The Oxford English Dictionary defines ‘well-being’ as “a general [state of] health and happiness”, showing its links with humans in their physical, emotional and psychological states. On the other hand, the term ‘burnout’ seems to carry a more medical definition, with the World Health Organization and ICD-11 both defining the term as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed”, and stresses that “burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life”.
In the modern day, we often hear both the terms ‘burnout’ and debates about ‘wellbeing’ when discussing “those in high-stress jobs”, while a recent study suggested that doctors are twice as likely to suffer burnout compared to those in other professions (Bourne et al., 2019). However, often those studying vocational degrees such as medical students or student nurses (who are required to undertake hours of placement, followed by revision, deadlines and exam stress week after week) are overlooked.
In this blog, I review a new study conducted by Farell et al. (2019), who not only acknowledge burnout amongst medical professionals but also further ask “what about our doctors in training?”. Their original research was carried out in the form of an anonymous online survey for current medical students in the UK pertaining to wellbeing. The paper made me think about the characteristics needed to be ‘a good physician’, which medical schools often interview to positively select for; such as resilience. The authors mention that there is a reducing trend in junior doctors and the UK Medical Council report an increase in mental health issues among medical students. It also raised a question on stigma surrounding mental health and help-seeking behaviours; especially for people who deem themselves ‘capable’, and have potentially never had any previous experience in struggling to cope with what is expected of them, such as many intelligent and high achieving students. The study also highlighted the increased use of alcohol (and illicit substances) compared even to their non-medical counterparts in the UK. This could be seen as an abnormal coping strategy in the form of the students self-medicating when they are struggling. “The term self-medicating is used when substances, drugs or alcohol, are abused to mask symptoms of a mental health issue. When a person feels stressed, certain changes to the chemistry in the brain and functions of the central nervous system are made”, and often the use of drugs or alcohol can temporarily counteract these changes (American Addiction Centres, 2014).
Being at university often presents young people with a plethora of new challenges, such as working in a different manner, moving away from home and living alone, having to cook and clean for themselves, making new friends and adjusting to new surroundings. A study by the Education Policy Institute (2018) showed that:
- 1/5 of students spent all of their student loan within the first 100 days
- Over 60% of the students reported their maintenance loan was enough
- 46% reported that financial difficulties have a negative impact on their mental health
The academic demands of university life may also be a significant source of stress. In the Unite Students survey, 71% of respondents reported that “performing well in tests and coursework” caused them stress, and 65% felt stressed trying to keep up with their studies. Many of these factors make all students more vulnerable to be predisposed to mental health problems, and the added pressure on medical students with extra hours, commuting to placements and a heavier workload, can heighten this predisposition.
The study asked medical students from England to complete an anonymous survey, taking into account their demographic characteristics such as their year of study, gender, age, parents’ educational background and any previous mental health issues. They noticed there was a slight reluctance from English Medical Schools to take part (perhaps this was due to potential ‘bad publicity’ if they were shown to have students with a higher than average burnout rate, or asking students about illicit substance use, which is controversial as is contraindicative of professionalism as defined by GMC Good Medical Practice).
Excel was used to present the data, and previously established questionnaires with established thresholds (CAGE and GHQ12) were used, prior to the survey opening. The online survey platform ‘Typeform’ was used to collect the data, and the programme automatically created graphical information for each survey question. All the information was password protected and stored anonymously. Those taking part in the survey were not required to give personal identifiers when filling it out.
The data collected came from a total of 84 students, from King’s College, Guy’s and St Thomas’, St George’s University of London, Sheffield and Hull & York Schools of Medicine. Of those participants, 62 were females, 21 males and 1 not specified.
Mental health diagnoses
17% of those who responded had previous existing mental health diagnoses prior to medical school, and 29% had been diagnosed at the time of completing the survey. 35% of the students recorded currently seeing a GP or other healthcare professional about their mental health.
18% scored positive for CAGE alcohol misuse or dependency. 4.8% stated that they had used drugs to uplift their mood, but only 2.4% of those surveyed felt concerned about their drug use. Whilst 29% reported cannabis use, there was little difference statistically based on whether or not the students had been diagnosed with mental health issues at medical school or not (33% compared to 27% of those without).
Burnout and exhaustion
According to GHQ-12, 77% were classed as ‘cases’ suggesting a possibility of mental health issues. 82% of the students were classed as being burnt out, 85% met criteria for exhaustion, and 82% for disengagement. If the study is representative of a wider medical student population, we could be headed for a generation of exhausted and disengaged foundation doctors, thus resulting in a less effective or efficient healthcare system.
The study demonstrates that medical students are struggling with issues of burnout and exhaustion, and whilst we are beginning to target these issues in our medical professionals, there seems to be an area of neglect for the students at the earlier stages on the same career paths.
Strengths and limitations
This study is a great addition to the literature as:
- It highlights key issues in the gaps we still have when tackling mental health stigma as a whole, and especially targeting the wellbeing of those who society perhaps deems the most ‘capable’.
- The methodology allowed a more honest response, as students were asked anonymously about various lifestyle aspects and so it presents an exploration of a wide spectrum of factors indicative of burnout, exhaustion and wellbeing.
- The study has the potential to inform future research and policy, as it urges medical schools to be aware of their findings and start addressing prevention.
However, the paper itself recognises that the study had a small sample size, which may not be truly representative of all medical schools across the country. Famously all medical schools have varying teaching styles and therefore different selection processes, interviewing for different characteristics and personality traits, alongside the required academic qualifications. Thus, it is possible that the cohort of students within each medical school could be different to each other and show trends that a larger sample size across more universities may not confirm. There is also an idea of ‘drug culture’ being more extreme in different student cities, so there is a chance that the statistics regarding alcohol and drug use in these five medical schools is not typical for every UK university. It is also possible that many students were not completely honest in their responses regarding substance use for fear of any implications this may have on their career.
There is also a suggestion that there may have been a slight selection bias as statistically 16.7% of adults in the UK have a mental health diagnosis, compared to the 29% surveyed for this research. Perhaps those more interested in mental health conditions from personal experience were more likely to be willing to participate and take the survey. The number qualifying for burnout and exhaustion is alarmingly high, thus further investigation may be required.
Implications for practice
The findings of this study call for further research to eliminate the possible selection biases and to use a bigger sample size in order to find more reliable evidence. Prevention is the key. The paper urges medical schools to spread awareness, reducing any stigma in admitting students are struggling or needing to ask for help, as well as intervening early when things are going wrong.
Famously in every in-flight safety demonstration, passengers are urged to secure their own oxygen mask before helping others. In this same way, we cannot take good care of others until we first learn to take care of ourselves.
Conflicts of interest
Farrell, S., Kadhum, M., Lewis, T., Singh, G., Penzenstadler, L., & Molodynski, A. (2019). Wellbeing and burnout amongst medical students in England. International Review Of Psychiatry, 31(7-8), 579-583. doi: 10.1080/09540261.2019.1675960
Bourne, T., Shah, H., Falconieri, N., Timmerman, D., Lees, C., & Wright, A. et al. (2019). Burnout, well-being and defensive medical practice among obstetricians and gynaecologists in the UK: cross-sectional survey study. BMJ Open, 9(11), e030968. doi: 10.1136/bmjopen-2019-030968
Well-being (n) – Definition | Oxford Advanced Learner’s Dictionary (2020). Retrieved 27 January 2020, from https://www.oxfordlearnersdictionaries.com/definition/english/well-being
Burnout definition WHO – https://www.who.int/mental_health/evidence/burn-out/en/
Pell, C. (2017) Feeling the burn: do interventions to prevent burnout in doctors work? Mental Elf. Last assessed: 9 Jan 2020
Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. (2014). American Addiction Centers. Retrieved 27 January 2020, from http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf
Prevalence of mental health issues within the student-aged population – Education Policy Institute (2018). Retrieved 27 January 2020, from https://epi.org.uk/publications-and-research/prevalence-of-mental-health-issues-within-the-student-aged-population/
Student Resilience: Unite students insight report (2016). Retrieved 27 January 2020 from https://www.unitestudents.com/about-us/insightreport/2016-full-report