Jorge Cervantes, MD, Cayetano Heredia University
Burnout, defined as a state of emotional, physical, and mental exhaustion is highly prevalent among physicians, residents1. As medical school poses demanding psychological requirements, it is no surprise that burnout is also prevalent amongst medical students. Major U.S. multi-institutional studies estimate that at least half of all medical students may be affected by it during their medical education.2 This follows an upward trend where the more years in the degree, the higher the score in all burnout scales.3-5 Burnout has become a public health problem, as it is tied to depression, anxiety, suicidal behavior, substance abuse, poor interpersonal relations and occupational performance, and lower perceived job satisfaction.
The coronavirus disease 19 (COVID-19) pandemic affected medical students in clinical clerkships.6 All three spheres of burnout, i.e., emotional exhaustion, depersonalization, and personal accomplishment, were affected in third-year medical students through the pandemic.7 The pandemic also posed unique challenges for medical students' wellness,8 with increased prevalences of depression and anxiety and frequent psychiatric co-morbidities associated with burnout.9,10 Student distress is a condition that correlates with low mental quality of life, suicidal ideation, and serious thoughts of dropping out. A multicenter study of 3,162 students representing 110 medical schools showed that 52.9% met the criteria for distress, with 22% taken a gap from work for the sake of their personal well-being. An independent risk factor for distress included involvement in the clinical phase of medical school.11
Even more, symptoms of post-traumatic stress disorder (PTSD) have been reported in high percentages in third-year medical students. More than 90% of students have experienced stressful clerkship-related events, which were traumatic and/or COVID-19-related.9 A recent study from York reported that more than half of third-year medical students had witnessed the separation of patient care or differences in patient care based on insurance. A great number of the responders reported that having experienced these events lead to the development of cynicism (i.e. depersonalization) and burnout.12
Separation of patients based on insurance status leads to racial segregation in healthcare,12 as certain ethnicities like Black and Latino, experience health insurance inequalities compared to White patients. Disparities and healthcare segregation may pose a negative impact in patient care and medical education.
Clerkship is an important stage of medical training. Medical students construct their identity as student physicians through clinical clerkships.13 Medical students are uniquely positioned to be change-makers in this setting, but at the same time may experience fear to make their voices be heard or advocate for changes against these disparities.12
What can we do?
Diverse educational experiences appear particularly helpful in the process of facilitating culturally competent care by physicians.14 Culturally competent actions are only predicted by cultural awareness. Social learning theory, using culturally appropriate educational materials, can increase the health care of the Latino population.15 Medical students' training may lack specific emphasis on certain conditions affecting the Hispanic population. For example, conditions affecting minorities are only addressed when their rates are significantly high in such populations.16 Even in such cases, the reporting appears to deal mostly with African Americans.
Although clerkships may offer robust experiential learning opportunities, these only sometimes involve students spending many hours in the clinical setting.17 Medical schools need to pay attention to the regulation of work hours for medical trainees to avoid falling into the culture of “all work and no play.” Medical students report negative perceptions of their colleagues' work–life balance during their clinical rotations, which could be related to burnout in clerkships.18
Resiliency appears to be crucial in counterbalancing burnout. A higher resilience is associated with having the ability to stop thinking about school.19 Having personal time for themselves after school, exercise, and physical activities allows clerkship students to keep thoughts related to medical school out of their minds. The importance of having a primary group is underscored when observing that medical students living with a companion,18 or having family support3 had decreased burnout levels during their clerkships.
In conclusion, a heavy workload, low feeling of community, low fairness, and witnessing discrepancies in healthcare can impact medical students' motivations, emotional exhaustion, depersonalization/cynicism, and low personal accomplishment.4 Academic and organizational settings of medical curricula need to consider the risk of burnout in medical students, especially during clerkship.
References
1. De la Cerda-Vargas MF, Stienen MN, Campero A, Perez-Castell AF, Soriano-Sanchez JA, Nettel-Rueda B, et al. Burnout, Discrimination, Abuse, and Mistreatment in Latin America Neurosurgical Training During the Coronavirus Disease 2019 Pandemic. World Neurosurg. 2022;158:e393-e415.
2. Ishak W, Nikravesh R, Lederer S, Perry R, Ogunyemi D, Bernstein C. Burnout in medical students: a systematic review. Clin Teach. 2013;10(4):242-5.
3. Gil-Calderon J, Alonso-Molero J, Dierssen-Sotos T, Gomez-Acebo I, Llorca J. Burnout syndrome in Spanish medical students. BMC Med Educ. 2021;21(1):231.
4. Thun-Hohenstein L, Hobinger-Ablasser C, Geyerhofer S, Lampert K, Schreuer M, Fritz C. Burnout in medical students. Neuropsychiatr. 2021;35(1):17-27.
5. Asencio-Lopez L, Almaraz-Celis GD, Carrillo Maciel V, Huerta Valenzuela P, Silva Goytia L, Munoz Torres M, et al. Burnout syndrome in first to sixth-year medical students at a private university in the north of Mexico: descriptive cross-sectional study. Medwave. 2016;16(3):e6432.
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15. Navarro AM, Senn KL, McNicholas LJ, Kaplan RM, Roppe B, Campo MC. Por La Vida model intervention enhances use of cancer screening tests among Latinas. Am J Prev Med. 1998;15(1):32-41.
16. Mayo RM, Sherrill WW, Griffin SF, Parker VG. Content, placement, and acquisition of cancer education for Latino patient care: a qualitative study of medical and nursing students. J Cancer Educ. 2012;27(4):618-24.
17. Barnum TJ, Halverson AL, Helenowski I, Odell DD. All work and no play: Addressing medical students' concerns about duty hours on the surgical clerkship. Am J Surg. 2019;218(2):419-23.
18. Lin YK, Lin BY, Lin CD, Chen DY. Relationship between medical students' negative perceptions of colleagues' work-life and burn-out during clerkships: a longitudinal observational cohort study. BMJ Open. 2021;11(10):e049672.
19. Park S, Porter M, Park K, Bielick L, Rooks BJ, Mainous AG, 3rd, et al. What Are the Characteristics of Fourth-Year Medical Students With Higher Levels of Resilience? PRiMER. 2019;3:22.
About the author: Cervantes obtained his M.D. degree from Cayetano Heredia University in Peru. He received research training in tropical medicine in Japan and conducted dengue surveillance in the Amazon, before pursuing a doctorate in biomedical sciences in Kagoshima University, Faculty of Medicine in Japan. Cervantes has worked on immunology and infectious diseases, focusing on the innate immune aspects of phagocytes as a postdoctoral fellow in Japan and later in UConn Health and Connecticut Children’s Medical Center. His interests include antimicrobial peptides and host-pathogen interactions in the field of tuberculosis, leprosy and Lyme disease. Cervantes is an expert on the human lung microbiome in tuberculosis and how mucosa-associated microbiota can confer risk for the development of precancerous lesions in the colon. Cervantes also works on inflammatory processes occurring in microglia triggered by bacterial-derived peptides in the context of multiple sclerosis. Cervantes is passionate about translating his findings and applying his knowledge to public health problems like leprosy, tuberculosis, tick-borne diseases and infectious diseases education. Cervantes is an advocate for scientific integration into medical education. Cervantes believes that the assimilation of basic science and understanding of new technologies is paramount to how medical professionals can base clinical reasoning. When learners understand how basic science knowledge informs clinical practice, their confidence on foundational scientific underpinnings transcends assumptions and reliance on learners’ intuitively practicing and advancing medicine on evidence-based foundations of science. The more that future health professionals can achieve excellence in clinical decision making, the better the future of the health care systems will be to promote patients’ health and quality of life. Cervantes serves on the editorial board for renowned journals such as Frontiers in Immunology, Frontiers in Public Health, Clinical Microbiology Reviews, PLoS ONE as well as a reviewer for a long list of scientific and medical education journals. Cervantes is also the Editor in Chief for Clinical Infection and Immunity. Cervantes served for 2 consecutive terms as the president for the American Society for Microbiology Rio Grande Branch, and now he is a Council on Microbial Sciences (COMS) representative and a member of the ASM Future Leaders Mentoring Fellowship (FLMF) program. Cervantes is the Southern Secretary-Treasurer of the American Federation of Medical Research (AFMR). Cervantes is the ASTMH Scientific Program Committee, Pneumonia, Respiratory Infections and Tuberculosis Chair, as well as member of the ASTMH Travel Award Committee.
About the work: Clerkship is an important stage of medical training. Many medical students experience stressful clerkship-related events, sometimes related to witnessing separation of patient care or differences in patient care on the basis of insurance. These may lead to developing cynicism (i.e. depersonalization) and burnout.
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