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Burnout: The Other Epidemic

The high-stress setting of medical school sets the stage for burnout, especially given that many medical students don’t have adequate tools for self-care. Adding a pandemic is a recipe for disaster – so how can students (and staff) alleviate the pressure?

Burnout – it’s a natural part of medical student life, right?

Unfortunately, that’s the mindset of many doctors (and medical students) – and it’s only recently that the devastating long-term effects of burnout have come to our attention. The problem is compounded by the fact that many people may not fully understand what burnout is, how it originates, or what can be done to mitigate it.

Slow burn
Burnout often arises from a prolonged, nerve-wracking setting. Medical students are particularly susceptible because of their often-overwhelming academic workload, the pressure to learn vast amounts of information within a limited period, and their intense feelings of obligation to medicine as future physicians.

Students often describe feeling disconnected and lacking the impetus to learn. They walk through life drained, lackadaisical, and emotionally worn out. Some feel inept; others depersonalized. Among the challenges medical students face, burnout is a key concern because of its association with diminished life satisfaction, thoughts of dropping out, and even suicidal ideation. Its negative impacts encompass students’ mental health, academic performance, sleep quality, learning capacity, and knowledge and job attainment. Worse yet, it’s a vicious cycle; these negative effects lead to ever higher amounts of stress and burnout. Even before COVID-19 struck, medical students were tackling their own epidemic. A meta-analysis in 2016 postulated that 27.2 percent of medical students fit a probable diagnosis of major depressive disorder and a monumental 11.1 percent confessed to suicidal ideation (1). Reports by the American Foundation for Suicide Prevention show that medical students are nearly three times more likely than their peers in other career paths to commit suicide (1,2,3). They are also more likely to succumb to substance abuse; one study found that almost 33 percent of medical students admitted to alcohol abuse, compared with 16 percent of their non-medical peers (4) – and alcohol consumption in medical students is also correlated with higher levels of stress, anxiety, and pressure (5,6).

Nearly 50 percent of students have experienced burnout by the time they prepare to enter residency.

Psychological distress advances chronologically. Studies demonstrate that, at the time of enrollment, medical students have similar – if not better – psychological health to their peers (3,7); by the end of their second year, medical students display considerably more precursors to anxiety and burnout (8). Further studies indicate that mental health deteriorates after students start medical school and continues deteriorating throughout school (9,10). Nearly 50 percent of students have experienced burnout by the time they prepare to enter residency (11). Especially given that these statistics only reference the final stages of burnout, it’s clear that the number of medical students suffering its effects is distressingly high.

Pandemic pile-on
COVID-19 is influencing not only students’ socioeconomic lives, but also their psychological and mental wellbeing, worsening existing levels of burnout. Higher emotional stress in these difficult times also increases the risk of depression. Even now, the ongoing march of the pandemic brings to the forefront the importance of prioritizing health and wellbeing – particularly for medical students, who face not only changes to their lives, but also a dramatic shift in the medical education landscape. 

Tried and tested methods of instruction and assessment, though still useful and relevant, are no longer practical – so they are gradually giving way to new and innovative online teaching methods. Although COVID-19 has brought with it upset and upheaval, it also carries a silver lining: medical curricula, teaching, learning, and assessment methodologies have been forced into the 21st century – and, with them, approaches to the physical and psychological health of staff and students. 

With students now pulled out of classrooms to stop the spread of the disease and studying from home instead, the loss of both classroom and in-person cohort experiences has highlighted new challenges. Struggles previously contained at school have been unmasked, underscored by the continued expectations of a demanding medical school curriculum. And, as unexpected changes continue to arise, students must quickly learn adaptability, endurance, and mental resilience – and they need our help. Everyone involved in medical education must foster wellness and stress management for their students. The new stressors brought on by the pandemic are diverse and influential – but, fortunately, so are the potential coping strategies.

Finding the right response
The first step in preventing or ameliorating a burnout situation and emotional stress is to recognize emotional stressors and acknowledge our responses to them. People often tend to feel anxious, embarrassed, or guilty when they encounter strong feelings, such as despair or resentment – and, as a result, they try to hide or suppress those feelings. Unfortunately, a buildup of negative emotions can lead to irritability, agitation, apathy, and emotional fatigue – key signs of burnout. Accepting and reflecting on these feelings – and receiving assistance from others – can be essential in coping. And that’s why all staff and students can benefit from fundamental strategies, such as training sessions on how to recognize and reduce signs of distress. It’s also worth removing mystery and stigma from professional assistance, such as cognitive behavioral therapy. But beyond that, what are the main issues medical students face – and how can they begin to tackle them?

A new environment
The challenges associated with shifting from school (an ordered environment) to home (almost entirely unordered) can place students under pressure. Sleep deprivation, detachment, self-criticism, and emotional overload are all likely to arise when students must act as their own peers, tutors, and support systems – and these factors have a proven association with burnout. Structuring and maintaining a regular schedule can help re-establish a sense of normalcy in everyday life. This includes coordinating a routine sleep-wake routine, studying at regular hours, and setting a schedule for meals, recreation, and other activities.

When spending the majority of one’s time between the same four walls, it’s easy to forget about physical needs.

When spending the majority of one’s time between the same four walls, it’s easy to forget about physical needs: sleep, proper diet, exercise, relaxation, and social activities. It’s also easy to succumb to the temptations of unhealthy coping strategies, such as drinking or drug use. Not only do these strategies carry health risks of their own, but they are also counterproductive, often camouflaging dangerous levels of stress, depression, or anxiety that require treatment.

Setting healthy limits
To come to terms with the fact that life as we know it has changed, people need to spend time considering new challenges and brainstorming ideas to overcome them. This thought process can help them acclimatize to the “new normal.”

Above all else, students must understand the need for self-care. It may seem as though everyone else is taking on additional projects and activities with the free time they suddenly have – but time doesn’t exist purely to be filled. It’s important to resist extra commitments rather than risk crumbling under pressure. Excessive demands on self – and the self-criticism resulting from failure to fulfil a commitment – will only hurt, not help. Not every experiment will succeed; not every exam will yield a passing grade; not every new hobby will become a lifelong pursuit. We must acknowledge that we will sometimes fail despite our best efforts – and we must be ready to forgive ourselves and move on.

Lack of in-person contact
Studying without face-to-face faculty or peer support is tough – but traditional study techniques can be adapted to suit our new, socially distanced world. Learning from home does not mean learning in isolation. Why not work with peers via video call or seek out other students on social media? These approaches don’t just support learning; they also help people cope with stress. Social media, for instance, allows users to feel connected to one another while at the same time expanding their educational horizons. Peer support groups, even online, can help students manage conflict, improve self-perception, and cultivate empathy. Student-led mentorship programs provide opportunities to communicate and examine feelings. Shared contemplation highlights the fact that no one is alone in their difficulties and may help students discover how their peers solved similar problems – and, when one student’s past struggles help another succeed, both experience a self-esteem boost.

Even when face-to-face contact is impossible, human connection remains a vital part of our lives. Sharing our challenges, accomplishments, and the small joys of everyday life can be an effective stress reliever and a powerful weapon in our arsenal against burnout.

Modeling good health
As educators, we can (and must) be good role models for self-care and empathy. We must engage with our students online and offer support where possible, not just in academics, but also career counseling and life coaching. But, above all, we must look after our own wellbeing – and ensure that our students see us “putting on our own oxygen masks” as well.

These measures can go a long way toward alleviating medical students’ stress and reducing burnout. In the long run, they may even enhance the quality of the medical school curriculum by fostering conscientious care and societal engagement among students, leading to a healthier educational environment. Ultimately, I hope we see a new generation of doctors who understand the full picture of health and wellness – both for their students and for themselves.

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  1. LS Rotenstein et al., “Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis,” JAMA, 316, 2214 (2016). PMID: 27923088.
  2. D Goebert et al., “Depressive symptoms in medical students and residents: a multischool study,” Acad Med, 84, 236 (2009). PMID: 19174678.
  3. American Foundation for Suicide Prevention, “Physician and Medical Student Suicide Prevention” (2020). Available at:
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About the Author
Ritcha Saxena

Professor and Course Director at Medical University of the Americas, Devens, Massachusetts, USA.

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