stress score increased from 15.5 at baseline to 23,7 post program (P < .001)
18	Snapp et al. (2023)	Descriptive study	N = 60	First-year medical student at Augusta University and University of Georgia Medical Partnership	To evaluate the impact of peer-assisted learning (PAL) session designed for resilience and well-being among first-year medical students	Evaluate the perceptions and experiences of first-year medical students regarding the peer-assisted learning intervention	N/A	“Peer Assisted Learning” (PAL) program	75% of respondents indicated the intervention met their goal
18	Snapp et al. (2023)	Descriptive study	N = 60				N/A	Positive emotional regulation strategy	96% stated they planned to use positive emotional regulation strategies during stressful situations
19	Wilson et al. (2023)	Descriptive study	N = 10	4th year medical students enrolled in Sidney Kimmel Medical College at Thomas Jefferson University	To examine the sources of stress and means of coping for medical students throughout their medical school experience, using a photo-elicitation methodology to gain insights into their lived experiences and identify opportunities to address burnout.	Identify stressors throughout medical school and relevant strategies to deal with stress	A variety of stressors that begin to surface early in training and are unique to medical students	Photo-elicitation method	Identified stressors including: “Hierarchy,” “evaluation,” “cynicism,” “COVID-19,” “Imposter syndrome”
19	Wilson et al. (2023)	Descriptive study	N = 10					Photo-elicitation method	Identified strategies to deal with stress including “Coping,” “Interpersonal relationships,” “Support,” “Sleep”
20	Williams et al. (2021)	Prospective Cohort study	N = 38	Nova Southeastern University medical students	To examine the effectiveness of a Peer-Assisted Learning (PAL) program in enhancing first-year medical students' perceptions of wellness, reducing test-taking anxiety, and improving their academic performance and self-confidence.	Improve first-year medical students' perceptions of wellness, reducing test-taking anxiety, and enhancing academic performance and self-confidence through the implementation of a Peer-Assisted Learning (PAL) program	N/A	Peer Assisted Learning (PAL)	No outcomes were statistically significant

Table 2.

Barriers encountered by Medical Schools in Addressing Medical Student Burnout.

Primary Author (year)	Barriers	Socioecological Model
Primary Author (year)	Barriers	Individual	Interpersonal	Organizational	Community	Society
Abrams et al. (2022)	Medical schools may not have enough students from marginalized backgrounds to address every contributor to distress			X
	Medical schools may not have adequate infrastructure to match students with supporters		X	X
	Students who would serve as peer supporters are sometimes themselves stressed, tired, and overworked or have compassion fatigue	X	X
	Medical schools are small communities and concerns over confidentiality exist	X	X	X
Ahlers et al. (2021)	Screen fatigue	X		X
	Unfamiliarity with attendees, such as for special interest groups and wellness programs	X	X
	Underreporting of mental health challenges due to medical student reluctance to seek help and treatment for mental health concerns	X		X
Arenas & Brisson (2020)	N/A
Briggs et al. (2021)	N/A
Cameron et al. (2019)	N/A
Dyrbye et al. (2019)	Financial barriers limit the budgets for well-being activities			X		X
Dyrbye et al. (2019)	Program evaluation may be limited to student participation rates and reports of satisfaction	X	X	X
Flickinger et al. (2022)	No or low availability of faculty with expertise in mindfulness and appreciative practice techniques			X
Langness et al. (2022)	Poor faculty support	X	X	X
	Lack of mentorship resources		X	X		X
	Lack of community-building programs	X	X	X	X
	High workload	X		X
Lee et al. (2022)	COVID-19 pandemic restrictions limiting social interactions	X	X	X	X	X
	Limited time for wellness initiatives	X		X		X
	Lack of institutional prioritization for mental health resources	X		X		X
Ludwig et al. (2015)	Increased perceived stress	X
	Risk for depression due to workload	X		X
	Insufficient emphasis on wellness programs in early years			X
Lynch et al. (2022)	Limited academic and emotional support during Step 1 preparation	X		X
	Overwhelming number of wellness resources			X
	Lack of clarity in program goals	X		X
MacArthur et al. (2021)	Mandatory wellness initiatives increasing distress	X		X
	Perceived time burden conflicting with academic demands	X
	Wellness programs not meeting individual preferences for coping	X		X
Nakashima et al. (2020)	Time constraints limiting participation	X		X
	High workload during clerkship	X		X
	Limited effect on fatigue levels	X
	Inadequate social support integration	X	X	X
Pipas et al. (2020)	Lack of time for self-care	X		X
	Competing academic and clinical demands	X		X
	Stigma surrounding self-care	X	X		X	X
	Limited participation from high-risk individuals	X		X
Real et al. (2015)	Inherent difficulties in routinely administering in-depth surveys to assess levels of student burnout		X
Robledo-Gil et al. (2018)	Stigma around seeking help and feelings of shame and discouragement	X	X		X	X
	Preference for familiar relationships over designated resources	X	X
	Efficacy survey responses may not represent responses from students that most struggle to seek resources	X	X	X
Sathe et al. (2023)	Participants' self-assessments of engagement in the program are susceptible to recall bias	X
	Response bias for program efficacy surveys	X
	Lack of resources to support larger groups of students			X
	Lack of a control group, due to the ethical dilemma of withholding resources from some students, for comparison to assess program effectiveness		X	X	X	X
Snapp et al. (2023)	N/A
Wilson et al. (2023)	“One-size-fits-all” approaches to fostering wellness and reducing burnout are likely overly simplistic and inadequate due to varying stressors and coping strategies among individual students	X		X
Wilson et al. (2023)	Studies at single institutions represent the experiences of a limited group of students and there is limited transferability to other settings	X	X	X
Williams et al. (2021)	Response bias for program efficacy surveys	X
Williams et al. (2021)	Lack of existing validated questionnaires that are directly aimed at wellness as it pertains to medical school			X	X

Table 3.

Role of Peer Support and Faculty Mentorship in Addressing Medical Student Burnout.

Article #	Primary Author/Year	Findings, Outcomes, or Strategies related to faculty mentorship	Findings, outcomes, or strategies related to peer support
1	Abrams et al. (2022)	N/A	Peer-support programs present a low-cost, sustainable modality to promote well-being in medical students
			Being a peer supporter increased students' self-reported empathy and self-efficacy to help others
			Serving as a peer supporter may not be an effective means to promote self-efficacy amongst women
2	Ahlers et al. (2021)	N/A	Having senior students involved in VLWC programming reach out to their first- and second-year mentees can encourage attendance and in turn promote students' wellness and sense of connectivity to their peers
3	Arenas & Brisson (2020)	N/A	A structured peer-mentoring program between first- and second-year medical students significantly reduced anxiety, improved prioritization skills, and raised awareness of the importance of striving to maintain work-life balance amongst M1s
			Having a big sib reduced the anxiety of M1s even prior to their arrival at school or meeting with their big sib
			M2s found that serving as peer-mentors motivated them to help their mentees and facilitated sustained longitudinal mentorships, thus augmenting their professional development
4	Briggs et al. (2021)	40% of students reported that the opportunity to find informal mentors would make them more likely to increase participation in wellness exercise events	The opportunity to do it alongside peers motivated students to participate in wellness exercise events
5	Cameron et al. (2019)	N/A	N/A
6	Dyrbye et al. (2019)	N/A	N/A
7	Flickinger et al. (2022)	77% of students in the intervention group found faculty mentorship valuable in comparison to 80% in the control group	92% of students in the intervention group found value in having a peer group to talk with in comparison to 90% of students in the control group
8	Langness et al. (2022)	N/A	Peer social support reduced stress and anxiety during clerkship
8	Langness et al. (2022)	N/A	Built camaraderie through Fireside Chats
9	Lee et al. (2022)	Faculty mentors helped facilitate Fireside Chats, fostering trust and providing guidance.	Fireside Chats improved peer relationships and provided mutual emotional support during clerkships.
10	Ludwig et al. (2015)	N/A	N/A
11	Lynch et al. (2022)	N/A	Peer-mentorship program (“Step Siblings”) reduced stress and fostered a sense of community.
12	MacArthur et al. (2021)	N/A	Reflective writing sessions helped students connect and foster peer support
12	MacArthur et al. (2021)	N/A	Reduced feelings of loneliness
13	Nakashima el al. (2020)	N/A	Wellness sessions provided peer interactions that enhanced emotional well-being and reduced isolation.
14	Pipas et al. (2020)	Faculty participation demonstrated vulnerability and self-reflection, fostering mentorship and trust.	Student-faculty collaboration increased emotional support and promoted shared wellness strategies.
15	Real et al. (2015)	Most students interacted with their faculty mentor on a weekly or monthly basis and it was found that this institution had a lower prevalence of burnout than others	N/A
16	Robledo-Gil et al. (2018)	N/A	PAs were perceived as non-threatening, impartial, and sympathetic
			PAs were able to effectively connect students with resources
			Students valued communicating with someone with shared experiences
			PAs reduced barriers such as fear of judgment and stigma
17	Sathe et al. (2023)	Participants and peer mentors reported wanting more academic support	Students felt a strong sense of community and personal support
17	Sathe et al. (2023)		Students reported the most valuable program component was decreased anxiety
18	Snapp et al. (2023)	N/A	75% of the post survey respondents indicated their goals were met including for making connections with peers
18	Snapp et al. (2023)	N/A	Peer coaches led small breakout groups and provided real-life applications of emotional self-regulation
19	Wilson et al. (2023)	N/A	Interpersonal relationships were identified as helping students cope and deal with stress
19	Wilson et al. (2023)	N/A	Camaraderie was identified as a strategy to deal with stress
20	Williams et al. (2021)	N/A	100% of students agreed the PAL program fostered a sense of community
20	Williams et al. (2021)	N/A	59.1% agreed they had gained mentorship throughout the program

Table 4.

Recommendations for Future Design and Implementation of Effective Wellness Programs to Address Burnout in Medical Schools.

Article #	Primary Author/Year	Recommendations & Lessons Learned	Major Identified Themes
1	Abrams et al. (2022)	Schools should recognize different forms of support needed for students of different identities, especially marginalized identities or international medical students	Medical institutions should value individual preferences and provide various types of support to reach students of different identities and backgrounds
		Administrative leaders need to create structural changes to improve the culture of medicine
		Utilize thorough application, screening, and training processes for selecting peer supporters to avoid any harm
		Peer-support programs need to ensure they properly respect and incorporate all aspects of identity for sexual, gender, and racial minorities in medical school
2	Ahlers et al. (2021)	Incorporate virtual wellness programming into medical school curricula
		Provide variety in the platform of virtual events, such as intermittent audio-only telephone events
		Have senior students involved in VWLC programming reach out to their first- and second-year mentees to encourage attendance
		Emphasize involvement of special interest groups to attract students of all different backgrounds and interests
		Offer cost-free access to a virtual conferencing platform
		Student volunteers who are willing to share interests/hobbies with peers	Improve evaluation methods and promote regular data collection regarding wellness-program methods, barriers, and successes to develop strategies for program improvement
		Promote a culture that values regular community events
3	Arenas & Brisson (2020)	Collect data regarding barriers to mentoring identified by M2s and develop according to strategies to improve their mentoring skills
3	Arenas & Brisson (2020)	Utilize structured peer-mentoring programs as opposed to unstructured to have a greater impact on student wellness
4	Briggs et al. (2021)	Institutions, student groups, grassroots nonprofits, and other wellness organizations should leverage student, large-group, or nonprofit discounts to stretch limited funding, and they should also collaborate and pool administrative and advertising resources to broaden outreach, secure buy-in at all levels, and maximize the impact of such investments
		Event organizers should be sure to include administrative approval and encouragement, adequate publicity, group transportation to/from offsite events, transport of exercise equipment, and clearly defined start/end times and event expectations
		Organizers can design outings with specific goals in mind and explicitly advertise events with social purposes, such as to facilitate meeting mentors, encourage existing friends to join, and/or provide an opportunity to socialize with those at other institutions or professional departments
		Adding educational components to exercise events could incentivize students to join while synergizing with the traditional medical school curriculum
5	Cameron et al. (2019)	Medical schools should incorporate both group and individual life coaching sessions for medical students to reduce stress and increase self-efficacy
5	Cameron et al. (2019)	For similar efficiency to this study, coaching programs should be led by trained professional life coaches as opposed to medical school faculty	Ensure mentoring programs are well-structured and consider use of professional coaches
6	Dyrbye et al. (2019)	Implement dedicated well-being competencies and rigorously evaluate their impact to ensure appropriate allocation of time and resources
		Strengthen evaluation methods of well-being programs to alleviate learner distress and ultimately improve student well-being
		Provide access to and encourage the iterative use of self-assessment tools to improve self-awareness and identify areas for improvement in the context of well-being
7	Flickinger et al. (2022)	Integrate the Flourish curriculum with students required clinical skills course so that all students can benefit from the opportunity without a time commitment outside of class responsibilities
8	Langness et al. (2022)	Develop faculty-led wellness initiatives to support medical students
8	Langness et al. (2022)	Integrate informal programs like Fireside Chats to promote social interaction and stress relief
9	Lee et al. (2022)	Expand Fireside Chats to include diverse mentors and topics
9	Lee et al. (2022)	Implement programs in other clerkships to ensure consistency in student support
10	Ludwig et al. (2015)	Incorporate structured wellness curricula earlier in medical school	Outline specific goals and strategies for wellness initiatives to promote efficiency, particularly with social events
10	Ludwig et al. (2015)	Target both academic and emotional support systems to reduce burnout over time
11	Lynch et al. (2022)	Develop peer-mentorship programs like Step Siblings for all students
11	Lynch et al. (2022)	Ensure clear goals and strategies for wellness initiatives to avoid confusion
12	MacArthur et al. (2021)	Align wellness programs with individual student preferences
		Reduce mandatory components that may increase perceived stress
		Focus on fostering community and reducing isolation through peer support
13	Nakashima et al. (2020)	Extend wellness curricula to all clerkships, addressing social support and fatigue
13	Nakashima et al. (2020)	Increase program flexibility to fit into demanding schedules
14	Pipas et al. (2020)	Dedicate time and institutional resources to wellness	Increase program flexibility and reduce stressful mandatory events to better enable participation in wellness-centered activities
		Promote a cultural shift to reduce stigma around self-care
		Include wellness strategies that address both personal and system-level burnout
15	Real et al. (2015)	Need to examine the intangible components of wellness initiatives and identify their most salient features
15	Real et al. (2015)	Larger scale prospective dose-response evaluations to demonstrate the effectiveness of wellness initiatives
16	Robledo-Gil et al. (2018)	Implement a similar peer-advocate program across medical schools
17	Sathe et al. (2023)	Need to include more student tutors and address student individual needs in the pre-survey
17	Sathe et al. (2023)	Need to acquire more relevant background information on individuals
18	Snapp et al. (2023)	Future training needs to address lifestyle choices to support greater well-being
19	Wilson et al. (2023)	Developing individualized strategies
		Addressing diverse stressors associated with medical school
		Emphasizing interpersonal relationships
		Providing mental health resources
		Conducting similar studies with greater sample size to develop targeted interventions
20	Williams et al. (2021)	To have a larger sample size to achieve statistical significance and be able to replicate this study at other institutions
		To further study the effect of these programs on the tutors themselves
		To evaluate the efficacy of such programs in both medical and non-medical programs
		To improve the survey administration system

Table 5.

CASP Checklist.

Study #	Study aim(s)	Study Design	Selection of Subjects	Selection Bias1	Sample Generalizability	Stat Power	Response Rate	Valid Measures	Stat Sig	CI	Quality Score
1	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	9
2	Yes	Yes	Yes	Yes	No	No	Yes	No	No	No	5
3	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	No	No	7
4	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	No	8
5	Yes	Yes	Yes	Yes	Yes	No	No	Yes	Yes	No	7
6	Yes	Yes	Yes	Yes	Yes	No	Yes	No	No	No	6
7	Yes	Yes	Yes	No	No	No	No	No	No	No	3
8	Yes	Yes	Yes	Yes	No	No	No	No	Yes	Yes	6
9	Yes	Yes	Yes	No	No	No	Yes	No	No	No	4
10	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	No	7
11	Yes	Yes	Yes	Yes	No	No	Yes	No	No	No	5
12	Yes	Yes	Yes	Yes	Yes	No	Yes	No	No	No	6
13	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	9
14	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	No	8
15	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	Yes	8
16	Yes	Yes	Yes	Yes	No	No	Yes	No	No	No	5
17	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	No	7
18	Yes	No	No	No	No	No	No	No	No	No	1
19	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	No	8
20	Yes	Yes	Yes	Yes	Yes	No	No	No	No	No	5

Steps 4 and 5: Data Charting and Collation, Summarization, and Reporting of Results

Study characteristics were compiled and organized by the primary author and year of publication, providing information on the study design, sample size, study population, age range, study purpose, outcome of interest, risk factors contributing to burnout, and the type and outcomes of any interventions implemented (Table 1). Table 2 identifies the barriers encountered by U.S. medical school programs in addressing medical student burnout and contextualizes these barriers within the five levels of the Social-Ecological Model (SEM) (individual, interpersonal, organizational, community, and societal levels).²⁴ The Social-Ecological Model (SEM) has been applied in public health research for its ability to address both individual behaviors and broader societal influences on health outcomes.²⁴ Its focus on layered interactions provides a comprehensive framework for evaluating the complex factors shaping health outcomes across social environments.²⁴ Table 3 describes the impact of faculty mentorship and peer social support on measures of medical student well-being and mental health outcomes. Table 4 presents a list of potential future recommendations for the development and implementation of evidence-based wellness programs aimed at mitigating burnout in medical schools. As described by Elo and Kyngas (2008), three phases of qualitative content analysis were employed for the results of the primary qualitative research: (i) preparation, (ii) organizing, and (iii) reporting.²⁵ During the preparation phase, we defined the overarching topic and identified key themes. The organizing phase involved inductive content analysis. Finally, in the reporting phase, we presented the synthesized findings in Table 5. Moreover, the research team utilized the CASP checklist, a well-established critical appraisal tool, to thoroughly assess the methodological rigor and overall quality of the included studies.²³ By applying this checklist, the authors ensured that each selected study upheld standards of credibility, while also allowing for the clear identification of strengths, weaknesses, and limitations of the reported findings.²³ This same critical appraisal technique has been utilized in prior scoping reviews, further supporting its methodological integrity.^26,27

Results

The initial study extraction resulted in 1473 articles from PubMed (n = 437), Scopus (n = 996), and Cochrane (n = 40). After screening, 743 studies were excluded for focusing on the wrong outcome, including those that did not address factors associated with or increasing the risk of medical burnout during medical school (n = 454), did not explore the impact of wellness programs in medical school, or did not examine the role of faculty mentorship and peer social support in improving student burnout rates (n = 211). Additionally, studies were excluded for having the wrong study design (n = 56) or being conducted outside the U.S. Duplicate studies were removed (n = 700). Thirty studies met the inclusion criteria. Following a full-text review, 10 more studies were excluded, resulting in 20 studies retained for analysis (Figure 1).

Figure 1.

Study selection process using the PRISMA flow chart.

Of the 20 retained studies, published between 2015 and 2023, nearly three-quarters (15/20, 75%) were published in 2020 or in later years. Study designs included descriptive studies (n = 7), cohort studies (n = 3), quasi-experimental studies (n = 3), longitudinal studies (n = 1), observational studies (n = 1), a randomized controlled experimental study (n = 1), qualitative studies (n = 1), single-arm intervention studies (n = 1), a pilot study (n = 1), and a mixed-methods study (n = 1). Sample sizes varied, from as few as 10 fourth-year students in a descriptive study to 2984 students across 45 U.S. medical schools in a large observational study. However, most studies (65%) had fewer than 150 participants. The studies were conducted across diverse U.S. medical institutions, including both osteopathic and allopathic schools, spanning pre-clinical and clinical curricula. Access to database data involved medical schools across the U.S., such as Yale University, Augusta University, Oregon Health & Science University, Nova Southeastern University, Vanderbilt University, and Georgetown University School of Medicine. Interventions developed included medical student peer-support groups (n = 6), well-being curriculum interventions (n = 5), virtual wellness and learning community programs (n = 1), exercise events (n = 1), fireside chats (n = 1), and a reflective writing wellness course (n = 1), and faculty-directed life coaching (n = 1).

Scope of US Medical School Wellness Programs to Prevent and Address Medical Student Burnout

Included studies developed, implemented, and/or evaluated interventions to improve student wellness programs. Broadly, the interventions fell into three categories: peer-directed, faculty-directed, or alternative wellness approaches. Of the 20 studies, approximately 7 interventions (35%) were peer-directed, 5 interventions (25%) were faculty-directed, and the remaining took an alternative approach (n = 8). The most common interventions included peer-mentorship programs (n = 6), well-being curriculum interventions (n = 5), virtual wellness programs (n = 1), exercise-based events (n = 1), fireside chats (n = 1), reflective writing courses (n = 1), and faculty-led life coaching (n = 1). Key outcomes measured included stress reduction (n = 10), decreased anxiety (n = 2), improved student well-being (n = 5), and enhanced peer social support (n = 3) (Table 1).

Risk Factors Associated with Increased Risk of Medical Burnout During Medical School

Several key contributors to medical student burnout were highlighted in included studies (Table 2). Commonly identified factors consisted of failure to nurture personal relationships that support emotional resilience (n = 4), the academic rigors of medical education (n = 4), poor time management (n = 3), poor financial planning or a high debt burden (n = 3), lack of physical activity (n = 2), and the COVID-19 pandemic (n = 2). Other risk factors included lack of empathy (n = 1), lack of self-efficacy (n = 1), anxiety (n = 1), limited insight into career and life goals (n = 1) , poor diet (n = 1), poor sleep (n = 1), lack of emotional or spiritual awareness (n = 1), low faculty support (n = 1), absence of mentorship programs (n = 1), non-male gender (n = 1), clinical phase or gap year status (n = 1), high levels of emotional exhaustion and depersonalization (n = 1), and the challenges of adapting to the stress of patient care and working within a hospital team (n = 1). One study found nearly half of students met burnout criteria, characterized by high emotional exhaustion. Emotional exhaustion was strongly associated with stressors such as academic performance pressure, lack of time for self-care, feelings of inadequacy, and peer interactions.²⁸ Recognizing these growing trends, many schools have implemented programs to identify and assess student wellness. Although 59% of schools reported assessing student well-being, only 26% of schools provided medical students with access to self-assessment tools that would provide them with insight into their own level of well-being.¹⁴ Furthermore, institutions that offered a greater number of well-being resources were associated with lower average levels of medical student distress (Table 2).²⁹

Role of Faculty Mentorship and Peer Social Support in Improving Burnout and Well-Being in Medical Students

Most peer-directed interventions focused on low-cost peer-mentorship or advocacy programs facilitated through mentorship between different class years (n = 6/7, or 86%) (Table 3). One intervention centered on recommendations to increase student participation in exercise events promoting wellness.³⁰ These peer-directed interventions varied in their focus, with some emphasizing emotional support and mentorship to promote overall well-being (n = 3), while others integrated peer-assisted learning (PAL) to enhance academic performance and resilience through structured educational sessions (n = 2).^31-35 Additionally, one intervention specifically targeted the stress associated with USMLE Step 1 preparation, providing peer mentorship focused solely on emotional support rather than academic guidance during a challenging season of medical school (n = 1).³³ One study focused on peer-assisted education and tutoring sessions as a mechanism to enhance curriculum comprehension for students adjusting to medical school, highlighting its perceived benefits in improving knowledge and reducing test-taking anxiety.³⁴ Of these seven peer-centered intervention studies, all seven reported positive findings, indicating that peer mentorship often reduced self-reported anxiety and stress, improved coping mechanisms, and enhanced student focus work-life balance: many receiving positive feedback from students.^30-36 Peer support is often cited for its ease of implementation, cost-effectiveness, and the sense of community it fosters (Table 3).

Faculty-directed approaches were often focused on institutional initiatives (n = 2), clerkship-specific interventions (n = 2), or mentorship/coaching sessions (n = 1). Of the faculty-directed interventions, institutional wellness initiatives and curricula sought to integrate multiple wellness strategies (n = 2).^37,38 One small pilot study found that their initiative led to a 28% reduction in symptoms of burnout, along with a decrease in perceived stress.³⁸ Clerkship-specific interventions (n = 2) had varied results: one study demonstrated lowered stress and anxiety levels in medical students, while another found no improvement in fatigue and social support but noted improvements in mental, physical, and emotional well-being.^39,40 Lastly, mentorship through the faculty coaching forum (n = 1) represented another avenue of intervention.⁴¹ Surprisingly, one-on-one life coaching programs with faculty failed to produce significant improvements in time management; however, it did lead to significant increases in self-efficacy regarding stress management.⁴¹ Other interventions present in the literature included a proposed reflective writing course, which medical students largely appreciated in theory.⁴² However, they felt that adding the burden of writing assignments to their curriculum would likely increase stress rather than alleviate it.⁴² One school developed a comprehensive approach to USMLE preparation that included weekly group exercises, daily affirmation emails, daily tutoring and gratitude-sharing activities, which enhanced self-efficacy among students.⁴³ Yet, this intervention was also associated with increased perceived stress and a decline in emotional health scores.⁴³ Another school developed a series of sessions incorporating storytelling, mindfulness, and reflective writing to provide options for coping, stress reduction, and emotional growth, but the study was limited by a small sample size due to voluntary participation.⁴⁴

Lessons Learned

In summary, these studies demonstrate a diverse range of approaches to improving student wellness as influenced through peer and faculty mentoring, highlighting the importance of intervention frequency, continuity across all stages of medical training, and the value of intimate, informal settings in enhancing faculty and student engagement (Table 4).

Critical Appraisal Skills Programme (CASP) Checklist

While all 100% (n = 20) of the studies in this review discussed study aims, only 95% (n = 19) of the studies described the study design and selection of subjects. Selection bias was mentioned in 85% (n = 17). Only 45% (n = 9) of studies discussed sample generalizability and valid measures. When explaining the statistical analysis of the studies, 75% (n = 15) noted response rate and only 10% (n = 2) of the studies stated statistical power. Further, when providing results, 50% (n = 10) of the studies discussed statistical significance and just 20% (n = 4) of the studies stated confidence intervals. Overall, the quality scores of all the studies ranged from 1 (n = 1, 5%) to 9 (n = 2, 10%) out of 10. 5% (n = 1) of studies had a score of 3, 5% of studies (n = 1) had a score of 4, 20% (n = 4) of studies had a score of 5, 15% (n = 3) of studies had a score of 6, 20% (n = 4) of studies had a score of 7, and 20% (n = 4) of studies had a score of 8. Studies with a quality score of 6 or 7, which comprises 35% of studies in this review, indicate a high-quality score of moderate rigor (Table 5).

Discussion

This scoping review aimed to define risks for medical student burnout in U.S. medical school and to assess the impact and role of schools’ wellness programs in addressing such burnout. It also evaluated the roles of faculty mentorship and peer social support in improving medical student burnout and well-being. Our findings provide future recommendations for the development and implementation of effective wellness programs in U.S. medical schools to improve medical student overall performance and mental well-being.

Results illustrate that medical school wellness programs reduce student stress and anxiety rates while helping to improve participants’ self-efficacy regarding coping strategies and self-care. Despite our study showing the importance of such programs, there remains a need for the establishment of more interventions to combat stress and mental health issues among medical students while enhancing their performance. Although different programs utilize often very different approaches, they collectively underline the overall value of institutional wellness programs in addressing student burnout. For example, medical students at the Kirk Kerkorian School of Medicine reported lower perceived stress when they spent more time engaged in wellness activities during the pre-clerkship and clerkship phases of medical school.⁴⁵ Similarly, looking outside solely the medical school context, college campuses have seen the beneficial impact of appropriately developed wellness programs. The Be REAL (Resilient Attitudes and Living) program, developed initially as a mindfulness-based coping-enhancement program at the University of Washington, showed an improvement in anxiety rates and a trend towards reducing depression.⁴⁶ These findings were illustrated not only when the program was run by facilitators in the research team, but also when the intervention was delivered by university staff, thus making it easier for institutions to implement.⁴⁶ At the University of California at San Diego (UCSD), researchers found that for-credit Learning Sustainable Well-being (LSW) courses led to an increased feeling of empowerment, increased compassion for self and others, and intention to continue practices learned in the class amongst students who took the courses.⁴⁷ Additionally, when comparing students in LSW courses with those not, students in LSW courses reported significantly greater mindfulness and psychological well-being.⁴⁷

Several currently implemented medical school wellness programs geared towards addressing medical student burnout are comprised of peer-directed interventions. Approaches vary and range from a focus on low-cost mentorship between peers for emotional support to promoting student participation in exercise events for physical well-being to peer-assisted learning to boost academic performance and reduce test-taking anxiety.^30-36 Of the studies focused on peer-directed interventions that were examined in this scoping review, all reported positive student mental health outcomes.^30-36 These included reduced student anxiety and stress, development of better coping mechanisms, and a stronger work-life balance. In addition, peer-directed approaches not only foster a sense of community but also are easy and cost-effective for institutions to implement. Examining peer-support programs across the nation, similar impacts of peer interaction on student well-being are seen. At one university in the Western United States, students who reported a greater frequency of speaking with their peers in their second year, particularly about challenges they experienced in school, reported higher self-perceived competence regarding academic performance even years later in their senior year.⁴⁸ Another study of undergraduate students located at a liberal arts college in the Midwest, found that students’ everyday interactions with peers contributed to more positive beliefs of academic self-efficacy.⁴⁹ In comparison to their peers, self-efficacious students have been shown to often adopt more challenging goals, illustrate more resilience, and experience lower levels of stress, anxiety, and depression in the face of academic difficulties, thus underscoring the value of peer interaction.⁴⁹

This scoping review examined several faculty-directed approaches to improving burnout and well-being among medical students. The approaches ranged in focus from institutional initiatives to clerkship-specific interventions to mentorship/coaching sessions. Institutional initiatives were found to reduce burnout and perceived stress, while clerkship-specific interventions contributed to improvements in students’ mental well-being. Mentoring and coaching was found to depend largely on appropriate training for efficacy. Faculty mentoring has also been shown to have a strong impact among nursing students who, across several different studies in both the U.S. and abroad, reported reduced levels of stress, anxiety, and depression when participating in mentoring programs in didactic or clinical settings.⁵⁰ At the Saint Louis University School of Medicine, rates of depression, anxiety, and stress were significantly lower among medical students who participated in an expanded wellness program comprised of longitudinal, integrated curricular-changes including faculty mentorship.⁵¹ For graduate students, those with positive, high-quality faculty mentoring have been shown to not only have greater levels of positive mental health and well-being at that time, but also in the years of study following high-quality mentoring.⁵²

Based on findings from the literature, we propose solutions to the aforementioned barriers identified in this scoping review. Medical institutions can address the lack of diverse approaches by valuing individual preferences and provide more varied types of support in order to reach students of different identities and backgrounds.^31,39 For example, students at the Arizona campus of Mayo Clinic Alix School of Medicine noted that wellness curriculums can be more inclusive and well-received by broadening their horizons from more conventional activities associated with wellness, such as yoga and mindfulness, to include those less stereotypically linked, such as book clubs, interest groups, or integration of humanities within the core curriculum.¹⁸ To combat a dearth of appropriately trained faculty and a lack of clarity in goals, mentoring programs should be well-structured and consider use of professional coaches.^41,42,53,54 Additionally, wellness initiatives can outline specific goals and strategies to promote efficiency, particularly with social events.^30,31

To better assess program efficacy and develop strategies for improvement, programs can better evaluation methods and promote regular data collection regarding wellness program methods, barriers, and successes.^14,34 One program at the Frank H. Netter School of Medicine is considering using an objective structured clinical examination format to assess students’ counseling skills with standardized patients after Lifestyle Medicine and Student Wellness sessions, thus allowing facilitators to determine how well students can apply the skills they learn without relying solely on self-perceived knowledge.⁵⁵ Programs can also increase student participation in wellness-centered activities by increasing flexibility and reducing stressful mandatory events.^40,42,44 To address students’ time constraints, the Frank H. Netter School of Medicine found that delivering their wellness content in a scheduling gap when students did not have competing clinical responsibilities resulted in greater program engagement.⁵⁵ Schools such as the University of Missouri have also worked to increase student buy-in via the implementation of a mandatory wellness orientation for first-year medical students to decrease stigma and increase recognition of the importance of early intervention for mental well-being.⁵⁶

Although there exist various examples of wellness approaches to improve medical student burnout, institutions continue to face barriers to implementing such interventions. From the student perspective, barriers include time constraints, fatigue, and stigma around seeking help, all of which limit student participation in wellness programs (Table 2). Major institutional barriers encountered towards implementation of such programs include one-size-fits-all approaches that fail to address individual concerns, lack of clarity in program goals, and limited availability of appropriately trained faculty (Table 2). Among those with implemented programs, there remain barriers such as response bias towards appropriate evaluation of program efficacy. An additional major institutional barrier to implementing wellness programs includes financial constraints. A study surveying 32 medical schools across the U.S. found that institutional budgets for wellness activities were typically small, and only 26% of institutions surveyed used funds towards evaluating the efficacy of their wellness programs.¹⁴ In another survey of wellness programs across the U.S. and Canada, 45 of 86 institutions (52%) reported a lack of financial support as a barrier to further developing their wellness program, making it the most reported barrier in the study.⁵⁷ Of the 7 surveyed schools that did not have a wellness program already in place, nearly 30% reported that inadequate financial support as a barrier to creating one and 57% cited insufficient administrative support as an addition barrier for the same.⁵⁷ This extends beyond the individual institution to encompass a lack of not only sustained funding for wellness programs, but also for increased research in this area. Of the limited studies that exist on this topic, researchers frequently highlight the importance of an iterative process and emphasize the need for medical schools to routinely monitor student well-being and assess the impact of new wellness programs.⁵¹ Recommended areas for further research include randomized control trials to assess efficacy of wellness interventions, more approaches focused on psychological domains of well-being, and longitudinal studies to assess long-term impacts of interventions—all of which will require according funding.¹⁹

Limitations

Our scoping review was limited in that, while we conducted a comprehensive search of the literature through three databases, only 20 articles met our inclusion criteria. This is in part due to the fact that our review was limited to articles in only these three databases and did not encompass tracing of reference lists, gray literature, manual searches of journals, or published scientific reports. An additional limitation is that since a remaining 65% scored an average or low score in terms of rigor, generalizability of results might be limited by the quality of evidence in drawing conclusions for future studies. This highlights a need for larger amounts of research in this area, which can be further accomplished by additional training and staff in U.S. medical colleges to identify and address medical student burnout at early stages for effective intervention.

Conclusion

In a time of increasing anxiety and depression amongst medical students specifically, the need for institutional support and student wellness programs is greater than ever. The findings of this study will inform the future development, dissemination, and implementation of innovative wellness programs to improve rates of burnout among medical students. Our findings also highlight the role of peers and faculty in addressing medical student burnout, as well as strategies for their successful integration in such programs. Further research in this area is needed to assess the efficacy of existing wellness programs by means beyond student self-perceptions. As research continues in this track and institutions improve their evaluation of student wellness and wellness programs, a call for increased attention and funding to this matter is imperative to better the mental health and overall well-being of our medical students.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Kyler Brinton

Lea Sacca

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