Dyrbye, Liselotte N. MD; Thomas, Matthew R. MD; Huntington, Jefrey L.; Lawson, Karen L. MD; Novotny, Paul J. MS; Sloan, Jeff A. PhD; Shanafelt, Tait D. MD
Medical school curricula are designed to ensure every graduate is knowledgeable, skillful, and professional.1 Limited evidence suggests that student distress (i.e., depression, anxiety, psychological problems, burnout) may adversely affect development of these qualities.2–4 Psychological morbidity appears to adversely impact academic performance2–4 and contribute to student substance abuse5–10 and academic dishonesty.11–14 Others have demonstrated that cynicism,15–17 an unwillingness to care for the chronically ill,18,19 and decreased empathy15,17,20 parallel student distress.
Unfortunately, while medical students matriculate with mental health profiles similar to those of their nonmedical peers,21,22 studies document that mental health deteriorates during medical school.6,21–32 This decline in mental health begins during the first year of training24,25 and persists through the remainder of medical school.26 Studies of U.S. and British medical students suggest that up to half of them have symptoms of depression22,27–29 and poor mental health.23–25 The majority of the articles in the literature about medical student stress and depression focus on sources of stress attributable to the training experience.4,23,33 These studies point to academic pressure,4 workload,23,33 financial concerns,33 sleep deprivation,33 exposure to patient death and suffering,34,35 student abuse,8,36–39 and a “hidden curriculum” of cynicism40–47 as sources of stress. Some researchers call for curricular changes to address these factors.28,42,44,48–51 In addition to the rigors of training, medical students experience a number of major personal life events (illness, death of family members, marriage, birth or adoption of a child, etc.) common to individuals their age and beyond the direct control of medical educators.52 Such personal life events are known to contribute to depression, anxiety, and substance use in the general population.53–58
Burnout is a measure of professional distress with three domains: emotional exhaustion, depersonalization, and low sense of personal accomplishment.59 Emotional exhaustion is characterized by feeling emotionally depleted by one's work; depersonalization, by treating people as if they are impersonal objects; and low personal accomplishment, by feeling that one's work is inconsequential.59 Although a number of studies have reported high rates of burnout in residents60,61 and practicing physicians,62–64 we could fine no published studies about the prevalence of burnout among U.S. medical students. Some have speculated the origin of physician burnout occurs during medical school.65,66 In contrast to the established relationship between personal life events and depression,53–56,58 burnout is believed to be a consequence of work-related factors. Personal life events, however, may also influence burnout, although the relationship of personal life events to burnout or professional development among medical students is unknown.
With these gaps in research in mind, in 2004 we performed a multicenter survey of all medical students in the state of Minnesota to explore the frequency of burnout among U.S. medical students, identify whether it varies through the course of schooling, and explore the relationship of personal life events to professional burnout and other aspects of student distress.
All 1,098 medical students in the state of Minnesota were asked to participate in this study. Participation was elective and all responses were anonymous. Medical students in Minnesota attend a private medical school (Mayo Clinic College of Medicine), a traditional public university (University of Minnesota Medical School—Minneapolis campus), or a public university with a focus in primary care (University of Minnesota Medical School—Duluth campus). The institutional review boards of the Mayo Clinic and the University of Minnesota approved this study.
We surveyed the students electronically in April 2004. A cover letter stated that the purpose of the survey was to better understand the factors that contribute to student well-being and identify how medical schools can make changes to improve student quality of life (QOL). Participants were blinded to any specific hypothesis of the study. The questionnaire consisted of 118 questions regarding demographic information, recent personal life events, burnout, symptoms of depression, alcohol usage, and QOL. E-mail messages reminded students to complete their questionnaires.
Validated survey tools were used to identify burnout,67–70 symptoms of depression,71,72 at-risk alcohol use,73,74 and mental and physical QOL.75,76 Burnout was measured using the Maslach Burnout Inventory (MBI), a validated 22-item questionnaire considered a standard tool for measuring burnout.67–70 The instrument has three subscales to evaluate each of the domains of burnout, characterized as emotional exhaustion, depersonalization, and low sense of personal accomplishment. According to convention, we considered a high score for medical professionals on the depersonalization or emotional exhaustion subscale an indicator of professional burnout.67
Other aspects of student well-being were measured to assess whether variation in burnout followed a pattern similar to variation in other measures of student distress. Symptoms of depression were identified using the two-item Primary Care Evaluation of Mental Disorders,71 a validated screening tool that performs as well as longer instruments do.72 At-risk alcohol use and alcohol dependence were measured using items from the Alcohol Use Disorders Identification Test.73,74 Mental and physical QOL were measured using the Medical Outcomes Study Short Form (SF-8).75–77 Norm-based scoring methods of responses on this instrument are used to calculate mental and physical QOL summary scores.76 The average mental and physical QOL summary scores for the U.S. population are 50 (scale 0–100; standard deviation [SD] = 8).76
Items to explore the occurrence of personal life events hypothesized to have a significant effect on students' well-being and similar to individual items from longer “life events” survey tools54,57,58,78,79 were developed for our questionnaire. These items simply asked students if they had personally experienced the following life events within the prior year: marriage, divorce, birth or adoption of a child, a major illness, a major illness of a significant other or close family member, and the death of a close family member. Consistent with the literature we considered divorce, personal illness, illness in a close family member or significant other, or death of a close family member as “negative” life events, and marriage or birth or adoption of a child as “positive” life events.80–89 Finally, students were asked about their current level of educational debt.
The primary analysis involved descriptive summary statistics for estimating the prevalence of burnout, a positive depression screen, at-risk alcohol use, mental and physical QOL, and life events for medical students. Next, we compared the prevalence of burnout, a positive depression screen, at-risk alcohol use, and mental and physical QOL by the year in school and number of negative or positive personal life events experienced in the previous 12 months. The Cochran-Armitage trend test90 was used for assessing trends in proportions, and simple linear regression was used for assessing trends in continuous variables. Finally, we used forward stepwise logistic regression to evaluate independent associations among age, sex, year in training, and personal life events in the previous 12 months with burnout, symptoms of depression, at-risk alcohol use, and mental and physical QOL. All analyses were done using SAS version 8.
Of the 1,098 medical students in the state of Minnesota at the time of our study, correct e-mail addresses could be confirmed for 1,087 students. The survey was completed by 545 students (a response rate of 50%). Table 1 shows the demographic characteristics of responders along with the rotation type at the time of the survey for third-year and fourth-year students. Nonresponders were more likely to be men and less likely to be first-year students (both p < .0001). Among responders, women were more likely than men to be single (184 of 297 women [62%] were single versus 129 of 247 men [53%], p = .007) and less likely to have children (16 of 297 women [5.5%] had children versus 40 of 247 men [15.5%], p < .001).
Burnout by year in training
Two-hundred and thirty-nine students (45%) met criteria for burnout on the MBI (Table 2). Mean scores for emotional exhaustion (21.8, SD 9.99), depersonalization (6.4, SD 4.95), and personal accomplishment (36.1, SD 8.72) were all in the moderate range. One-hundred and eighty-five students (35%) had high emotional exhaustion, 137 (26%) had high depersonalization, and 164 (31%) had a low sense of personal accomplishment. Although a consistent increase sense of personal accomplishment was observed by year in training (a desirable trait) a similar increase in depersonalization (undesirable) was also observed. The overall prevalence of burnout also increased among students in more advanced years of training (Table 3).
Other symptoms of distress by year in training
Students also had a high frequency of symptoms of depression and at-risk alcohol use (Table 2). Two-hundred and ninety-six students (56%) screened positive for symptoms of depression, and 114 (22%) had at-risk alcohol use. Students overall physical QOL according to the SF-8 was significantly higher than was that of both national samples of age-comparable individuals (53.3 versus 51.4; p < .0001) and the general U.S. population (53.3 versus 50; p < .0001), while their overall mental QOL was significantly lower than that of both national samples of age-comparable individuals (43.7 versus 47.2; p < .0001) and the general U.S. population (43.7 versus 50; p < .0001). Notably, the mean mental QOL score for students was greater than one-half standard deviation below the population norm, a difference that has been considered clinically significant.91
Variation in the prevalence of symptoms of depression and at-risk alcohol use was observed by year in training (Table 3). Contrary to the trend observed with burnout, symptoms of depression and at-risk alcohol use were highest in the early years of training and decreased by year in school. Differences in mean mental and physical QOL scores were also observed by year in school.
Life events within the previous 12 months
The frequencies of positive and negative personal life events in the previous 12 months are shown in Table 4. Two-hundred and one students (37%) experienced at least one major negative personal life event (divorce, major illness-personal, major illness of close family member, death of close family member) in the previous 12 months, with 160 (29.4%), 36 (6.6%), and 5 (0.9%) experiencing one, two, and three negative events, respectively. No student reported experiencing all four negative personal life events in the previous 12 months. Seventy-six students (14%) experienced at least one positive personal life event (marriage, birth/adoption of a child) in the previous 12 months, with only three (0.5%) experiencing both positive life events. Having a close family member experience a major illness (n = 108, 20%) was the most frequently reported life event, followed by the death of a close family member (n = 81, 15%). A significant number of students also reported personally experiencing a major illness (n = 55, 10%), while fewer reported divorce (n = 4, 1%). Events hypothesized to have a positive affect on QOL such as marriage (n = 52, 9%) and having or adopting a child (n = 27, 5%) were also relatively common.
Variations in the frequency of these events by year in training are shown in Table 4. As expected, due to a general association with age, third-year and fourth-year students were more likely to get married or have/adopt a child in the previous 12 months. The number of students who were married increased from 42 (24%) in the first year to 76 (49%) by the fourth year (p = .0001), with a similar trend for the number of students with children: seven, (4%) year 1, 31 (20%) year 4; p = .0001. The number of students with more than $100,000 of educational debt also increased dramatically over the course of training: two, (1%) year 1, 73 (48%) year 4; p = .0001.
Relationship between life events and personal and professional distress
As expected, specific personal life events were associated with depression and at-risk alcohol use even after adjustment for age, sex, and year in training. Personally experiencing a major illness in the previous 12 months was strongly associated with symptoms of depression (odds ratio [OR] 2.965; p = .003) and inversely correlated with at-risk alcohol use (OR 0.362; p = .0399). Having children correlated with a dramatically lower risk of symptoms of depression (OR 0.230; p = .005). Although the majority of the other negative personal life events explored were associated with increased odds of symptoms of depression and at-risk alcohol use, these findings did not reach statistical significance.
Negative personal life events also demonstrated a significant relationship to professional burnout. Personally experiencing a major illness in the previous 12 months was strongly associated with burnout (OR 2.594; p = .002). Some other negative personal life events were also associated with increased odds of burnout; however, these findings did not reach statistical significance. Positive personal life events were not related to professional burnout.
While demographic characteristics and year in training also correlated with personal and professional distress on multivariate analysis, the magnitude of these effects was less than that of personal life events. Increased age was associated with reduced at-risk alcohol use (OR 0.701; p = .0041), while increased year in training was associated with a slightly higher risk of burnout (OR 1.193; p = .0355). Women were more likely to experience symptoms of depression (OR 1.676; p = .0055) but less likely to have at-risk alcohol use (OR 0.522; p < .0041).
We next evaluated the likelihood of burnout, depression, and at-risk alcohol use as well as mental and physical QOL scores by the number of negative and positive life events in the previous 12 months. Given the small number of students (five) who experienced three negative personal events in the previous year, students were categorized as experiencing zero, one, or two or more negative personal life events for this analysis. Similarly, as only three students were both married and had given birth to or adopted a child in the previous 12 months, students were categorized as experiencing zero or one or more positive personal life event for this analysis.
The number of negative life events experienced in the previous 12 months correlated with the prevalence of burnout (p = .0160) with a trend toward correlation with symptoms of depression (p = .0864; see Figure 1). Experiencing one or more positive life events was associated with a lower prevalence of symptoms of depression (p = .0047) and at-risk alcohol use(p = .0151), but did not relate to burnout (p = .8556). Mean mental QOL (p = .0005) and physical QOL (p < .001) also decreased with increasing number of negative personal life events. While mean mental QOL improved with positive life events (p = .0058), no statistically significant relationship was found between mean physical QOL and experiencing positive personal life events (p = .6176; see Figure 2).
Student distress has been increasingly recognized as an important factor in professional development.4,19,22,33,92–96 Our results confirm a high prevalence of personal distress among medical students, with mental quality-of-life scores lower than national samples of age-comparable individuals and a prevalence of symptoms of depression in our survey similar to those found in other studies of medical students over the last 2 decades.22,27–29 As reported by others,22,25,27–29 we also found a peak in depression during the second year of medical school. When compared to the 30-day prevalence of major depression in the general population97–99 and in individuals of comparable age,100 the prevalence of mood disorder is strikingly higher among medical students. In contrast, the percentage of medical students who reported “binge drinking” in our sample was much lower than that for age-comparable individuals in both Minnesota (n = 77, 15% versus 27.8%) and the United States (24.1%).101
Despite a high frequency of burnout among resident physicians in the United States (range 56–76%61,102,103), burnout has not been well characterized in U.S. medical students. We found burnout was common (n = 239, 45%) in medical students from the three institutions studied, with the prevalence of burnout higher for students in more advanced years of training. The increasing prevalence of professional burnout in successive years of training occurred despite an increasing sense of personal accomplishment and was coincident with decreasing symptoms of depression and at-risk alcohol use, making burnout the most common measure of distress among fourth-year students in our series. Our finding of a lower prevalence of burnout in medical students than reported in samples of residents102,104,105 and an increase in depersonalization and burnout as students advance through training supports the hypothesis that physician burnout has its origin in medical school.65,66 Notably, depersonalization is the component of burnout most strongly associated with negative effects on professionalism among residents.102 This finding suggests that efforts to address burnout must begin early in the physician training process.
In our study, positive life events were less common among students than among the general population. Fewer medical students gave birth to or adopted children in the last year than did age-comparable Minnesotans.106 While fewer medical students were married at the time of the survey than were age-comparable Minnesotans and those of comparable age in the general U.S. population,107 the prevalence of marriage in the last year was similar between medical students and the age-comparable general population (19, 12.3% students vs. 11.5% in the population).108 Similarly, among the negative life events studied, fewer students were divorced in the last year than were individuals in the age-comparable general population.108 Despite these differences relative to the general population, the frequencies of being married or having children in our sample are similar to those frequencies in other samples of U.S. medical students.109 The population prevalence for the other life events evaluated (major personal illness, major illness in close family member, death in close family member) are not well recorded, and although the frequency of these events in our sample is comparable to these events in other samples of medical students,52 no comparison to the general population can be made.
Personal life events are known to contribute to depression and alcohol consumption in the general population.53–58,110 As expected, we found such a relationship between these variables among the medical students in this survey. Unlike these measures of personal distress, burnout is considered a measure of professional distress related to job-specific stressors. Most studies of physician burnout have attributed burnout to the rigors of training for and practicing medicine.61,62,102,111–113 Despite this theory, personal life events were strongly related to the experience of professional burnout among medical students in this study. On multivariate analysis, personally experiencing a major illness was associated with a higher likelihood of burnout; also, the number of negative personal life events students experienced within the previous 12 months strongly correlated with the presence of burnout. These findings suggest that both curricular factors related to year in training and also personal factors are related to burnout among medical students.
How should medical schools respond?
How should medical schools respond to these findings? First, educators need to be aware of the prevalence of personal and professional distress and to the frequency of personal life events that may relate to this distress among students. Second, programs need to develop support systems to help students address these challenges, including confidential resources for treatment of depression114–119 and substance abuse115 as well as advocacy programs to assist students when they experience major personal or family events.120 Third, programs need to educate students about the variety of personal and professional stressors experienced during training and inform them how to access available resources. Descriptions of such programs have been reported and may serve as models.6,51,114,120–134 The importance of personal events identified in this study does not eliminate the effects of curricular factors known to contribute to student distress, which must also be addressed.
Finally, the experience of personal and professional stress does not end at graduation. Students must be taught the concept that physicians are themselves therapeutic instruments and as such require calibration.51,135–137 Medical schools need to equip graduates with the skills necessary to assess personal distress, determine its effect on their care of patients, recognize when they need assistance, and develop strategies to promote their own well-being. These skills are essential to maintain perspective, professionalism, and resilience through the course of a career and should be considered an essential competence for medical school graduates. Curricula to help students develop such skills have been suggested and are a place to begin.51,135–139
Limits and strengths of this study
Our study is limited by several factors. First, although the response rate is typical of that found in physician surveys,140,141 response bias remains a possibility. The influence of personal distress and burnout on response rate is unknown. Burned out students may have been more interested in the topics explored and thus more likely to complete the survey, or, alternatively, more apathetic and less likely to complete the survey. Second, although this was a multicenter study and 209 (nearly 40%) students in this study were from outside the state of Minnesota, the generalizability of these results from a single Midwestern state to other regions of the country is unknown. The prevalence of a positive depression screen and at-risk alcohol use among students in this survey are similar to other studies of medical students,6,7,22,28,142 suggesting that the distress we observed is typical for students in the United States. Third, we assessed a limited number of personal life events; other personal life events not explored may also be important.57,78,143 Finally, this study is limited by its cross-sectional nature and cannot determine whether the life events explored are causally related to the aspects of well-being investigated.
Our study has several important strengths. To our knowledge this is the first multicenter study of burnout in U.S. medical students and the only study to explore the impact of personal life events on burnout, depression, alcohol use, and QOL among this group. The students in our survey were from three very different medical school environments (state-sponsored traditional, state-sponsored primary care focus, private subspecialty-oriented), lending generalizability to most types of institutions in the United States. Finally, the majority of the instruments used in our survey were validated ones, allowing comparison to the general population and other samples of medical students, residents, and practicing physicians.
Goals for the future
Personal distress influences the care physicians deliver patients.102,113,144–149 Unfortunately, burnout and depression appear to be a common problem among U.S. medical students. Both personal and professional factors appear to contribute to student burnout. Experiencing major personal life events simultaneously with the challenges of medical school may magnify both sources of stress, and medical schools have a responsibility to support students who experience such personal life events during the course of training. Additional studies are needed to identify what curricular factors contribute to student burnout so they may be addressed. Medical schools must also train young physicians to evaluate their personal health, determine its influence on their practices, and equip them with skills to promote personal well-being. Such skills should be considered essential for all medical school graduates.
1Liaison Committee on Medical Education. Functions and structure of a medical school. Standards for accreditation of medical edu-cation programs leading to the MD degree 〈http://www.lcme.org/pubs.htm#fands
〉. Accessed 29 December 2005. Washington DC, AAMC, October 2004 edition with updates as of October 2005.
2Spiegel DA, Smolen RC, Hopfensperger KA. Medical student stress and clerkship performance. J Med Educ. 1986;61:929–31.
3Spiegel DA, Smolen RC, Jonas CK. An examination of the relationships among interpersonal stress, morale and academic performance in male and female medical students. Soc Sci Med. 1986;23:1157–61.
4Stewart SM, Lam TH, Betson CL, Wong CM, Wong AM. A prospective analysis of stress and academic performance in the first two years of medical school. Med Educ. 1999;33:243–50.
5Newbury-Birch D, Walshaw D, Kamali F. Drink and drugs: from medical students to doctors. Drug Alcohol Depend. 2001;64:265–70.
6Ball S, Bax A. Self-care in medical education: effectiveness of health-habits interventions for first-year medical students. Acad Med. 2002;77:911–17.
7Clark D, Eckenfels EJ, Daugherty SR, Fawcett J. Alcohol-use patterns through medical school: a longitudinal study of one class. JAMA. 1987;257:2921–26.
8Sheehan H, Sheehan D, White K, Leibowitz A, Baldwin DC. A pilot study of medical student ‘abuse': student perceptions of mistreatment and misconduct in medical school. JAMA. 1990;263:533–37.
9Croen LG, Woesner M, Herman M, Reichgott M. A longitudinal study of substance use and abuse in a single class of medical students. Acad Med. 1997;72:376–81.
10Baldwin DC Hughes PH, Conard SE, Storr CL, Sheehan DV. Substance use among senior medical students. A survey of 23 medical schools. JAMA. 1991;265:2074–78.
11Dans PE. Self-reported cheating by students at one medical school. Acad Med. 1996;71(1 suppl):S70–S72.
12DeWitt C, Baldwin DC Daugherty SR, Beverley D, Rowley BD, Schwarz M. Cheating in Medical School: A survey of second year students at 31 schools. Acad Med. 1996;71:267–73.
13Rennie S, Rudland J. Differences in medical students' attitudes to academic misconduct and reported behavior across the years-a questionnaire study. J Med Ethics. 2003;29:97–102.
14Anderson RE, Obenshain SS. Cheating by students: findings, reflections, and remedies. Acad Med. 1994;69:323–32.
15Crandall SJ, Volk RJ, Loemker V. Medical students' attitudes toward providing care for the underserved. Are we training socially responsible physicians? JAMA. 1993;269:2519–23.
16Eron L. Effect of medical education on medical students' attitudes. J Med Educ. 1955;30:559–66.
17Woloschuk W, Harasym PH, Temple W. Attitude change during medical school: a cohort study. Med Educ. 2004;38:522–34.
18Griffith CH, Wilson JF. The loss of idealism throughout internship. Eval Health Prof. 2003;26:415–26.
19Davis BE, Nelson DB, Sahler OJ, McCurdy FA, Goldberg R, Greenberg LW. Do clerkship experiences affect medical students' attitudes toward chronically ill patients? Acad Med. 2001;76:815–20.
20Hojat M, Mangione S, Nasca T, et al. An empirical study of decline in empathy in medical school. Med Educ. 2004;38:934–41.
21Carson AJ, Dias S, Johnston A, et al. Mental health in medical students: a case control study using the 60 item General Health Questionnaire. Scott Med J. 2000;45:115–16.
22Rosal MC, Ockene IS, Ockene JK, Barrett SV, Ma Y, Hebert JR. A longitudinal study of students' depression at one medical school. Acad Med. 1997;72:542–46.
23Guthrie EA, Black D, Shaw CM, Hamilton J, Creed FH, Tomenson B. Embarking upon a medical career: psychological morbidity in first year medical students. Med Educ. 1995;29:337–41.
24Moffat KJ, McConnachie A, Ross S, Morrison JM. First year medical student stress and coping in a problem-based learning medical curriculum. Med Educ. 2004;38:482–91.
25Aktekin M, Karaman T, Senol YY, Erdem S, Erengin H, Akaydin M. Anxiety, depression and stressful life events among medical students: a prospective study in Antalya, Turkey. Med Educ. 2001;35:12–17.
26Guthrie E, Black D, Bagalkote H, Shaw C, Campbell M, Creed F. Psychological stress and burnout in medical students: a five-year prospective longitudinal study. J R Soc Med. 1998;91:237–43.
27Givens JL, Tjia J. Depressed medical students' use of mental health services and barriers to use. Acad Med. 2002.;77:918–21.
28Clark DC, Zeldow PB. Vicissitudes of depressed mood during four years of medical school. JAMA. 1988;260:2521–28.
29Mosley TH Perrin SG, Neral SM, Dubbert PM, Grothues CA, Pinto BM. Stress, coping, and well-being among third-year medical students. Acad Med. 1994;69:765–67.
30Roberts LW, Warner TD, Lyketsos C, Frank E, Ganzini L, Carter D. Perceptions of academic vulnerability associated with personal illness: a study of 1,027 students at nine medical schools. Collaborative Research Group on Medical Student Health. Compr Psychiatry. 2001;42:1–15.
31Tyssen R, Vaglum P, Gronvold NT, Ekeberg O. Suicidal ideation among medical students and young physicians: a nationwide and prospective study of prevalence and predictors. J Affect Disord. 2001;64:69–79.
32Parkerson GR Broadhead WE, Tse CK. The health status and life satisfaction of first-year medical students. Acad Med. 1990;65:586–88.
33Wolf TM, Faucett JM, Randall HM, Balson PM. Graduating medical students' ratings of stresses, pleasures, and coping strategies. J Med Educ. 1988;63:636–42.
34MacLeod R, Parkin C, Pullon S, Robertson G. Early clinical exposure to people who are dying: learning to care at the end of life. Med Educ. 2003;37:51–58.
35Wear DP. “Face-to-face with It”: Medical students' narratives about their end-of-life education. Acad Med. 2002;77:271–77.
36Silver HK, Glicken AD. Medical student abuse: incidence, severity, and significance. JAMA. 1990;263:527–32.
37Elnicki DM, Linger B, Asch E, et al. Patterns of medical student abuse during the internal medicine clerkship: perspectives of students at 11 medical schools. Acad Med. 1999;74(10 suppl):S99–S101.
38Richman JA, Flaherty JA, Rospenda KM, Christensen ML. Mental health consequences and correlates of reported medical student abuse. JAMA. 1992;267:692–94.
40Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med. 1998;73:403–07.
41Stern DT. In search of the informal curriculum: when and where professional values are taught. Acad Med. 1998;73(10 suppl):S28–S30.
42Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of Med Educ. Acad Med. 1994;69:861–71.
43Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students' perceptions of their ethical environment and personal development. Acad Med. 1994;69:670–79.
44Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med. 1993;68:249–54.
45Wear D. On white coats and professional development: the formal and the hidden curricula. Ann Intern Med. 1998;129:734–37.
46Hundert EM, Hafferty F, Christakis D. Characteristics of the informal curriculum and trainees' ethical choices. Acad Med. 1996;71:624–42.
47Kassebaum DG, Cutler ER. On the culture of student abuse in medical school. Acad Med. 1998;73:1149–58.
48Strayhorn G. Effect of a major curriculum revision on students' perceptions of well-being. Acad Med. 1989;64:25–29.
49Wolf TM, von Almen TK, Faucett JM, Randall HM, Franklin FA. Psychosocial changes during the first year of medical school. Med Educ. 1991;25:174–81.
50Wolf TM. Stress, coping and health: enhancing well-being during medical school. Med Educ. 1994;28:8–17.
51Novack DH, Epstein RM, Paulsen RH. Toward creating physician-healers: fostering medical students' self-awareness, personal growth, and well-being. Acad Med. 1999;74:516–20.
52Hojat M, Glaser K, Xu G, Veloski JJ, Christian EB. Gender comparisons of medical students' psychosocial profiles. Med Educ. 1999;33:342–49.
53Paykel ES. The evolution of life events research in psychiatry. J Affect Disord. 2001;62:141–49.
54Paykel ES. The interview for recent life events. Psych Med. 1997;27:301–10.
55Frank E, Tu XM, Anderson B, et al. Effects of positive and negative life events on time to depression onset: an analysis of additivity and timing. Psychol Med. 1996;26:613–24.
56Moerk KC, Klein DN. The development of major depressive episodes during the course of dysthymic and episodic major depressive disorders: a retrospective examination of life events. J AffectDisord. 2000;58:117–23.
57Honkalampi K, Koivumaa-Honkanen H, Hintikka J, et al. Do stressful life-events or sociodemographic variables associate with depression and alexithymia among a general population? A 3-year follow-up study. Compr Psychiatry. 2004;45:254–60.
58Frank E, Anderson B, Reynolds CF Ritenour A, Kupfer DJ. Life events and the research diagnostic criteria endogenous subtype. A confirmation of the distinction using the Bedford College methods. Arch Gen Psychiatry. 1994;51:519–24.
59Maslach C. Burned out. Hum Behavior. 1976;5:16–22.
60Lemkau JP, Purdy RR, Rafferty JP, Rudisill JR. Correlates of burnout among family practice residents. J Med Educ. 1988;63:682–91.
61Thomas N. Resident Burnout. JAMA. 2004;292:2880–89.
62Visser MR, Smets EM, Oort FJ, De Haes HC. Stress, satisfaction and burnout among Dutch medical specialists. Can Med Assoc J. 2003;168:271–75.
63Deckard GJ, Hicks LL, Hamory BH. The occurrence and distribution of burnout among infectious diseases physicians. J Infect Dis. 1992;165:224–28.
64Linzer M, Visser MR, Oort FJ, et al. Predicting and preventing physician burnout: results from the United States and the Netherlands. Am J Med. 2001;111:170–75.
65Wolf TM, Balson PM, Faucett JM, Randall HM. A retrospective study of attitude change during Med Educ. Med Educ. 1989;23:19–23.
66Krakowski A. Stress and the practice of medicine: the myth and the reality. J Psychosom Res. 1982;26:91–98.
67Maslach C.. Maslach Burnout Inventory Manual. 2nd ed. Palo Alto, CA: Consulting Psychologists Press, 1986.
68Rafferty JP, Lemkau JP, Purdy RR, Rudisill JR. Validity of the Maslach Burnout Inventory for family practice physicians. J Clin Psychol. 1986;42:488–92.
69Lee RT, Ashforth BE. A meta-analytic examination of the correlates of the three dimensions of job burnout. J Applied Psychol. 1996;81:123–33.
70Leiter M, Durup J. The discriminant validity of burnout and depression: a confirmatory factor analytic study. Anxiety Stress Coping. 1994;7:357–73.
71Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA. 1749;272:1749–56.
72Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: two questions are as good as many. J Gen Intern Med. 1997;12:439–45.
73Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. 1998;158:1789–95.
74Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption—II. Addiction. 1993;88:791–804.
75Ware J, Kosinski M, Dewey J, Gandek B.. How to Score and Interpret Single-Item Health Status Measures: A Manual for Users of the SF-8 Health Survey. Lincoln, RI: QualityMetric, 2001.
76Davis M. A multidimensional approach to individual differences in empathy. JSAS Catalog of Selected Documents in Psychology. 1980;10:85.
77Shanafelt T, West C, Zhao X et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med. 2005;20:559–64.
78Lu MC, Chen B. Racial and ethnic disparities in preterm birth: the role of stressful life events. Am J Obstet Gynecol. 2004;191:691–99.
79Sarason IG, Johnson JH, Siegel JM. Assessing the impact of life changes: development of the Life Experiences Survey. J Consult Clin Psychol. 1978;46:932–46.
80Coombs RH. The effect of marital status on stress in medical school. Am J Psychiatry. 1982;139:1490–93.
81Katz J, Monnier J, Libet J, Shaw D, Beach S. Individual and crossover effect of stress on adjustment in medical student marriages. J Marital Fam Ther. 2000;26:341–51.
82Collier VU, McCue JD, Markus A, Smith L. Stress in medical residency: status quo after a decade of reform? Ann Intern Med. Mar 5. 2002;136:384–90.
83Lemkau J, Rafferty J, Gordon R. Burnout and career-choice regret among family practice physicians in early practice. Fam Pract Res J. Sep. 1994;14:213–22.
84Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM. Mental health of hospital consultants: the effects of stress and satisfaction at work. Lancet. 1996;347:724–28.
85Burvill PW. Recent progress in the epidemiology of major depression. Epidemiol Rev. 1995;17:21–31.
86Regier DA, Boyd JH, Burke JD, et al. One-month prevalence of mental disorders in the United States. Based on five Epidemiologic Catchment Area sites. Arch Gen Psychiatry. Nov. 1988;45:977–86.
87Chentsova-Dutton Y, Shuchter S, Hutchin S, Strause L, Burns K, Zisook S. The psychological and physical health of hospice caregivers. Ann Clin Psychiatry. Mar. 2000;12:19–27.
88Willitts M, Benzeval M, Stansfeld S. Partnership history and mental health over time. J Epidemiol Commun Health. 2004;58:53–58.
89Haatainen KM, Tanskanen A, Kylma J, et al. Life events are important in the course of hopelessness-a 2-year follow-up study in a general population. Soc Psychiatry Psychiatr Epidemiol. 2003;38:436–41.
90Armitage P. Tests for linear trend in proportions and frequencies. Biometrics. 1955;11:375–86.
91Norman GR, Sloan JA, Wyrwich KW. The truly remarkable universality of half a standard deviation: confirmation through another look. Exp Rev Pharmacoecon Outcomes Res. 2004;4:515–19.
92Gill D, Palmer C, Mulder R, Wilkinson T. Medical student career intentions at the Christchurch School of Medicine. The New Zealand Wellbeing, Intentions, Debt and Experiences (WIDE) survey of medical students pilot study. Results part II. NZ Med J. 2001;114:465–67.
93Newton BW, Savidge MA, Barber L, et al. Differences in medical students' empathy. Acad Med. 2000;75:1215.
94Merrill J, Lorimor R, Thornby J, Woods A. Caring for terminally ill persons: comparative analysis of attitudes (thanatophobia) of practicing physicians, student nurses, and medical students. Psychol Rep. 1998;83:123–28.
95Stecker T. Well-being in an academic environment. Med Educ. 2004;38:465–78.
97Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. Jun 18. 2003;289:3095–05.
98Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61:807–16.
99Narrow WE, Rae DS, Robins LN, Regier DA. Revised prevalence estimates of mental disorders in the United States: using a clinical significance criterion to reconcile 2 surveys' estimates. Arch Gen Psychiatry. 2002;59:115–23.
100Blazer DG, Kessler RC, McGonagle KA, Swartz MS. The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey. Am J Psychiatry. 1994;151:979–86.
101National Center for Chronic Disease Prevention and Health Promotion. Behavioral Risk Factor Surveillance System. Minnesota—2003 Alcohol Consumption 〈http://www.cdc.gov/brfss/
〉. Accessed 30 December 2005. NCCDP, 2003.
102Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358–67.
103Gelfand 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; discussion 938–940.
104Purdy RR, Lemkau JP, Rafferty JP, Rudisill JR. Resident physicians in family practice: who's burned out and who knows? Fam Med. 1987;19:203–8.
105McCue JD, Sachs CL. A stress management workshop improves residents' coping skills. Arch Intern Med. 1991;151:2273–77.
106National Vital Statistics Reports. Trends in Characteristics of Births by State: United States, 1990, 1995, and 2000-2002 〈http://www.cdc.gov/nchs/births.htm
〉. Centers for Disease Control and Prevention. 2004. Accessed 30 December 2005.
110Cole G, Tucker L, Friedman GM. Relationships among measures of alcohol drinking behavior, life-events and perceived stress. Psychol Rep. 1990;67:587–91.
111Snibbe JR, Radcliffe T, Weisberger C, Richards M, Kelly J. Burnout among primary care physicians and mental health professionals in a managed health care setting. Psychol Rep. 1989;65:775–80.
112Gundersen L. Physician burnout. Ann Intern Med. 2001;135:145–48.
113Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114:513–19.
114Rathbun J. Helping medical students develop lifelong strategies to cope with stress. Acad Med. 1995;70:955–56.
115Pasnau RO, Stoessel P. Mental health service for medical students. Med Educ. 1994;28:33–39.
116Rodolfa E, Chavoor S, Velasquez J. Counseling services at the University of California, Davis: helping medical students cope. JAMA. 1995;274:1396–97.
117Lerner BA. Students' use of psychiatric services: the Columbia experience. JAMA. 1995;274:1398–99.
118Keil A. AIMS committees: a resource for medical students. JAMA. 1995;274:1399.
119Plaut SM, Maxwell SA, Seng L, O'Brien JJ, Fairclough GF. Mental health services for medical students: perceptions of students, student affairs deans, and mental health providers. Acad Med. 1993;68:360–65.
120Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. J Behav Med. 1998;21:581–99.
121Wolf TM, Randall HM, Faucett JM. A survey of health promotion programs in U.S. and Canadian medical schools. Am J Health Prom. 1988;3:33–36.
122Murdoch-Eaton DG, Levene MI. Formal appraisal of undergraduate medical students: is it worth the effort? Med Teach. 2004;26:28–32.
123Lee J, Graham AV. Students' perception of medical school stress and their evaluation of a wellness elective. Med Educ. 2001;35:652–59.
124Malik S. Students, tutors and relationships: the ingredients of a successful student support scheme. Med Educ. 2000;34:635–41.
125Murr AH, Miller C, Papadakis M. Mentorship through advisory colleges. Acad Med. 2002;77:1172–73.
126Coles C. Support for medical students in the United Kingdom. Med Educ. 1993;27:186–87.
127Hull SK, DiLalla LF, Dorsey JK. Student attitudes toward wellness, empathy, and spirituality in the curriculum. Acad Med. 2001;76:520.
128Gaber RR, Martin DM. Still-Well osteopathic medical student wellness program. J Am Osteopath Assoc. 2002;102:289–92.
129Hendricks-Matthews MK. Ensuring students' well-being as they learn to support victims of violence [published erratum appears in Acad Med. 1997;72:190]. Acad Med. 1997;72:46–47.
130Goldstone R, Drake M. Anticipation of predictable stressors: a course to promote well-being for women physicians of color. Acad Med. 2000;75:516.
131Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003;15:88–92.
132Nathan RG, Nixon FE, Robinson LA, Bairnsfather L, Allen JH, Hack M. Effects of a stress management course on grades and health of first-year medical students. J Med Educ. 1987;62:514–17.
133Coombs RH, Virshup BB. Enhancing the psychological health of medical students: the student well-being committee. Med Educ. 1994;28:47–54.
134Coombs RH, Perell K, Ruckh JM. Primary prevention of emotional impairment among medical trainees. Acad Med. 1990;65:576–81.
135Charon R. The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. 2001;286:1897–902.
136Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997;278:502–9.
137Epstein RM. Mindful practice. JAMA. 1999;282:833–39.
138Rabow MW, McPhee SJ. Doctoring to heal: fostering well-being among physicians through personal reflection. West J Med. 2001;174:66–69.
139Quill TE, Williamson PR. Healthy approaches to physician stress. Arch Intern Med. 1857;150:1857–61.
140Asch D, Jedrziewski M, Christakis N. Response rates to mail surveys published in medical journals. J Clin Epidemiol. 1997;50:1129–36.
141Kellerman S, Herold J. Physician response to surveys: a review of the literature. Am J Prev Med. 2001;20:61–71.
142Mangus R, Hawkins C, Miller M. Tobacco and alcohol use among 1996 medical school graduates. JAMA. 1998;280:1192–93.
143Kessing LV, Agerbo E, Mortensen PB. Does the impact of major stressful life events on the risk of developing depression change throughout life? Psychol Med. 2003;33:1177–84.
144Melville A. Job Satisfaction in general practice: implications for prescribing. Soc Sci Med. 1980;14A:495–99.
145Schmoldt RA, Freeborn DK, HD K. Physician Burnout: recommendations for HMO managers. HMO Pract. 1994;8:58–63.
146DiMatteo MR, Cd S, Hays R. Physicians' characteristics influence patients' adherence to medical treatment: results from the Medical Outcomes Study. Health Psychol. 1993;12:93–102.
147Haas JS, Cook EF, Puopolo AL, Burstin HR, Cleary PD, TA B. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15:122–28.
148Linn LS, Brook RH, Clark VA, Davies AR, Fink A, J K. Physician and patient satisfaction as factors related to the organization of internal medicine group practices. Med Care. 1985;23:1171–78.
149Lichtenstein RL. The job satisfaction and retention of physicians in organized settings: a literature review. Med Care Rev. 1984;41:139–79.