Abstract
Burnout is common in physicians and medical students in the United States and other countries. This commentary defines burnout in physicians and medical students. A literature review and my own outline will provide a partial list of its many causes of burnout through the four years of medical school. Current recommendations for reducing medical student burnout are more theoretical than practical in many cases. This review consists of my original suggestions for limiting burnout in medical students, including careful listening to the expected concerns and anxieties of beginning students, and support groups throughout the four years. I propose a reduction in the academic workload, more flexible scheduling of licensing examinations, and ways of lowering student educational debt. Reducing the duration of medical school to three years can also be helpful. Finally, a new beginning of the school day during the first two years is proposed.
The Nature of Burnout
Since the landmark work of Maslach and others, including her very useful inventory of measuring burnout, 1 burnout in professionals has been defined as extreme stress, having three main features: emotional exhaustion, cynicism/depersonalization and inefficacy. Certainly related disorders such as anxiety and depression are contributing factors to burnout, and the relationship is reciprocal.
The exhaustion of practicing physicians is both physical and mental. The workdays are very long. They often go home to finish their clerical work with electronic health records (EHRs), which also limits evening family time. Cynicism/depersonalization causes a loss of empathy for their patients. Inefficacy is a loss of confidence to practice medicine, and may lead to more medical errors, depression and even suicide. Ultimately physicians with burnout will consider nonclinical careers and/or early retirement. Much of the cause of burnout in US physicians is due to a majority now working for large corporations, including hospitals, clinics and academic centers, whose administrators may not have patient care as their primary goal.
Physicians don’t experience burnout because of a lack of resilience or determination. Burnout is not a disease. However, burnout can cause multiple psychiatric problems in physicians, especially in female doctors, members of ethnic minority groups, and Lesbian and gay practitioners.
Similarly, medical students’ possible psychiatric issues are not the cause of burnout. The studies of Brazeau and colleagues
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and Dyrbye, et al.
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make it clear that entering US medical students are mentally stronger than other professional and graduate students of similar age. They are highly motivated to learn about medicine, help patients, master new clinical skills, and eventually want to achieve job satisfaction. While Dyrbye, et al found that approximately 50% of medical students eventually do experience burnout, Almutairi and colleagues using a very large sample size, found a prevalence of 37% of burnout in medical students.
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Ley, et al
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studied thousands of medical students, concluding: “Symptoms of burnout, depression, and anxiety were observed throughout all four years of medical school, Early intervention is needed to support students.”
Causes of Medical Student Burnout
Medical student burnout may have even more causes than those afflicting practicing physicians. These include academic overload, competition from skilled classmates, enormous educational debt from loans, sleep deprivation, constantly changing locations, frequent examinations and choosing a specialty. Johnson, et al used the Medical Educational School Hassle Tool to examine the relative importance of more than 100 factors associated with osteopathic medical student burnout and depression. 6
Academic overload begins early in the first year, and it is compared to “drinking out of a fire hose.” Examinations during the first two years are frequent, putting pressure on students to “keep up,” in subjects they may never have studied before. Students already competitive enough to gain admission to medical school are now surrounded by colleagues with similarly solid academic credentials.
Second year consists of a major change in subject matter, in topics new for nearly all students. By the second semester, anxieties increase over taking the first licensing exam, required for a medical license in American states. At a time when they should continue their classroom introduction to clinical medicine, students must devote limited study time to a review of basic sciences. The workload is even greater for osteopathic students, who must learn osteopathic manipulative medicine in addition to the basic sciences. Advances in clinical care will always continue, adding to the huge information which second year students must comprehend.
Third year students leave familiar classroom settings for multiple clinics and hospitals, with vastly different responsibilities and criteria for evaluation, at rapidly changing, sometimes distant locations. They may be graded now more by appearance, perceived motivation, and their ability to keep up with patients’ courses rather than actual clinical knowledge. For the first time, medical students see patients with serious illnesses. Timed objective structured clinical examinations at the end of the third year, such as the Clinical Performance Examination Series, required by all California medical schools, 7 add to potential burnout.
Fourth year, once a relatively easy year, has changed due to a focus on “audition rotations” for possible residencies, putting pressure on students to make a good impression, with entirely new mentors, often at even more distant sites. The mental and monetary expense of these rotations is quite high, as discussed by Chen. 8 Choosing a specialty is a crucial requirement of this year, often before medical students have a strong sense of what they want to do. Students approaching graduation, especially women, often suffer from what is called imposter syndrome, believing that they are not really qualified to soon become physicians. This syndrome has a remarkably high correlation with burnout. 9
Suggestions for Reducing Medical Student Burnout
A review of the literature on how to reduce burnout in US medical students reveals two main approaches. One is a student wellness program, best expressed by the Stanford University School of Medicine, 10 and used by the majority of US medical schools. The second is a professional coaching approach, as advocated by the American Medical Association. 11 A recent review suggests that professional coaching may be more effective than wellness programs in practicing physicians. 12 I am not aware of any such comparisons of these two approaches published about medical students. My suggestions attempt to combine the most practical features of both approaches, along with my original ideas.
The academic workload can be reduced somewhat. The literature has shown that making classes pass-fail has limited burnout, 13 and nearly all US medical school courses are now pass-fail. Perhaps no exams should be scheduled for the first month of the first year. Another possibility would be starting the first year with a single course, such as cell biology with an introduction to biochemistry and anatomy. Burrell College of Osteopathic Medicine has done this with its Foundations of Anatomic and Molecular Medicine course. 14
The second year might also start with a single course, such as the general principles of pathology or pharmacology, before beginning the seemingly relentless study of systems’ diseases. Exams could be reduced in frequency and number by making them cover two systems at a time, rather than one.
Making the first required licensing exams pass-fail has probably lowered stress among second year students. Why not encourage some qualified students to take the exam in the summer between the first and second year, or during the winter break of their third year?
The problem of educational debt in the US is now much worse, due to the recent passage of the Big, Beautiful Bill by Congress. Making the new loan limit to $50,000 per year, and a professional school loan total of $200,000 will definitely increase medical student burnout. In fact, many students in the US will now be unable to apply to medical school because of insufficient loans. American medical yearly tuition alone often exceeds $50,000 USD at public schools, and over $60,000 USD at private schools. This, plus various fees, books and living expenses will raise the total cost well above the new limit. According to the Association of American Medical Colleges, for the class of 2024, total educational debt, including premedical education, was more than $300,000 for 23% of medical graduates, and the median cost of four years of medical school was $286,000 for public schools and $390,848 for private ones. 15
Medical schools should consider deferring part of tuition and other expenses, for students in good standing, until the completion of post graduate training. A more dramatic way to reduce educational debt is to shorten the duration of medical school. A few US schools have done this for highly qualified students, without any apparent decline in their ultimate clinical skills or their perceived readiness for residency training(16). For students with a strong background in the biological sciences, the first year of medical school could be reduced to only a half year.
Most important of all steps to reduce burnout is LISTENING to students’ concerns, right from the start. Small support groups should be formed, which would continue throughout the undergraduate years, where students’ concerns can be welcomed and addressed. Psychiatrists and experienced clinical psychologists must also be made available to students in need.
Fourth year might begin with a week devoted solely to choosing a specialty. Residents, and attending physicians from multiple specialties should give some lectures to students on the nature of their clinical work. Many faculty members and deans would want to give lectures and be available to help students.
Finally, to limit sleep deprivation, why not begin first and second year classes at 9am rather than 8am? This might be an ideal time for stressed students to ask questions about recent lectures and clinical sessions. School days could begin with catered breakfast, for little or no charge, allowing for informal exchanges of ideas. This might improve camaraderie in medical students, who are notoriously competitive, and improve lecture attendance, which has been declining in US medical schools.
Conclusions
Medical education will remain demanding and stressful, but student burnout can be limited. The numerous inherent and changing sources of burnout must be recognized, including heavy academic workload, educational debt, licensing exams, changing roles during the four years, and the pressure to choose a specialty. Making the limitation of burnout a high priority during a medical education will likely limit the future onset of burnout in practicing physicians.
