Dyrbye, Liselotte N. MD; Harper, William MD; Moutier, Christine MD; Durning, Steven J. MD; Power, David V. MD; Massie, F. Stanford MD; Eacker, Anne MD; Thomas, Matthew R. MD; Satele, Daniel; Sloan, Jeff A. PhD; Shanafelt, Tait D. MD
Professional burnout and other forms of psychological distress are common among physicians and medical students.1–4 This distress has serious personal consequences and may compromise patient care,4–7 the size of the physician workforce,8,9 competency,10 and professionalism.11 Despite these adverse consequences, whether or not a state of positive mental health enhances professionalism is unknown. Insight in this area may be helpful to wellness programs for physicians and medical students in helping such programs decide whether their primary aim should be to eliminate burnout, to pursue the more elusive goal of promoting positive mental health, or to do both.
The World Health Organization suggests that “health is a complete state of physical, mental, and social well-being and not merely the absence of disease or infirmity.”12 Similarly, the 1999 report of the surgeon general on mental health considered mental health (1) distinct from the absence of mental illness, (2) indispensable to personal well-being, relationships, and contributions to society, and (3) in need of immediate attention.13 Although what it means to be mentally healthy varies between cultures and is influenced by personal values,13 it is commonly viewed as having positive feelings (e.g., happiness, positive feelings toward one’s life) and positive functioning in life (e.g., sense of purpose, fulfilling relationships, sense of belonging, contributing to society) rather than simply the absence of negative feelings, symptoms, or impairment (e.g., the absence of professional burnout does not mean that a person is mentally healthy or thriving).12–15 Conceptually, framing positive mental health around the combination of feelings and function is similar to (but in the opposite direction as) the definitions of mental illness used in the Diagnostic and Statistical Manual of Mental Disorders16 (e.g., a diagnosis of depression requires both feelings of depressed mood/anhedonia as well as malfunctioning). Common to both positive and negative mental health conditions is a reliance on the individuals’ perceptions and self-assessment.
Despite calls for research on the promotion of positive mental health since the 1950s,13,17 there remains a paucity of research in this area, and the beneficial effects of achieving high mental health remain poorly understood.18 We performed a multicenter study of medical students to explore the relationship between positive mental health and burnout with professionalism and personal experience.
Participants and procedures
We have described the methods of data collection for this large, multisite study in detail elsewhere.11 Briefly, all 4,400 medical students from seven U.S. medical schools (chosen because of their diverse student population, variation in size, geographic location, public/private status, and the presence of a local investigator willing to complete the site-specific tasks necessary for student participation) were eligible to participate after the institutional review board at each school approved the study. In 2009, the survey research center at Mayo Clinic invited these students to participate in the study. Participation was elective, and responses were anonymous.
For a summary of the various study measures discussed below, see Appendix 1.
Mental health. The survey included the Mental Health Continuum Short Form (MHC-SF) to measure mental health.19 The MHC-SF is a 14-item instrument assessing emotional (three items), psychological (one from each of the six dimensions of Ryff’s construct of psychological well-being),20 and social well-being (one from each of the five dimensions of Keyes’21 model of social well-being).
The MHC-SF items measure the frequency with which responders have experienced symptoms of positive mental health during the past month (never, once or twice, about once a week, two or three times a week, almost every day, every day). Responders receive an overall summary score as well as subscores within each domain (emotional, psychological, and social well-being). The average MHC-SF score for the general U.S. population is 47.68 (SD 12.28).22 On the basis of established MHC-SF criteria,19 respondents are considered to have flourishing mental health if they have experienced ≥1 of the 3 symptoms of emotional well-being (i.e., they were happy, interested in life, satisfied) and ≥6 of the 11 symptoms of either positive social functioning (e.g., they felt they had something important to contribute to society, that they belonged to a community) or of positive psychological functioning (e.g., they felt confident to express their own opinions, that life has meaning to it, were positive about themselves) either daily or almost every day during the past month. Respondents who indicate a low frequency (i.e., “never” or “once or twice” during the past month) on ≥1 emotional well-being items and a low frequency on ≥6 signs of positive functioning have languishing mental health. Respondents who are neither flourishing nor languishing are considered to have moderate mental health. Previous population-based studies have borne out that flourishing mental health is better than moderate mental health and that moderate mental health is better than languishing mental health, as evidenced by work effort, conduct, absenteeism, and health care utilization.15,23,24
Burnout. The survey included the Maslach Burnout Inventory (MBI)25 to measure burnout. The MBI, widely considered the criterion standard,3 measures three domains of burnout: emotional exhaustion (EE), depersonalization (DP), and low sense of personal accomplishment (PA). The three-factor structure of the MBI has been confirmed in medical students.26 The reliability of the MBI in medical students is supported by Cronbach coefficient alphas for the EE, DP, and PA domains of 0.89, 0.78, and 0.81, respectively, which are nearly identical to the respective performances of the MBI in these domains in large population samples.18 Predictive validity evidence is supported by studies showing relationships between burnout, as measured by the MBI, and suicidal ideation,27 serious thoughts of dropping out,9 and low empathy28 among medical students. According to commonly accepted convention, we used EE, DP, and PA scores both as continuous variables and also as high scores using established cutoffs.25 Because high scores on either the EE (≥27) or DP (≥10) scales can distinguish clinically burned-out individuals from non-burned-out ones,29 burnout (as a dichotomous variable) was defined as having high EE and/or high DP.30,31
Personal experiences. To build on earlier work showing relationships between burnout and both suicidal ideation and serious thoughts of dropping out of medical school,9,27 the survey also included items about suicidal ideation and serious thoughts of dropping out of medical school within the previous 12 months.
Professional behaviors and beliefs. Previously published questionnaire items were used to assess professional behaviors and beliefs.11 Items regarding professional conduct explored cheating and dishonest professional behaviors that had been reported in previous studies of medical students.32–35 Altruistic professional beliefs were assessed by asking students to rate their levels of agreement with statements regarding physicians’ responsibility to society derived from the Medical Students’ Attitudes toward Providing Care for the Underserved (MSATU) instrument.34,35 Consistent with previous reports,11 responses to these items were dichotomized to “agree” (responses of “strongly agree” or “agree”) or “neutral/disagree” (responses of “neutral,” “disagree,” or “strongly disagree”) for analysis. Last, students were asked if they had provided care to the medically underserved in a community setting that was not related to a clerkship or required activity, to explore whether they had pursued such activities of their own initiative.
Standard descriptive summary statistics were used to characterize the sample. Differences in a dependent outcome variable by independent variables were evaluated using the Kruskal–Wallis test (continuous variables) or chi-square test (categorical variables), as appropriate. All tests were two-sided with type I error rates of 0.05. Participants were excluded from individual analyses if their data involved in the comparison were missing. The large sample size provided high precision. With 2,682 observations, percentages are accurate to within 2 percentage points with 95% confidence. Mean values are accurate to within 4% of the SD of the variable involved, a very small effect size. All analyses were conducted using Linux SAS 9.2 (Cary, North Carolina).
Of 4,400 medical students surveyed, 2,682 students returned surveys (response rate of 61%). Compared with the overall sample, responders were slightly more likely to be female (48.6% versus 45.1%), younger than 25 (32.6% versus 25.9%), and white (78.4% versus 68.4%). (We previously reported the demographic characteristics and MBI scores of the same group of medical students.)11 Collectively, 42.1% (1,079/2,562) had high EE, 35.8% (860/2,404) had high DP, and 52.5% (1,398/2,661) had positive depression screens. In addition, 17.4% (465/2,670) of respondents reported suicidal ideation, and 11.3% (297/2,627) reported serious thoughts of dropping out of medical school in the previous 12 months.
Our data confirmed the three-factor structure of the MHC-SF. Cronbach alpha was 0.921 for the entire MCH-SF and 0.899, 0.802, and 0.875 for the three domains of emotional, psychological, and social well-being, respectively, which is similar to the performance of the MCH-SF in other samples.36,37
Students’ mean MHC-SF score was 47.0 (SD 12.67). Of the 2,682 students who returned surveys, all but 31 could be assigned a category of mental health (i.e., languishing, moderate, or flourishing) based on responses to the MHC-SF. Overall, 1,409 (53.1%) students were flourishing, 1,128 (42.5%) were moderately mentally healthy, and 114 (4.3%) were languishing. The prevalence of students with flourishing, moderate, and languishing mental health by demographic characteristics is shown in Table 1. Relationship status, parental status, year in medical school, and race were significantly associated with student’s degree of mental health; however, no associations were observed based on sex, age, debt, or ethnicity.
Relationship of positive mental health with personal experiences
Flourishing students had a lower prevalence of suicidal ideation within the last 12 months (127/1,406 [9.0%]) than did those who were moderately mentally healthy (281/1,119 [25.1%]) or languishing (55/114 [48.2%]; overall P < .0001). Similarly, flourishing students were less likely to report serious thoughts of dropping out of medical school (14/1409 [1.0%]) than were those who were moderately mentally healthy (30/1,128 [2.7%]) or languishing (15/114 [13.2%]; overall P < .0001).
On the basis of previous work showing a strong association between professional burnout and recent suicidal ideation27 and serious thoughts of dropping out of medical school,9 we repeated the analysis by burnout status. As shown in Figure 1, positive mental health stratified students’ risk of suicidal ideation and serious thoughts of dropping out even after students with burnout were excluded (both P < .0001).
Relationship of positive mental health with professional behavior
Students who were languishing were more likely to have engaged in unprofessional behaviors (i.e., cheating and dishonest behaviors). The mean numbers of unprofessional behaviors were 0.4 (SD, 0.62), 0.4 (SD, 0.71), and 0.5 (SD, 0.85) for flourishing, moderate, and languishing mental health, respectively; overall P = .01. When each professional conduct item was evaluated separately, the prevalence of six out of seven cheating and dishonest behaviors decreased as students’ mental health improved (see Table 2).
Given the previously reported relationship between burnout and professional conduct,11 we repeated the just-described analysis by burnout status. There was no difference in the mean number of unprofessional behaviors among those with languishing, moderate, or flourishing mental health after burnout status was taken into account. With respect to individual behaviors, among students with burnout, mental health status did not relate to professional conduct except for one of the seven behaviors (i.e., signed an attendance sheet for a friend who was not present: 50/482 [10.4%], 95/706 [13.5%], and 18/90 [20.0%] for flourishing, moderate, and languishing mental health, respectively, overall P = .03). Similarly, in students without burnout, mental health status did not relate to professional conduct except for one other behavior (i.e., taking credit for another person’s work: 1/850 [0.1%], 1/328 [0.3%], and 1/13 [7.7%] for flourishing, moderate, and languishing mental health, respectively, overall P < .0001).
Relationship of positive mental health with professional beliefs
In aggregate, students who were flourishing endorsed a larger number of the five altruistic professional beliefs regarding physicians’ responsibility to society (3.3 [SD 1.57], 3.7 [SD 1.40], and 4.0 [SD 1.32] for languishing, moderate, and flourishing mental health; overall P < .0001). The prevalence of each professional belief also increased as students’ mental health improved (see Figure 2). For example, students with flourishing mental health had twofold-higher odds of endorsing the belief that they could personally make an impact on the problem of the medically underserved than did students with moderate mental health (OR 2.113; 95% CI 1.424, 3.136). In turn, students who were moderately mentally healthy had 80% higher odds of having such a belief than did students who were languishing (OR 1.811; 95% CI 1.553, 2.139). Overall, 33/107 (30.8%), 426/1,077 (39.6), and 718/1,359 (52.8%) of students with languishing, moderate, and flourishing mental health endorsed all five altruistic professional beliefs (P < .0001). Student mental health also correlated with whether or not students had actually provided care to the medically underserved outside of a clerkship or required activity (53/113 [46.9%], 615/1,113 [55.3%], and 802/1,378 [58.2%] for languishing, moderate, and flourishing mental health, overall P = .04).
Given the previously reported relationship between burnout and students’ altruistic professional beliefs about physicians’ responsibility to society,14 we repeated this analysis by burnout status (see Figure 3). The relationship between professional beliefs and mental health persisted among students with professional burnout in that the mean number of favorable beliefs toward serving the underserved was lowest for those who were languishing (3.2, SD 1.52), higher for those who were moderately mentally healthy (3.6, SD 1.42), and highest for those who were flourishing (4.0, SD 1.36, overall P < .0001). For students with professional burnout, a statistically significant association with mental health was observed for three of the five items regarding physicians’ responsibility to society (see Figure 3, top panel). Similarly, students with burnout who were flourishing* were more likely to:
* endorse a desire to provide care for the medically underserved (61/92 [66.3%], 569/739 [77.0%], and 426/501 [85.0%] for languishing, moderate, and flourishing mental health, respectively, overall P < .0001);
* feel they could make an impact on meeting the needs of the medically underserved (32/92 [34.8%], 402/740 [54.3%], and 353/500 [70.6%] for languishing, moderate, and flourishing mental health, respectively, overall P < .0001); and
* believe that medical students should be concerned about meeting the problems facing the underserved (73/92 [79.3%], 644/738 [87.3%], and 454/499 [91.0%] for languishing, moderate, and flourishing mental health, respectively, overall P = .004).
These findings suggest that, among those with burnout, positive mental health may reduce some negative consequences of burnout, especially with regard to certain aspects of professionalism.
Although there was a relationship between altruistic professional beliefs and mental health among students with professional burnout, the difference in the mean number of altruistic professional beliefs endorsed by students without burnout who were languishing, moderately mentally healthy, or flourishing was not statistically significant. As shown in Figure 3, bottom panel, when analyzing the individual altruistic professional beliefs among students free of burnout, the relationship with mental health was statistically significant for only one of five items (i.e., everyone is entitled to receive adequate medical care regardless of ability to pay: 10/14 [71.4%], 268/327 [82.0%], and 741/852 [87.0%] for languishing, moderate, and flourishing mental health, respectively, overall P = .03).
Data from this large, multi-institutional study suggest that higher mental health correlates with medical student professionalism and a better personal experience. Students’ mental health stratified the likelihood that students reported engaging in cheating/dishonest clinical behaviors as well as their altruistic views regarding physicians’ responsibility to society. Students’ degree of mental health also stratified whether students had experienced recent suicidal ideation or considered dropping out of medical school.
Although the association between suicidal ideation and serious thoughts of dropping out with positive mental health persisted independent of burnout, a more complex relationship seems to exist between positive mental health and professional behaviors and students’ altruistic views regarding physicians’ responsibility to society. Although positive mental health had a more limited relationship to professional behaviors and altruistic views about physicians’ responsibility to society among students without professional burnout, for students with burnout, positive mental health seemed to have a substantial effect on whether they maintained altruistic professional values. This study builds on a previous analysis showing a relationship between burnout and altruistic professional beliefs11 by documenting an incremental preservation of altruistic views about physicians’ responsibility to society as positive mental health improves. In sum, these findings suggest that efforts to eliminate suicide attempts and attrition among medical students and to foster altruistic professional values should focus not only on preventing burnout but also on optimizing personal mental heath.
Although limited existing data suggested that lower stress and fatigue36 and mindfulness37 may reduce the risk of burnout, little is known about approaches to promote positive mental health that could be incorporated into medical student wellness programs required by the Liaison Committee on Medical Education.38 Further study is warranted on the usefulness of strategies with the potential to bolster positive mental health, such as structured opportunities for students to contribute to a community, build meaningful relationships, and reflect on their well-being, autonomy, personal growth, personal value, and self-acceptance.19,20 Conceptually common to initiatives intended to prevent burnout and promote positive mental health is the recognition of self-care as a core competency for physicians, as also advocated by the Royal College of Physicians and Surgeons of Canada (in CanMEDS 2005)39 and the General Medical Council of the United Kingdom (in The New Doctor 2009).40 Formalization of self-care as a core competency within the United States (e.g., by the Accreditation Council for Graduate Medical Education and the Physician Charter) could further stimulate curricula innovation and evaluation to advance evidence-based approaches to equip trainees and physicians with skills that promote mental health and resilience. Meanwhile, given the high prevalence of students’ distress, schools should take steps to measure their students’ mental health while they develop methods to help improve it.
This study is limited by several factors. First, we relied on self-reported mental health status that was not corroborated by formal clinical assessment. Second, positive mental health is a multifaceted and evolving construct, and it is unlikely that the MHC-SF measures all the components that contribute to mental health. Third, because this study was cross-sectional, the causality and the direction of the relationships cannot be determined. Fourth, although our sample size was large and our response rate of 61% is robust for multi-institution physician41 and medical student surveys,1 our findings may be vulnerable to response bias. Our sample size, however, provides estimates of the mental health continuum diagnosis within 1.9% of the actual population value with 95% confidence. Fifth, the items regarding physicians’ responsibility toward society are vulnerable to social desirability bias. However, given the Web-based, anonymous nature of this study, such bias is unlikely to have been substantial. Last, we recognize that other factors, such as personal experiences, family income, and political viewpoints, not explored in this study, may also influence students’ attitudes toward the underserved.
The study has several important strengths. First, it is a large, multi-institutional study of students attending diverse public and private medical schools. Second, responders were representative of U.S. medical students with respect to sex, relationship status, and parental status. Third, we used established instruments to measure burnout and mental health. Fourth, items assessing professional behaviors and beliefs were derived from the literature32–35 and the MSATU.42,43
Our data show that positive mental health seems to be associated with enhanced professional behaviors and beliefs among U.S. medical students. For the good of both society and individual students, medical schools should help students not only avoid professional burnout but also learn strategies that promote positive personal mental health. Future studies are needed to evaluate the impact of positive mental health on professional development and evaluate the efficacy of interventions designed to promote positive mental health.
Funding/Support: This work was supported by a Professionalism Award from the Mayo Clinic, from the Mayo Clinic Department of Medicine, Division of Primary Care intramural funds, and from the Mayo Clinic Department of Medicine Program on Physician Well-being and the Mayo Medical School Office of Educational Research.
Other disclosures: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.
Ethical approval: Institutional review board approval was obtained from each institution before inviting the medical students to participate.
* We speculate that students who are flourishing yet burned out may feel that their medical training is of great purpose and that they have a sense they are contributing to society in a meaningful way but are simultaneously exhausted and desensitized. Thus they believe in their work, are committed to it, but have lost some of their ability to engage in it because of personal depletion. Nonetheless, we believe that only an identified survey with qualitative data can define the profile of such a student. Cited Here...
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