ORIGINAL ARTICLE
ABSTRACT
Objective
Burnout can affect medical professionals of all fields and tiers, but at what point does physician burnout begin to manifest itself? This study examines the first estimate of burnout rates in premedical students.
Participants
The survey respondents were premedical students, defined as actively pursuing acceptance into medical school to become physicians.
Method
The authors administered the Maslach Burnout Inventory to students during summer break and during fall semester final exams in 2013.
Results
Of the 224 initial survey responses, 92 (41%) were available with follow up data for comparison between the two time points. All (100%) of the premedical students had high levels of burnout in the depersonalization domain, while the personal accomplishment domain scores actually improved during final exams (p < 0.0001).
Conclusions
This study demonstrated that burnout is higher among premedical students than in medical students or residents.

Burnout is a psychological syndrome that is known to increase the risk of depression by 1.8-2.6 and its treatment results in less suicidal ideation.1-5 Burnout, as it affects physicians-in-training, is associated with absenteeism, low job satisfaction, and medical errors.6,7 Currently, the leading tool for the measuring burnout in the medical education pipeline is the Maslach Burnout Inventory.8 The Maslach construct defines burnout as a syndrome consisting of depersonalization, emotional exhaustion, and a sense of low personal accomplishment. Validated among physicians, it consists of three primary elements: exhaustion, cynicism, and inefficacy or loss of a personal sense of accomplishment.9

Burnout can affect medical professionals of all fields and tiers. Estimates of burnout prevalence among U.S. medical students range from 43-45%.10,11 Among graduate medical residents, burnout estimates range from 40-76%.6,12-16 Among practicing specialists and general practitioners, burnout is estimated to affect between 22% and 60%.17 Family medicine physicians were affected the most by burnout with rates topping 56-80%.6,17-19

At what point does physician burnout begin to manifest itself? To our knowledge, burnout has never been measured in a premedical education population. Could it be that burnout begins affecting students even before they enter medical school? If so, how does the prevalence of burnout in premedical students compare to other college students and what factors influence this burnout? This study sought to help answer these questions by producing the first estimate of burnout rates in premedical students.

METHODS

This study was exempted by the Institutional Review Board at Texas A&M Health Science Center at Baylor Scott & White Health (IRB #130164). The design was a cross sectional survey of undergraduate students recruited to an email contact list via social media. Students received informed consent during the solicitation email as well as before and after the survey. All participating students were incentivized to respond by being offered online college study techniques and speed-reading videos thought to appeal to a wide variety of premedical students. Information was provided for students to contact mental health services in the event they because psychologically distressed as a result of taking the survey.

An electronic survey was emailed during summer break (June 2013) and during fall semester final exams (early December 2013). The results were tracked using Survey Monkey and the data were secured with internal servers. Statistical analysis was performed using SAS software (version 9.3) and SPSS (version 19). A chi-square test was used to compare the levels of burnout in the summer versus the end of the fall semester, and where the sample was small, a Fisher’s exact text was performed. The 31-question survey included the Maslach Burnout Inventory, Human Services version (licensed from Mind Garden, Inc.) with the word “recipients” changed to “people”, and demographic questions such as age, gender, race/ethnicity, current country of residence, and marital status. Financial questions included an incremental scale assessing the students perceived level of impact that financial issues affect their overall stress level. Academic questions included major, current year in school, currently enrolled total semester hours, and current premedical prerequisites semester hours.

RESULTS

Demographic data

Respondents were adults over age 18 with a median age of 26. Fifty-eight percent were male and 42% were female. The race/ethnicity was distributed as follows: 137 (56%) white or Caucasian, 47 (19%) Asian, 35 (14%) black or African American, 13 (5%) Hispanic or Latino, 1 (0.4%) Native American or Pacific Islander, and 13 (5%) Other. The marital status was 169 (69%) single, 76 (31%) married, and 1 (0.4%) separated. Two-hundred and nine (85%) lived in the United States while 37 (15%) did not.

The respondents of the question about the effect on financial stress reported “not at all” 6 (2%), “a little bit” 84 (34%), “a lot” 100 (41%), and “very much” 53 (22%). One hundred-sixty two (66%) were undergraduate science majors, 20 (8%) were liberal arts majors and 48 (20%) reported “other” majors.

During the initial “summer break” sample, 160 (61%) reported taking no college classes or part time academic load, while 84 (39%) reported taking 12 semester credit hours or more. Half (23; 50%) of respondents were not taking any medical school prerequisite courses, 53 (22%) were taking between 1-3 semester hours of prerequisites, and 57 (23%) were taking 4 or more semester hours of prerequisite courses for medical school.

Initial Survey

In June 2013, a total of 1,830 emails were sent, 1,759 (96.1%) were delivered and 71 (3.9%) were unable to be delivered. Among the delivered emails, 595 (33.8%) were opened and 218 individuals clicked the survey link. At day five, 1,811 emails were sent with 1,749 delivered and 62 (3.4%) were unable to be delivered. There were 383 (21.2%) additional opens and four clicks. Two hundred-forty six viewed the survey resulting in 230 (93.5%) survey submissions.

There were 246 total responses with 5 duplicates and 17 with incomplete data. This left a total of 224 complete data sets analyzed in Burnout Table 2. The Emotional Exhaustion domain had an average score of 41.7 (range: 7-63; M=42). Low Emotional Exhaustion is rated as 0-16, Moderate 17-26, and High 27 or over. Three participants (1.3%) had low, 7 (3.1%) had moderate, and 214 (95.5%) had scores for high Emotional Exhaustion. Depersonalization had an average of 55.8 (range: 16-83; M=56). Low is rated as 0-6, Moderate 7-12, and High 13 or over. All (100%) of respondents had scores for high Depersonalization. The Personal Achievement domain had an average score of 29.6 (range: 0-67; with a bimodal distribution; M=27). Low is rated as 39 or greater, Moderate 32-38, and High 0-31. Forty-four participants (19.6%) had Low, 27 (12.1%) had Moderate, and 133 (59.4%) had scores for High burnout in the domain of Personal Achievement; that is, they had a diminished sense of personal achievement.

Follow-up Survey

There were 97 responses with 2 incomplete data sets. Eight people responded with a total of 10 non-selections for individual symptoms. These incomplete answers were substituted with zero. There were 3 duplicates, leaving a total of 92 respondents with complete data sets for analysis. The Emotional Exhaustion domain had an average of 55.3 (range: 24-81; M=56.5). No respondents had Low Emotional Exhaustion, 2 (2.2%) had Moderate, and 90 (97.8%) had scores for High Emotional Exhaustion. This was not significantly different than the levels of Emotional Exhaustion in the initial survey group (p = 0.48). Depersonalization had an average of 74.9% (range: 39-106; M=74.5). All (100%) of the respondents had scores for High Depersonalization. The Personal Achievement domain had an average of 44.9 (range: 17-94; M=44). Fifty-nine participants (64%) had Low, 11 (12.0%) had Moderate, and 22 (23.9%) had scores for High burnout in the domain of Personal Achievement. This represents a significant reduction in this domain of burnout during the week of final exams compared to the summer-time group (p < 0.001, Burnout Table 2).

Additional Data: Burnout Table 1

DISCUSSION

Independent of summer break, the prevalence of burnout, specifically depersonalization and emotional exhaustion, was higher among premedical students than medical students. Premedical students appear to have their sense of personal accomplishment invested in their educational pursuits, as burnout in this area actually improved during final exams.

All (100%) of the students sampled in both groups had high depersonalization. This depersonalization may be a result of stress from their educational pursuits, but it could reflect a stage of life issue (or a separate, acute stressor). Young adults, perhaps, have never had so many responsibilities and intense competition. Additionally, their identity can be tied to their performance and, until they get their medical school acceptance letter, their ultimate self-acceptance may elude them for years. The result can be a constant state of internal struggle and unrest.

Emotional exhaustion scores were over 95% during the summer break and the few who showed a trend of worsening burnout as final exams occurred. There appears to be a relatively small segment (<10%) with worsened burnout stress because of final exams. The call to action would be to help these students avoid, minimize, and cope effectively with emotional exhaustion when it appears during times of high stress. The other subdomains appear inherently immovable, suggesting that these psychometric properties may reflect a trait rather than state.

Limitations of this study include the fact that we did not measure the academic load of the students in the follow-up group to assess a dose-dependent relationship with burnout. These students may simply be “off the scale” of the Maslach Burnout Inventory, while a different instrument such as the State Trait Personality Inventory may be able to detect changes over time.

Could it be that future physicians inherently place stress upon themselves, even when on summer break? Perhaps the opportunity for stress, exhilaration, and privilege of competing to become physicians simply serves as an outlet for Type-A personalities. If this is true, then much of the current focus on medical student and resident burnout could be viewed differently. The human experience of such a novel conquest, namely medical education, and its associated burnout need not be considered a side effect. Premedical students, and perhaps medical students, may be generating much of their own stress and may not perceive it all as inherently bad – especially when class is not in session.

DISCLOSURES

Acknowledgments: none

Funding/support: Dr. Daniel Williams paid for the licensing fees for the Maslach Burnout Inventory.

Other disclosures: None

Ethical Approval: An exception for the research was granted from Scott & White Health IRB (IRB #130164)

Disclaimers: Not applicable

Previous Presentations: This manuscript has not been presented.

REFERENCES

  1. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann. Intern. Med. 2008;149:334-341.
  2. Netterstrøm B, Conrad N, Bech P, et al. The relation between work-related psychosocial factors and the development of depression. Epidemiol Rev. 2008;30:118-132.
  3. Ahola K, Hakanen J. Job strain, burnout, and depressive symptoms: a prospective study among dentists. J Affect Disord. 2007;104:103-110.
  4. Ahola K, Honkonen T, Kivimäki M, et al. Contribution of burnout to the association between job strain and depression: the health 2000 study. J Occup Environ Med. 2006;48:1023-1030.
  5. Siegrist J. Chronic psychosocial stress at work and risk of depression: evidence from prospective studies. Eur Arch Psychiatry Clin Neurosci. 2008;258(Suppl 5):115-119.
  6. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358-367.
  7. McCray LW, Cronholm PF, Bogner HR, Gallo JJ, Neill RA. Resident physician burnout: is there hope? Fam Med. 2008;40:626-632.
  8. Rafferty JP, Lemkau JP, Purdy RR, Rudisill JR. Validity of the Maslach Burnout Inventory for family practice physicians. J Clin Psychol. 1986;42:488-492.
  9. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3 ed: Palo Alto, CA: Consulting Psychologists; 1996.
  10. Dyrbye LN, Thomas MR, Huntington JL, et al. Personal life events and medical student burnout: a multicenter study. Acad Med. 2006;81:374-384.
  11. Dyrbye LN, Thomas MR, Huschka MM, et al. A multicenter study of burnout, depression, and quality of life in minority and nonminority US medical students. Mayo Clin Proc.2006;81:1435-1442.
  12. Gelfand DV, Podnos YD, Carmichael JC, Saltzman DJ, Wilson SE, Williams RA. Effect of the 80-hour workweek on resident burnout. Arch Surg. 2004;139:933-938.
  13. McCue JD, Sachs CL. A stress management workshop improves residents’ coping skills. Arch Intern. Med. 1991;151:2273-2277.
  14. Ramirez AJ, Graham J, Richards MA, et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer. Jun 1995;71:1263-1269.
  15. Bellini LM, Baime M, Shea JA. Variation of mood and empathy during internship. JAMA. 2002;287:3143-3146.
  16. Lemkau JP, Purdy RR, Rafferty JP, Rudisill JR. Correlates of burnout among family practice residents. J Med Educ. 1988;63:682-691.
  17. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114:513-519.
  18. Linzer M, Visser MR, Oort FJ, et al; Society of General Internal Medicine Career Satisfication Study Group. Predicting and preventing physician burnout: results from the United States and the Netherlands. Am J Med. 2001;111:170-175.
  19. Deckard GJ, Hicks LL, Hamory BH. The occurrence and distribution of burnout among infectious diseases physicians. J Infect Dis. 1992;165:224-228.