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Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South Florida, Tampa. He can be reached at DrLockwood@ubm.com.
From our own experience in academic medicine, Dr. Ed Funai and I can vouch for the fact that most medical students are going into medicine for the right reasons-to help others via a career wedded in both science and humanity. Ironically, those same medical students are also experiencing record levels of burnout, substance abuse and depression as they enter their third and fourth years.
From our own experience in academic medicine, Dr. Ed Funai and I can vouch for the fact that most medical students are going into medicine for the right reasons-to help others via a career wedded in both science and humanity. We can also attest to the intense desire that today’s students have to make the world a better place reminiscent of the heady days of President Kennedy’s Peace Corps. We have seen medical students clamoring to go into harm’s way in parts of the globe decimated by natural disasters and threatened by emerging pathogens, all in the hope of making a difference. Ironically, those same medical students are also experiencing record levels of burnout, substance abuse and depression as they enter their third and fourth years.
Burnout among medical students
In a survey of over 12,000 medical students, 80% reported burnout, alcohol abuse/dependence, or depressive symptoms.1 Another survey found that, compared with general population controls, medical students, residents/fellows, and early career physicians were more likely to be burned out and depressed.2 A carefully performed systematic review by Rotenstein and colleagues indicated that this is a global phenomenon.3 These authors found a prevalence of depression or depressive symptoms among medical students of 27.2% while the percentage of medical students seeking psychiatric treatment for their depression was 15.7%. Most worrisome, the overall pooled crude prevalence of suicidal ideation was 11.1%.
The origins of this epidemic of trainee burnout, substance abuse and depression are unclear and likely multifold. The sheer volume of material to be mastered continues to grow near exponentially while the time to learn it remains stagnant. Record levels of indebtedness appear to play a role as, we suspect, does growing competition for residency slots. And while there may also be ascertainment bias in these reported prevalence figures because we only began searching for evidence of these problems recently, we can’t help but think that burnout has an infectious-like quality and that third- and fourth-year students become exposed to burned out residents while on their rotation and the residents, in turn, are exposed to burned out early and mid-career attending physicians.
Burnout among practicing physicians
The physician burnout crisis should have been readily predictable. An aging population with growing comorbidities is being cared for by a system with too few physicians, leading to increasing workloads. Compounding the problem are unrelenting compliance and regulatory burdens and ill-advised and premature introduction of decidedly user-unfriendly electronic health records (EHRs). The latter have not been shown to reduce costs or improve quality but unarguably consume an enormous amount of time during the day and are increasingly being accessed at night when many physicians try to catch up on their charting.
Adding to this confluence of pain are generational factors. Generation-X and millennial students and residents, raised in the 80-hour-work-week environment, appear particularly vulnerable to burnout as they enter their early and mid-careers, while older physicians exposed to far harsher training regimens appear more resistant to burnout. A final element of this witches’ brew is the current chaotic nature of the American healthcare delivery system in which the Center for Medicare & Medicaid Services (CMS) reconsiders its commitment to the highly complex Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and hospital value-based payments schemes. Many physicians and hospitals have invested considerable time and dollars preparing for these changes. Similarly, Congress is attempting to kill the Affordable Care Act by a thousand cuts rather than a simple coherent repeal and replace strategy. All this chaos creates uncertainty and frustration among physicians, elements that promote burnout.
A recent survey conducted jointly by the American Medical Association and the Mayo clinic reported that burnout is increasing among virtually all medical specialties with a more than 10% increase in just 3 years.4 For example, 51% of family medicine physicians reported burnout in 2011 compared with 63% in 2014. Similar trends were observed among general pediatrics, urology, orthopedic surgery, physical medicine and rehabilitation, pathology, radiology and general surgery.
In a 2018 survey of over 15,000 ob/gyns across various subspecialties, 50% felt burned out, depressed, or both.5 Even more concerning, a far higher percentage of female ob/gyns reported burnout (55%) compared to men (32%). As expected, bureaucratic burdens, often related to EHRs, and long hours were cited as the two biggest contributors. When asked if resources were available to help them cope, a mere 27% said such offerings were at their disposal. Another recent Medscape survey of 15,543 physicians practicing in the United States across 29 medical specialties demonstrated that ob/gyns had the fourth highest rates of burnout (46%) and led all other fields in those experiencing both burnout and depression (20%).6 Respondents listed exercise, talking with family and close friends and sleep as their top three coping mechanisms. They also opined that increased compensation, more manageable workloads and decreased government regulations would reduce burnout.
Beyond the personal pain engendered by burnout and associated substance abuse and depression, burnout is also an independent predictor of medical errors, malpractice suits, hospital-acquired infections and patient mortality.7-10 Burnout also increases provider turnover which adds costs. These sequelae, in turn, drive work load and exacerbate burnout.
Difficulty of turning the tide
Medical school leadership across the United States is well-aware of the problem, and there are growing resources being put in place for students who need mental health support when they are having problems. Examples include campus-embedded mental health counselors and psychologists, reduced lecture time, wellness programs (e.g., yoga, exercise class, massage therapy, nap rooms, fitness centers, and access to healthier foods). Another strategy is creation of collegia which are groupings of students across all 4 years who study, work, and socialize together to promote inter-year mentorship. However, what medical school leadership has little control over is the deteriorating emotional tenor of the healthcare system that students are exposed to when they start their clinical rotations in earnest. Preventing such student “contamination” requires addressing burnout among attending residents and attending physicians.
Organized medicine was slow to recognize this crisis but is finally beginning to act. The National Academy of Medicine, in association with over 50 other organizations including the Association of American Medical Colleges (AAMC) and the Accreditation Council for Graduate Medical Education (ACGME) have recently launched a national Action Collaborative on Clinician Well-Being and Resilience.11 The collaborative has 4 initial goals which include increasing visibility of clinician stress and burnout; improving health care organizations’ baseline understanding of challenges to clinician well-being; identifying evidence-based solutions; and monitoring the effectiveness of potential solutions.12 One immediate coalition deliverable will be creation of an online “knowledge hub” repository for available data, models, and toolkits to prevent burnout.
Among the novel solutions being proposed to curb burnout is a team-based model called ambulatory process excellence (APEX) created by the Department of Family Medicine at the University of Colorado Health System.13 In APEX, medical assistants (MAs) who have received added training proactively gather patient data, organize visits, reconcile medications, and review basic preventive care strategies. These data are then shared with the provider who sees the patient while the MA stays in the room to document the visit in the EHR. After the provider leaves the MA completes patient education. APEX requires a higher ratio of MAs to physicians but increased provider productivity appears to more than make up for the added expense.
The contagion of physician burnout has reached down to the level of our medical students, threatening the welfare of our entire profession as well as public health more broadly. While steps are being taken to mitigate medical student stressors, it is vital that we treat the source of the “infection,” which is burnout among residents, early and mid-career physicians. This cure will require “decluttering” healthcare by reducing non-value-added aspects such as ineffective regulations and administrative busywork while also creating more efficient, effective and error-free value-adding care models.
Acknowldegement: Dr. Ed Funai, Professor of Obstetrics and Gynecology at USF Health Morsani College of Medicine collaborated on this editorial. Dr. Lockwood thanks him for his contributions.
1. Jackson ER, Shanafelt TD, Hasan O, Satele DV, Dyrbye LN. Burnout and Alcohol Abuse/Dependence Among U.S. Medical Students. Acad Med. 2016 Sep;91(9):1251-6.
2. Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, Shanafelt TD. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014 Mar;89(3):443-51.
3. Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, Sen S, Mata DA. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. JAMA. 2016 Dec 6;316(21):2214-2236.
4. American Medical Association. Medical specialties with the highest burnout rates. Available at https://wire.ama-assn.org/life-career/medical-specialties-highest-burnout-rates Accessed March 12, 2018.
5. Graham S. Medscape ob/gyn lifestyle report 2018: personal happiness vs work burnout. Available at https://www.medscape.com/slideshow/2018-lifestyle-ob-gyn-6009231#4 Accessed March 12, 2018.
6. Peckham C. Medscape physician lifestyle & happiness report 2018. Available at https://www.medscape.com/slideshow/2018-lifestyle-happiness-6009320 Accessed March 12, 2018.
7. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251:995-1000.
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10. Welp A, Meier LL, Manser T. Emotional exhaustion and workload predict clinician-rated and objective patient safety. Front Psychol. 2015;5:1-13.
11. National Academy of Medicine. Action collaborative on physician well-being and resilience. https://nam.edu/initiatives/clinician-resilience-and-well-being/
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13. Wright AA, Katz IT. Beyond Burnout - Redesigning Care to Restore Meaning and Sanity for Physicians. N Engl J Med. 2018 Jan 2