NICE, France — Almost half of medical students experience burnout even before reaching residency, which can place them at increased risk for depression and dropping out of medical school, new research suggests.
In a meta-analysis of more than 16,500 medical students, Ariel Frajerman, MD, Centre Hospitalier Sainte Anne, Paris, France, and colleagues found that almost 46% of the students were suffering from burnout, with emotional exhaustion the most common symptom.
Describing the findings as “alarming,” the investigators noted that there is “an urgent need to develop preventive strategies to improve wellbeing and mental health in medical students.”
The results were presented here at the European Psychiatric Association (EPA) 2018 Congress.
Preresidency Burnout
Frajerman explained that the origins of the current analysis lie partly in two studies published about 10 years ago.
The first was a systematic review published in 2006 of psychological distress among Canadian medical students. In that review, no studies of burnout were found.
The second was a review of burnout among medical residents published 1 year later. For that analysis, 19 articles published between 1975 and 2005 were identified; the prevalence of burnout was between 18% and 82%.
“In this period, medical students before residency are not supposed to have burnout, whereas in residents, it’s very high,” Frajerman said.
To determine the prevalence of burnout in medical students prior to residency, the team conducted a systematic search of Medline for all studies published in English between 2010 and 2017.
Studies were included if they assessed burnout using validated questionnaires; the favored questionnaire was the Maslach Burnout Inventory. From an initial 5440 articles identified, 23 studies, involving 16,769 medical students, were selected for the meta-analysis.
Emotional Exhaustion
The researchers determined that 8011 medical students were suffering from burnout, giving an estimated overall prevalence rate of 45.8%.
The prevalence was highest in Middle Eastern countries, which Frajerman said likely reflects the region’s poor working conditions resulting from ongoing war and terrorism.
The prevalence of burnout appeared higher in North America than in Europe. However, Frajerman pointed out that only four of the included studies were conducted in Europe, far fewer than across the Atlantic.
Prevalence data for subscales of the Maslach Burnout Inventory were available in only eight studies, involving a total of 6926 medical students.
These data showed that 42.2% of the students experienced emotional exhaustion, 25.8% suffered from depersonalization, and only 21.2% had a sense of personal accomplishment.
Placing the findings in context, Frajerman said that a 2013 review by Waguih Ishak, PhD, and colleagues found nine studies of burnout in medical students published between 1974 and 2011. In those studies, the prevalence was between 45% and 71%.
“Over almost 40 years, they found only nine studies, whereas in 9 years, we found 23 studies. So really it’s a recent subject of interest in medical studies,” he said. The results show that “burnout in medical students is very frequent, so it has to be taken into consideration.”
Long Hours to Blame?
Moreover, a meta-analysis published in 2016 showed that the prevalence of depression among medical students was 27.2% and that the prevalence of suicidal ideation was 11.1%.
“So we have no excuse,” Frajerman said. “We know there is bad mental health in medical students, even before residency.”
He noted that often, burnout is recognized only later on.
“So if we want to improve that, we have to treat it [earlier] to prevent the appearance of burnout, because it is the most frequent symptom and is a risk factor for depression and dropout.”
Asked by an audience member about the causes of burnout, Frajerman said previous studies suggest that the occurrence of burnout is linked to the amount of time spent on duty.
“The more you work, the more you are at risk of burnout,” he said. This means that medical schools need to be “stricter” in setting limits on the amount of time students work, he said.
Other studies have shown that relaxation programs and other activities organized by the school faculty diminish burnout, because the students feel that their welfare is being considered and because such activities help to reduce rates of depression.
Session chair Guillaume Vaiva, MD, PhD, Centre Hospitalier Régional Universitaire de Lille, asked whether burnout during medical school was predictive of burnout later on.
Frajerman explained that there are no long-term studies on burnout, but that burnout among medical students is predictive of depression and of dropping out of medical school.
Pressure to Excel
After the session, Medscape Medical News discussed the results with two EPA members, neither of whom were involved in the meta-analysis.
Jordan Sibeoni, MD, PhD, Argenteuil Hospital Centre, France, said he was not surprised at the level of burnout reported, adding that medical studies “are tough. You have to work a lot, and there is this ideal of excellency. You have to perform; you have to excel.”
At his university, psychiatrists see medical students once a month if they need advice, orientation, or some psychological or psychiatric support. “And we receive a lot of medical students,” Sibeoni said.
“Most of the time, it’s anxiety or depressive aspects that can be related to burnout. The most problematic ones are the ones that have failed many years, and then it’s not 6 years but it becomes 10 years, with this idea that it will never end.
“Sometimes, because of the system, they fail only one exam out of 10 or 20 exams, and they have to do all the year again; they are completely devastated by this,” he added.
Ana Moscoso, MD, Pitié-Salpêtrière Hospital, Paris, France, agreed, noting that by their very nature, students are vulnerable. Burnout occurs “at the interface with the system, with the institution, so you need to add all this together.”
If an institution learns that levels of burnout among its students are high, “you need to address this issue, because it’s something that is clearly not going well,” Moscoso added.
Individual or Institutional Responsibility?
Sibeoni went on to ask whether it’s the responsibility of a medical university to take care of a student’s well-being, or if it’s the responsibility of the individual to seek help when needed.
“I think for depression and anxiety, maybe this is an individual responsibility. But when you speak about burnout, it should be the teaching hospitals and the medical university who should do something for that,” he said.
The “ambience in general between peers is also something that is definitely important,” added Moscoso.
“If we make a parallel with our field [of psychiatry], evidence shows that if you work in a setting where you are confronted with tough patients or with a lot of workload, even though those things can play a role in burnout, the most important thing is the mental health of the institution,” said Moscoso.
“There is also the matter of training,” said Sibeoni. He noted that he participated in a systematic review of how empathy is taught to medical students. The results showed that most students did not receive any formal training.
“They aren’t even sure that it’s teachable. They even say that medical studies, as they are, make them feel that you shouldn’t be empathetic and you should be hiding your emotions and always be in control of yourself,” he said.
“In lots of studies, you can see that empathy is a protective factor for burnout. So, if you teach medical students not to be empathetic, it’s also like a stress factor for burnout.”
The researchers, Dr Sibeoni, and Dr Moscoso have disclosed no relevant financial relationships.
European Psychiatric Association (EPA) 2018 Congress. Abstract OR0050, presented March 5, 2018.
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