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Study shows link between student burnout, professional misconduct
New study has implications for hospitals
Fresh research on burnout in the medical profession makes it clear that hospital ethics boards need to be proactive on this issue. Their role could include educating and suggesting policies to prevent physician and resident burnout and any resulting repercussions.
A survey of more than 2,500 medical students at seven U.S. medical schools has found that more than half experience burnout. Among those who described burnout, unprofessional conduct behavior was higher, as were non-altruistic attitudes.1
"We found a high prevalence of burnout among medical students," says Liselotte N. Dyrbye, MD, MHPE, an associate professor of medicine at the Mayor Clinic Rochester in Rochester, MN.
The study found that 52.8% of students had burnout according to the Maslach Burnout Inventory.1
"Students who had burnout were much more likely to say they engaged in unprofessional behavior, such as cheating," she says. "We also found that students with burnout were less likely to hold altruistic views about physicians' responsibilities to society, and they were less likely to think they would be able to make an impact on meeting the needs of the underserved."
The research has broader implications.
"I think it was a very important study because it confirms what a lot of us were concerned about that this measure of burnout carries with it some significant consequences," says Jonathan A. Ripp, MD, MPH, an assistant professor of medicine in the division of general internal medicine in the department of medicine at Mt. Sinai School of Medicine in New York, NY.
Ripp has studied burnout among medical residents and interns and found that an anxious personality or feeling insecure about one's skills was correlated with experiencing burnout.
His research and the recent medical student study raise questions about how physician burnout might impact patient care and ethical behavior in hospital settings.
"Our concern is that it might lead to suboptimal patient care," Ripp says.
At the very least, the medical student study suggests that burnout can result in a less humanitarian attitude toward patients. Burnout degrades the principles of humanism in medicine, Ripp notes.
"The study shows there may be two ends of the spectrum: humanism and idealism on one and burnout on the other," Ripp says.
Studies repeatedly have shown there is a high prevalence of burnout among physicians and residents, Dyrbye notes.
"We wondered where this burnout had its origin, in residency or earlier?" she explains.
"Our first study was in Minnesota in 2006, and we found 50% of medical students had burnout," she adds. "Then we conducted a series of studies subsequently and, at last in 2009, we had several U.S. medical schools involved."
One of the common factors among medical students experiencing burnout was having had a recent negative life event, Dyrbye says.
"They're standing on the end of a diving board and just getting by because medical school is stressful and they're experiencing death and dying for the first time," she explains. "Then their mom gets sick, and that tips them over the edge."
The study found that minority students generally report less burnout and tend to be more resilient, with one exception: If they perceive that their race has adversely impacted their experience, they report more burnout, she says.
Another factor that appeared to have some relationship to burnout's long-term impact involves work.
"Students who work for an income while in medical school are less likely to recover from burnout," Dyrbye says.
Investigators checked on students' reported burnout symptoms over two time periods separated by one year, and found that having any kind of job made recovery more difficult.
"It's yet one more responsibility on their plate, and it doesn't matter how many hours they work," Dyrbye says. "Also, having children adds an extra stress and a layer of complexity, so people who have children while in medical school struggle more."
One factor that seems to result in a lower burnout status is faculty support: "Students who perceive they are getting a high level of support from faculty are less likely to have burnout," Dyrbye says.
Again, these types of nuances and findings have some potential implications for hospitals and ethics boards, particularly when viewed within the context of previous research showing that residents who are burned out are more likely to believe they've made a medical error, she says.
"Whether or not burnout among resident physicians is impacting their ethical standards, we don't know that," she says. "We can speculate that if we see [ethical lapses] in students it might persist in residents."
Likewise, the findings that faculty support can help with burnout suggests that hospitals could play a role in reducing burnout among physicians through education, improved leadership support, and policies that improve job satisfaction and autonomy.
"Those who report less fatigue and stress seem to be more resilient to developing burnout over the span of one year," Dyrbye says.
Hospital ethics boards also can take the lead in preventing unethical and non-altruistic behaviors among physicians by providing education and training in the areas of professionalism and ethics, she suggests.
Ethics boards might also address a hospital's hidden curriculum. Some hospitals might teach physicians to treat all patients equally, but simultaneously send the message that low-income patients are less important when they give these patients less attention and second-class treatment and care.
"If there is the appearance of people getting care based on their socioeconomic status, then this is a clear message to trainees about what is valued," Dyrbye says.
Another way hospital ethics boards can promote physician professionalism is through ensuring hospitals have policies that adhere to the American Medical Association's (AMA's) policies on appropriate ways to handle pharmaceutical industry representatives and other representatives. They also should stress staff education on these policies.
The medical student survey found that very few students (14%) agreed with the AMA's ethics policy on appropriate ways to interact with industry, Dyrbye says.
"We asked them questions, such as, 'Do you think it's appropriate to attend an industry-sponsored dinner at a nice restaurant?'" she says. "That is not acceptable by AMA standards, but 46% of students said it was fine."
About 27% of students said it was okay to accept a free day of skiing following a medical talk at an industry-sponsored event, and 22% of students said it was okay to accept $500 from an industry representative after taking a five-minute survey, she adds.
"These obviously are not fine, and that's another piece of the puzzle that needs some attention," she says. "We did not find a consistent relationship between burnout and students' attitudes toward the pharmaceutical industry; it's just a big piece here that's missing in terms of student education."
The medical student study suggests burnout will erode future physicians' altruism, professionalism, and service to society, Dyrbye says.
"We need physicians who are advocates for patients and promote public health," she adds. "Burnout threatens to impede this process."