Physician burnout is a public health crisis that threatens the wellness of physicians, as well as the patients and communities for whom they care. Our definition of burnout stems from 20th century psychological theories that describe the extent to which chronic workplace stressors are reflected in the psyche and spirit of the exposed workers, thus predisposing them to “crushing exhaustion, feelings of cynicism and alienation, and a sense of ineffectiveness—the trio known as burnout.”1
“Burnout” was officially added to the World Health Organization’s International Classification of Disease in 2019, and defined as an occupational syndrome emerging from chronic workplace stressors that have not been adequately addressed or managed.2 The acceptance of this term by WHO speaks to the extent to which “burnout” has become ubiquitous.
That same year, a group of physicians within the Massachusetts Medical Society collaborated to publish a call to action on physician burnout. They stated firmly that “physician burnout is a public health crisis,” further explaining that “a primary impact of burnout is on physicians’ mental health, but it is clear that one can’t have a high performing health care system if physicians working within it are not well. Therefore, the true impact of burnout is the impact it will have on the health and well-being of the American public.”3
The call-to-action was a plea for institutions and society at large to recognize the extent to which the health of our communities is contingent on the health of our healthcare workers. Beyond outlining various concrete action steps for hospitals to take in order to mitigate physician burnout, the publication challenged readers to rethink their current approach to managing burnout. Specifically, they commented that wellness approaches—such as mindfulness, yoga, and resilience training—should only be deployed in conjunction with other systemic- and institutional-level reforms.3 This multi-directional approach is informed by the understanding that burnout is not a personal problem, but a systemic one.
Jennifer Moss develops this idea in her 2019 article, “Burnout is about your workplace, not your people.”4 She refers to an interview with Christina Maslach—developer of the original Burnout Inventory—where Maslach introduced the now popularized metaphor: a canary in a coal mine. Canaries were once used by coal miners to help detect the presence of toxic gases; the death of a canary thus indicated that the mine was not a safe work environment, not that there was something wrong with the canary.1
Maslach explains that when canaries enter a cave, “they are healthy birds, singing away…But when they come out full of soot and disease, no longer singing, can you imagine us asking why the canaries made themselves sick? No, because the answer would be obvious: the coal mine is making the birds sick.”4
The physician who experiences professional burnout can be viewed as a type of warning signal that the conditions of the workplace are unhealthy and even unsafe. And as the rate of physician burnout continues to rise across the United States, it is becoming even more clear that this is not a problem isolated to a handful of physicians at a few hospitals—or a scattering of canaries within mines. Rather, this is a plight so deeply ingrained within the system that it begs us to critically evaluate the entire practice of medicine—or mining as a whole.
One method of doing so is to focus on the experiences of medical students, with the goal of investigating the prevalence of burnout at this stage of training so to identify the optimal point of intervention. In a lecture titled “Doctors in Distress,” Dr. Ed Ellison remarks on the physician burnout crisis and prompts listeners to consider where the problem originates.5 He then offers:
Actually it begins in medical school, where we take these bright shining stars and we often wear them down to a dull nub. Studies show that students entering medical school actually have a higher incidence of wellness and resilience and optimism than those entering any other field of graduate study. And yet by the time they graduate, medical students’ sense of wellness and resilience and optimism is worse than that of any other graduate field.
“So it makes us ask ourselves,” Dr. Ellison then continues, “what are we doing to our medical students?”5
This particular question is one of utmost importance for several reasons. First, if medical school is indeed the starting point of physician burnout as Dr. Ellison theorizes, then it would follow that studying the specific experiences of American medical students would give us a clearer understanding of the specific factors that contribute to feelings of burnout. Further, the investigation of burnout among medical students also offers researchers the unique opportunity to devise interventions that can be placed upstream of the problem—that is, to mitigate physician burnout before medical students even become physicians. And finally, it is important to study the experience of medical students because there is a relative dearth of evidence in the literature about burnout among this community when compared to studies evaluating residents, fellows, and attending physicians.6
Table 1
below summarizes the existing literature that specifically evaluates burnout longitudinally among American medical students.7–10
Study | Journal | Study Type | Sample Size | Conclusions |
Dyrbye et al. (2008) | Ann Intern Med | Cross-sectional Study; Longitudinal Cohort Study | 4287 (from 7 institutions) | - Burnout was reported by 49.6% of respondents - Suicidal ideation within the past year was reported by 11.2% of respondents. - In the longitudinal cohort, burnout, quality of life, and depressive symptoms at baseline predicted suicidal ideation over the following year (P < 0.002 for all). - Burnout and low mental quality of life at baseline were independent predictors of suicidal ideation over the following year. - Of the students who met criteria for burnout in the first year of the study, 26.8% had recovered by the second year. - Recovery from burnout was associated with markedly less suicidal ideation. |
Dyrbye et al. (2010) | Medical Education | Longitudinal Cohort Study | 792 (from five institutions) | Students who did not have burnout at either time-point (coined “resilient” students by the researcher) were less likely to experience depression, had a higher quality of life, were less likely to be employed, had experienced fewer stressful life events, reported higher levels of social support, perceived their learning climate more positively, and experienced less stress and fatigue (all p < 0.05) when compared to students who indicated burnout at either or both time points (“vulnerable” students). - The following factors were independently associated with recovery from burnout: perceiving student education as a priority for faculty/staff, experiencing less stress, not being employed, and being a minority. - There were no differences in demographic characteristics between “resilient” and “vulnerable” students. |
Hansell et al. (2018) | Fam Med | Longitudinal Cohort Study (t = 4 years) | 120 (within one medical school class) | - The overall presence of emotional exhaustion, depersonalization, stress, distress, and burnout significantly increased (p < 0.01) during the time between orientation and graduation. - Distress and burnout scores both peaked at the end of Clerkship Year. |
Dyrbye et al. (2021) | Academic Medicine | Longitudinal Cohort Study (t = 4 years) | 14,126 (national) | - Mistreatment reported during the second year of medical school was associated with higher exhaustion and disengagement scores, as well as higher odds of career regret (p < 0.0001) when measured at the time of graduation. -A more positive emotional climate reported during the second year of medical school was associated with lower exhaustion and disengagement scores at the time of graduation. |
Table 1: A summary of the relevant literature on the subject of medical student burnout in the United States.
The main takeaways from these studies include the following:
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Burnout was reported in nearly half of the medical students who responded to a 2008 survey—a rate of burnout comparable to physicians at the time.7,11
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Suicidal ideation was reported in 1 out of 10 medical students who responded to a 2008 survey. Thus, suicidal ideation was more common among medical students than practicing physicians at the time.7,12
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Rates of distress and burnout among students within one medical school class peaked at the end of their Clerkship year.9
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A more positive emotional climate during the 2nd year of medical school was associated with lower rates of exhaustion and disengagement at the time of graduation.10
These research findings exemplify the urgency of the problem at hand. Not only are medical students in the US capable of experiencing burnout, they are already experiencing it at rates comparable to practicing physicians without yet bearing the full responsibility of patient care, paperwork, and administrative tasks. Further, medical students are also more likely to experience suicidal ideation than practicing physicians.7,11,12
Dr. Liselotte Dyrbye has made substantial contributions to the literature and has in large part shaped our understanding of medical student burnout. Dr. Dyrbye’s research has demonstrated the utility of using longitudinal data to capture change in burnout scores throughout the course of medical school. Dr. Dyrbye has also pioneered the use of the Association of American Medical Colleges (AAMC) survey data within medical student burnout research.10 Still, researchers have yet to explore the national trends in medical student burnout over an extended period of time (beyond 4 years), or compare the prevalence before and after the Covid-19 pandemic. It would be useful to evaluate these trends, as well as compare burnout scores at different times throughout medical education. This kind of research could help us understand if medical student burnout is a problem that has improved, worsened, or stayed the same over the past decade.
This study aims to evaluate the trend in burnout scores among American medical students over the past ten years, with the goal of ultimately improving the circumstances for the future generation of physicians and their patients.