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 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
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.
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