Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population

A national study of medical students' attitudes toward self-prescribing and responsibility to report impaired colleagues

PURPOSE

The authors investigated medical students' attitudes about appropriate prescribing behaviors, their personal responsibility to report impaired colleagues, and what factors may influence these beliefs.

METHOD

The authors conducted a cross-sectional study of U.S. medical students in 2012 to assess attitudes about appropriate prescribing behaviors and responsibility to report impaired colleagues, and to explore relationships between prescribing beliefs and burnout, depression, and alcohol abuse/dependence. Chi-square test and multivariate logistic regression were performed.

RESULTS

Of 12,500 medical students invited to participate, 4,402 (35%) completed surveys. Believing it is appropriate to prescribe an antidepressant to self or spouse was rare (<10%) in comparison with believing it is appropriate to prescribe an antibiotic for oneself (34.5%) or a spouse (57.7%).In multivariate analysis, students with burnout were more likely to agree that each of the inappropriate prescribing behaviors was acceptable (ORs 1.15-1.51). Students with burnout were less likely to believe they had a personal responsibility to report colleagues with impairment due to alcohol or substance use (OR 0.87). Students personally experiencing symptoms of depression were less likely to believe medical students should report colleagues impaired by mental health problems (OR 0.72). Similarly, students with alcohol abuse/dependence were less likely to believe they had a duty to report colleagues impaired by alcohol/substance use (OR 0.55).

CONCLUSIONS

Suboptimal attitudes about prescribing and personal responsibility to report impaired colleagues are common among medical students. Suboptimal attitudes are associated with personal distress, further evidence of a link between personal distress and professionalism.

Perceptions of gender equality in work-life balance, salary, promotion, and harassment: results of the NASPGHAN task force survey

OBJECTIVES

Gender equality in the workplace has not been described in pediatric gastroenterology.

METHODS

An electronic survey that explored perceptions of career parity, work-life balance, and workplace harassment was sent to all members of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Reponses were anonymous.

RESULTS

Of the 303 respondents (21%), there was an even distribution across geographic region, age, and gender (54% men). Gender affected perception of salary and promotion; 46% of men but only 9% of women feel that "women earn the same as men" (P < 0.001). Similarly, 48% of men but only 12% of women feel that "women rise at the same rate as men" (P < 0.001). Both genders of academic practice respondents, compared with other practice models, perceived men were promoted more quickly than women (P = 0.008). Women had higher dissatisfaction with mentoring than men (29% vs 13%, P = 0.03). Significantly more men than women reported spouses with "flexible jobs" (35% vs 14%, P < 0.001). Having a spouse with "flexible job" or having children (preschool or school age), however, did not affect satisfaction with work-life balance for either gender. Overall, women are more likely to be dissatisfied with work-life balance than men (P = 0.046).

CONCLUSIONS

Satisfaction with work-life balance is lower among women versus men pediatric gastroenterologists, but does not correlate with flexibility of spouse's job or caring for young children. Gender-divergent perception of promotion, parity of compensation, and mentoring requires further investigation.

Impact of organizational leadership on physician burnout and satisfaction

OBJECTIVE

To evaluate the impact of organizational leadership on the professional satisfaction and burnout of individual physicians working for a large health care organization.

PARTICIPANTS AND METHODS

We surveyed physicians and scientists working for a large health care organization in October 2013. Validated tools were used to assess burnout. Physicians also rated the leadership qualities of their immediate supervisor in 12 specific dimensions on a 5-point Likert scale. All supervisors were themselves physicians/scientists. A composite leadership score was calculated by summing scores for the 12 individual items (range, 12-60; higher scores indicate more effective leadership).

RESULTS

Of the 3896 physicians surveyed, 2813 (72.2%) responded. Supervisor scores in each of the 12 leadership dimensions and composite leadership score strongly correlated with the burnout and satisfaction scores of individual physicians (all P<.001). On multivariate analysis adjusting for age, sex, duration of employment at Mayo Clinic, and specialty, each 1-point increase in composite leadership score was associated with a 3.3% decrease in the likelihood of burnout (P<.001) and a 9.0% increase in the likelihood of satisfaction (P<.001) of the physicians supervised. The mean composite leadership rating of each division/department chair (n=128) also correlated with the prevalence of burnout (correlation=-0.330; r(2)=0.11; P<.001) and satisfaction (correlation=0.684; r(2)=0.47; P<.001) at the division/department level.

CONCLUSION

The leadership qualities of physician supervisors appear to impact the well-being and satisfaction of individual physicians working in health care organizations. These findings have important implications for the selection and training of physician leaders and provide new insights into organizational factors that affect physician well-being.

What Factors Promote Resilience and Protect Against Burnout in First-Year Pediatric and Medicine-Pediatric Residents?

Burnout has high costs for pediatricians and their patients. There is increasing interest in educational interventions to promote resilience and minimize burnout among pediatric trainees. This study tested a conceptual model of factors that might promote resilience and protect against burnout, and which could serve as targets for addressing burnout in pediatric residents. Questionnaires were administered in a cross-sectional survey of (n = 45) first-year pediatric and medicine-pediatric residents. A minority (40%) of residents met one or more criteria for burnout. Physician empathy and emotional intelligence were not significantly correlated with burnout or resilience. Self-compassion and mindfulness were positively associated with resilience and inversely associated with burnout. Thus many residents in this sample endorsed burnout; mindfulness and self-compassion were associated with resilience and may promote resilience and protect against burnout in these trainees. Future studies should explore the impact of training in mindfulness and self-compassion in pediatric trainees.

A mindfulness-based stress prevention training for medical students (MediMind): study protocol for a randomized controlled trial

Background

Medical training is very demanding and associated with a high prevalence of psychological distress. Compared to the general population, medical students are at a greater risk of developing a psychological disorder. Various attempts of stress management training in medical school have achieved positive results on minimizing psychological distress; however, there are often limitations. Therefore, the use of a rigorous scientific method is needed. The present study protocol describes a randomized controlled trial to examine the effectiveness of a specifically developed mindfulness-based stress prevention training for medical students that includes selected elements of cognitive behavioral strategies (MediMind).

Methods/Design

This study protocol presents a prospective randomized controlled trial, involving four assessment time points: baseline, post-intervention, one-year follow-up and five-year follow-up. The aims include evaluating the effect on stress, coping, psychological morbidity and personality traits with validated measures. Participants are allocated randomly to one of three conditions: MediMind, Autogenic Training or control group. Eligible participants are medical or dental students in the second or eighth semester of a German university. They form a population of approximately 420 students in each academic term. A final total sample size of 126 (at five-year follow-up) is targeted. The trainings (MediMind and Autogenic Training) comprise five weekly sessions lasting 90 minutes each. MediMind will be offered to participants of the control group once the five-year follow-up is completed. The allotment is randomized with a stratified allocation ratio by course of studies, semester, and gender. After descriptive statistics have been evaluated, inferential statistical analysis will be carried out with a repeated measures ANOVA-design with interactions between time and group. Effect sizes will be calculated using partial η-square values.

Discussion

Potential limitations of this study are voluntary participation and the risk of attrition, especially concerning participants that are allocated to the control group. Strengths are the study design, namely random allocation, follow-up assessment, the use of control groups and inclusion of participants at different stages of medical training with the possibility of differential analysis.

Trial registration

This trial is recorded at German Clinical Trials Register under the number DRKS00005354 (08 November 2013).

Mental health self-care in medical students: a comprehensive look at help-seeking

OBJECTIVE

The authors characterize medical student help-seeking behaviors and examine the relationship with stress, burnout, stigma, depression, and personal health behaviors.

METHODS

In 2013, the authors administered an electronic survey of all enrolled students at Yale School of Medicine (183 responders, response rate=35 %), inquiring about students' primary medical and mental health care, personal health behaviors, support systems, and help-seeking behaviors. Students completed the Attitudes to Mental Health Questionnaire, the Patient Health Questionnaire-2, and a modified Maslach Burnout Inventory. The authors analyzed the results with logistic regression, the Wilcoxon rank-sum test, the Kruskal-Wallis test, or a test for significance of Kendall rank correlation.

RESULTS

Most students reported having a primary care provider (PCP), yet few reported seeking care when sick (33 %). Nineteen percent of students reported having a mental health provider, fewer than reported having a PCP (p<0.0001). Twenty-five percent of students reported increased mental health needs since beginning medical school, and these students were more likely to agree that their needs were untreated. The majority of students endorsed stress, which correlated with increased and unmet mental health needs (p<0.001). Burnout peaked in second- and third-year students and correlated with stress and increased and untreated needs. Most students reported comfort with asking for academic help; those uncomfortable were more likely to have mental health needs for which they did not seek treatment (p=0.004). Mental health stigma was low.

CONCLUSIONS

Medical students had a significant unmet need for health care, influenced by barriers to accessing care, stress, burnout, and depression. Academic help seeking and supportive faculty relationships appear related to mental health treatment seeking. Targeted interventions for stress and burnout reduction, as well as incorporation of reflective practice, may have an impact on overall care seeking among medical students. Future studies should expand to other medical and professional schools.

Are there high-risk groups among physicians that are more vulnerable to on-call work?

BACKGROUND

Work done in the emergency departments is one stressful aspect of physicians' work. Numerous previous studies have highlighted the stressfulness of on-call work and especially of night on call. In addition, previous studies suggest that there may be individual differences in adjusting to changes in circadian rhythms and on-call work.

OBJECTIVE

The objective of this study was to examine whether physicians' on-call work is associated with perceived work-related stress factors and job resources and whether there are groups that are more vulnerable to on-call work according to sex, age, and specialization status.

METHODS

This was a cross-sectional questionnaire study among 3230 Finnish physicians (61.5% women). The analyses were conducted using analyses of covariance adjusted for sex, age, specialization status, and employment sector.

RESULTS

Physicians with on-call duties had more time pressure and stress related to team work and patient information systems compared with those who did not have on-call duties. In addition, they had less job control opportunities and experienced organization as less fair and team climate as worse. Older physicians and specialists seemed to be especially vulnerable to on-call work regarding stress factors, whereas younger and specialist trainees seemed vulnerable to on-call work regarding job resources.

CONCLUSIONS

Focusing on team issues and resources is important for younger physicians and trainees having on-call duties, whereas for older and specialists, attention should be focused on actual work load and time pressure.

Workforce, learners, competencies, and the learning environment: Research in Medical Education 2014 and the way forward

Medicine in the United States is changing as a result of many factors, including the needs and demands of 21st-century society. In this commentary, the authors review the 2014 Research in Medical Education (RIME) articles in the context of these changes and with an eye toward the future. The authors organized the 12 RIME articles into four broad themes: career development and workforce issues; competency and assessment; admissions, wellness, and the learning environment; and intended and unintended learning. Although the articles represent a broad range of issues, the authors identified three key take-home points from the collection: (1) Schools may be able to address the looming shortage of primary care physicians through admission selection criteria and targeted curricular activities; (2) better understanding of the competencies required to perform complex physician tasks could lead to more effective ways to teach and assess these tasks; and (3) the intended and unintended learning that take place in the medical learning environment require careful attention in order to produce physicians who are both skilled enough and well enough to meet the needs of society.

Distress among matriculating medical students relative to the general population

PURPOSE

Many medical students experience distress during medical school. If matriculating medical students (MMSs) begin training with similar or better mental health than age-similar controls, this would support existing concerns about the negative impact of training on student well-being. The authors compared mental health indicators of MMSs versus those of a probability-based sample of the general U.S. population.

METHOD

In 2012 all MMSs at six U.S. medical schools were invited to participate in a survey during orientation. The research team surveyed a probability-based sample of U.S. individuals using the same questions in 2011. Individuals from the population sample who completed a four-year college degree and matched within the appropriate age strata (< 30, 31-35, 36-40, > 40) were compared with MMSs. Surveys included demographics and validated instruments to measure burnout; depression symptoms; and mental, emotional, physical, and overall of quality of life (QOL).

RESULTS

Demographic characteristics of the 582/938 (62%) responding MMSs were similar to U.S. MMSs. Relative to 546 age-similar college graduates, MMSs had lower rates of burnout (27.3% versus 37.3%, P < .001) and depression symptoms (26.2% versus 42.4%, P < .0001) and higher scores across the four QOL domains assessed relative to controls (all P < .0001). These findings persisted on multivariate analysis after adjusting for age, sex, relationship status, and race/ethnicity.

CONCLUSIONS

These findings, along with high rates of distress reported in medical students and residents, support concerns that the training process and environment contribute to the deterioration of mental health in developing physicians.

Empathy among medical students: is there a relation with quality of life and burnout?

Background

We aimed to assess medical students' empathy and its associations with gender, stage of medical school, quality of life and burnout.

Method

A cross-sectional, multi-centric (22 medical schools) study that employed online, validated, self-reported questionnaires on empathy (Interpersonal Reactivity Index), quality of life (The World Health Organization Quality of Life Assessment) and burnout (the Maslach Burnout Inventory) in a random sample of medical students.

Results

Out of a total of 1,650 randomly selected students, 1,350 (81.8%) completed all of the questionnaires. Female students exhibited higher dispositional empathic concern and experienced more personal distress than their male counterparts (p<0.05; d≥0.5). There were minor differences in the empathic dispositions of students in different stages of their medical training (p<0.05; f<0.25). Female students had slightly lower scores for physical and psychological quality of life than male students (p<0.05; d<0.5). Female students scored higher on emotional exhaustion and lower on depersonalization than male students (p<0.001; d<0.5). Students in their final stage of medical school had slightly higher scores for emotional exhaustion, depersonalization and personal accomplishment (p<0.05; f<0.25). Gender (β = 0.27; p<0.001) and perspective taking (β = 0.30; p<0.001) were significant predictors of empathic concern scores. Depersonalization was associated with lower empathic concern (β = −0.18) and perspective taking (β = −0.14) (p<0.001). Personal accomplishment was associated with higher perspective taking (β = 0.21; p<0.001) and lower personal distress (β = −0.26; p<0.001) scores.

Conclusions

Female students had higher empathic concern and personal distress dispositions. The differences in the empathy scores of students in different stages of medical school were small. Among all of the studied variables, personal accomplishment held the most important association with decreasing personal distress and was also a predicting variable for perspective taking.

Ability of the physician well-being index to identify residents in distress

BACKGROUND

Resident well-being impacts competence, professionalism, career satisfaction, and the quality of care delivered to patients.

OBJECTIVE

We established normative scores and reported evidence of relationship between the Physician Well-Being Index (PWBI) score to other variables and consequence validity for the PWBI in a national sample of residents, and evaluated the performance of the index after substituting the original fatigue item with an item not associated with driving a car.

METHODS

We conducted a cross-sectional survey study of a national sample of 20 475 residents. The survey included the PWBI, instruments assessing mental quality of life (QOL) and fatigue, and items on recent suicidal ideation and medical error. Fisher exact test or Wilcoxon/2-sample t test procedures were used with a 5% type I error rate and a 2-sided alternative.

RESULTS

Of 7560 residents who opened the e-mail to participate in the study, 1701 (22.5%) completed the survey. Residents with low mental QOL, high fatigue, or recent suicidal ideation were more likely to endorse each of the PWBI items and a greater number of total items (all P < .001). At a threshold score of ≥ 5, the PWBI's specificity for identifying residents with low mental QOL, high fatigue, or recent suicidal ideation was 83.6%. PWBI score also stratified residents' self-reported medical errors. The PWBI performed similarly using either fatigue item.

CONCLUSIONS

The 7-item PWBI appears to be a useful screening index to identify residents whose degree of distress may negatively impact the quality of care they deliver.