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Addressing Student Burnout

What Medical Schools Can Learn From Business Schools

Pathipati, Akhilesh S.; Cassel, Christine K., MD

doi: 10.1097/ACM.0000000000002215
Invited Commentaries
Free

Although they enter school with enthusiasm for a career in medicine, medical students in the United States subsequently report high levels of burnout and disillusionment. As medical school leaders consider how to address this problem, they can look to business schools as one source of inspiration. In this Invited Commentary, the authors argue—based on their collective experience in both medical and business education—that medical schools can draw three lessons from business schools that can help reinvigorate students. First, medical schools should offer more opportunities and dedicated time for creative work. Engaging with diverse challenges promotes intellectual curiosity and can help students maintain perspective. Second, schools should provide more explicit training in resiliency and the management of stressful situations. Many business programs include formal training in how to cope with conflict and how to make high-stakes decisions, whereas medical students are typically expected to learn those skills on the job. Finally, medical schools should provide better guidance on practical career considerations like income, lifestyle, and financial skills. Whether in medicine or business, students benefit from open discussions about their personal and professional goals. Medical schools must ensure that students have an outlet for those conversations.

A.S. Pathipati is an MD/MBA student, Stanford University School of Medicine, Stanford, California; ORCID: http://orcid.org/0000-0003-2367-4174.

C.K. Cassel is executive advisor to the dean, Kaiser Permanente School of Medicine, Pasadena, California.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Christine K. Cassel, MD, Kaiser Permanente School of Medicine, 1 Kaiser Plaza, Oakland, CA 94612; telephone: (510) 267-7519; chriskcassel@gmail.com.

More than 20,000 students enter U.S. medical schools each year, brimming with enthusiasm for a career in medicine; yet, for too many of them, that enthusiasm fades. As a population, medical students suffer high rates of mental health problems1 and exhibit a well-characterized loss of empathy during training.2 By the time students complete their clinical years, a sizable number are disillusioned about their decision to become a doctor.

This disillusionment is not inevitable. Medicine can—and should—feel like a rewarding career choice. Given our collective experiences as a currently enrolled MD/MBA student and a former medical school dean familiar with formal professional education outside of medicine, we believe that good business schools provide an instructive comparison in pedagogical approaches and cultures. Business students report high levels of satisfaction with their education and career prospects.3 Although business and medical schools have different missions, the juxtaposition of educational environments offers three potential means of ameliorating medical student burnout: (1) provide more opportunities for creative problem solving, (2) deliver more training in resilience, and (3) offer better career counseling. Medical schools can draw on the ideas presented here to implement reforms and reinvigorate students.

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Rediscovering Creativity

Medical students are a talented group of people. Many are drawn to medicine because of the broad and varied challenges that it presents: helping a patient in need, conducting groundbreaking research, trying to transform the health care system, and more. But once they are in medical school, medical students may easily lose track of those goals. Preclinical curricula reward students for memorizing and recalling large volumes of information. Even creative attempts at more meaningful pedagogical techniques occur in the shadow of the United States Medical Licensing Exam Step 1. Clinical rotations reinforce this mentality of rote learning. Students’ day-to-day work in the clinical environment revolves around routine jobs like checking lab values, ordering scans, and writing notes. Medical students sense a tremendous emphasis on completing the tasks placed directly in front of them.

Completing routine activities is necessary for learning how to be a doctor. Such activities are also important for patient care; checklist models of care are key to patient safety. But for students, they can obscure deeper human and intellectual challenges, and the danger of such an emphasis is that students lose sight of opportunities to be intellectually creative. Students’ diverse interests are subsumed by the daily grind of medicine.

Business schools take a different approach. The difference is not because business is inherently more creative than medicine. Indeed, master of business administration or MBA graduates often come out of school performing rote jobs like creating slide decks or running analytics in spreadsheets. Even so, the process of schooling emphasizes thinking about broader issues. Business curricula often use case-based learning that asks students to generate and discuss ideas, and to understand sources of uncertainty, rather than to converge on a single answer.4 Courses on innovation and entrepreneurship are designed to foster creativity as students develop and revise business plans. Executive simulations ask students to make management decisions and defend them, forcing students to reflect on both what they are doing and why they are doing it. Outside of class, students enjoy time and space to think about what is important to them and discover their interests. They identify goals, discuss them with peers and mentors, and leave school with the belief that they can change the world.

We believe that medical schools can do a better job of inculcating that enthusiastic, problem-solving mind-set in budding doctors. The impulse in medical education seems to be to fill curricular time with lectures, seminars, and rotations; after all, there is so much for students to learn. Although well intentioned, such efforts may be counterproductive. Empirical studies show that increasing curricular flexibility without adversely affecting learning is possible. One of the best-known examples is at the Duke School of Medicine, where students have a dedicated year for scholarly work.5 Other institutions have also reduced curricular time while improving student outcomes.6

Students should have protected time to work on projects that they find meaningful throughout their training, including during clerkships. Schools should help students use this time to discover how they can make a positive difference by improving systems or creating innovations in clinical settings and/or local communities. Giving students opportunities to explore their interests can inspire them to solve large problems and keep them engaged in small ones.

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Managing a Stressful Environment

The work environment of medical school may be another source of anxiety. Medicine is an inherently stressful field. Students encounter life-and-death situations, interact with emotional patients and their families, and work with faculty who may themselves be highly stressed—all while learning the scientific foundations of human health and disease.

This pressure is often exacerbated by ineffective support from supervisors, particularly during clinical rotations. Although educators want the best for their students, the reality is that most physicians have minimal formal training on how to support trainees. As a result, clinical faculty often fail to recognize or capitalize on learning opportunities that are important for future physicians. For instance, one of the most emotionally heavy experiences a student can have is taking care of a dying patient. Yet a recent survey found that 84% of third-year medical students who cared for a patient who died never had an opportunity to discuss the experience with residents or faculty.7

Again, business schools provide important lessons. First and foremost, many management programs intentionally include explicit training on how to manage stressful situations.8 The most popular elective at Stanford’s Graduate School of Business, for example, forces students into uncomfortable interpersonal conflicts with their peers that they must resolve without faculty intervention. In other courses, students learn how to conduct difficult conversations such as those related to firing an employee, being passed over for a promotion, or experiencing professional failure. Although the scenarios may not involve life-and-death decisions, the same skills (e.g., understanding one’s personal reaction to stressful situations, learning behavioral approaches to sustaining optimism and moving on from mistakes, and gaining confidence in sharing uncertainty with colleagues8) are critical to develop resiliency in the high-stakes environment of medicine. Medical students, however, are expected to acquire such skills ad hoc as they encounter challenging situations on the job.

Along with skills development, business schools give students plentiful opportunities to reflect on their experiences. MBA students can then share what they have learned and experienced with classmates through multiple channels (e.g., classes dedicated to self-improvement, executive coaching sessions, informal conversations, and more). Many medical schools encourage such introspection but offer little protected time for it, and faculty provide little or no role modeling.

To their credit, some medical schools have taken steps to adapt. Georgetown’s Mind Body Medicine Program has had early success in promoting self-awareness and reducing stress among medical students,9 and Stanford has instituted programs ranging from peer counseling to designated time for supervised reflection. The new Kaiser Permanente School of Medicine has made wellness and resilience a major focus throughout its curriculum and even in the design of the building which features open spaces for interaction among faculty, students, and staff; quiet places for meditation; areas for casual exercise; and access to green space in an urban setting. On a national level, the Association of American Medical Colleges, the Accreditation Council for Graduate Medical Education, the National Academy of Medicine, and others have begun to develop resources to help schools and students prevent and reduce burnout.10

Many medical schools and national medical education organizations have made a commitment to developing a positive learning environment. We believe that lessons from business schools can help translate that commitment into results.

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Acknowledging the Importance of Career Opportunities

Finally, the growing availability of prestigious, well-compensated careers outside of medicine may cause considerable angst among medical students as they hear about the professional choices of their peers. While medical students go deeper into debt, spend late nights in the hospital, and ponder the many years of training still to come, their friends and former classmates earn promotions, buy homes, and start families.

Although late nights and many years of learning have always been earmarks of medical training, the opportunity costs have never been greater. Medical incomes have stagnated over the past few decades11 while high-paying jobs in finance, business, and, most recently, technology have reshaped the labor landscape for talented students. Comparisons are more vivid because staying in touch with friends has never been easier. The increased contact through social media creates a heightened awareness of the sacrifices required for a career in medicine.

Business schools offer two instructive ways to address career choice and personal finance concerns.12,13 First, they provide robust career counseling. Career centers gather and distribute data on salaries, work hours, prospects for promotion, and other factors across different jobs. Explicit discussions occur about weighing the social benefit and personal rewards of different choices. Second, business schools make a significant effort to connect students with mentors—including both faculty and alumni—from different professions. These role models offer guidance; provide support; afford realistic, honest insights into various careers; and serve as a sounding board on values and life choices. As a result, students have a clearer understanding of what lies ahead of them and have greater confidence that their school will support them.

By contrast, most medical schools offer limited counseling on practical career considerations. In our experience, students know little about how careers vary by specialty and practice setting. They learn from what they observe on clinical rotations, which is not always the typical (or best) representation of life in clinical practice.

At the same time, the values of medicine are lofty, reinforced by codes and ethical charters. A pervasive, implicit message is that physicians should make personal sacrifices to care for populations in need. While these values are central to the identity of the profession, physicians must inevitably make decisions based on their personal and family goals, which are too often dismissed as irrelevant. No safe place is available for holding a reproach-free discussion on the trade-offs of personal and social values. Students who voice questions may feel judged as “sellouts” or unscrupulous opportunists who are “going into medicine for the money.”

The result of this silent curriculum is an increasing inclination of medical students toward so-called lifestyle specialties that are widely perceived to have higher earnings and a better lifestyle.14 These choices may simply reflect a lack of exposure to the diverse opportunities for practice in other fields. For example, if given the right opportunities, students could learn that primary care in a well-managed group practice can be very rewarding and allow for work–life balance; they could meet specialists who have done well financially and still find ways to contribute to the safety net; and they could be inspired by physicians who are leaders in public health, policy, or corporate management. However, the academic setting, culture, and timeline of medical school often preclude these possibilities.

Medical students deserve honest, informed conversations about the realities of different career pathways. Topics like money and lifestyle matter, and students must learn how to think about them. Medical schools should take steps to change the current culture by improving and increasing formal discussions of professional choices and aspirations, by introducing career counseling, and by teaching basic financial skills. Simply having financial literacy and an understanding of how to evaluate alternatives can help ease students’ anxiety about their future, especially given the sizable loan burdens they face.

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Building a Better Medical School

Medical training is a long and demanding process, but one that can be improved. As medical schools seek to innovate and to improve the student experience, they can look to business schools as a source of ideas. The two forms of training are different, but some of those very differences present opportunities for reform. With the right approach, medical schools can educate more creative, more resilient, and more informed students, which, in turn, may produce a healthier, happier, and more productive physician workforce.

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Acknowledgments:

The authors wish to thank Sachin H. Jain, MD, MBA, for helpful suggestions to this Invited Commentary.

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References

1. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: A systematic review and meta-analysis. JAMA. 2016;316:2214–2236.
2. Chen DC, Kirshenbaum DS, Yan J, Kirshenbaum E, Aseltine RH. Characterizing changes in student empathy throughout medical school. Med Teach. 2012;34:305–311.
3. Graduate Management Admission Council. 2017 alumni perspectives survey report. http://www.gmac.com/market-intelligence-and-research/research-library/measuring-program-roi/2017-alumni-perspectives-survey-report.aspx. Published 2017. Accessed March 3, 2018.
4. Anderson E, Schiano B. Teaching With Cases: A Practical Guide. 2014.Brighton, MA: Harvard Business Publishing.
5. Laskowitz DT, Drucker RP, Parsonnet J, Cross PC, Gesundheit N. Engaging students in dedicated research and scholarship during medical school: The long-term experiences at Duke and Stanford. Acad Med. 2010;85:419–428.
6. Slavin SJ, Chibnall JT. Finding the why, changing the how: Improving the mental health of medical students, residents, and physicians. Acad Med. 2016;91:1194–1196.
7. Smith GM, Schaefer KG. Missed opportunities to train medical students in generalist palliative care during core clerkships. J Palliat Med. 2014;17:1344–1347.
8. Useem M, Cook J, Sutton L. Developing leaders for decision making under stress: Wildland firefighters in the South Canyon Fire and its aftermath. Acad Manag Learn Educ. 2005;4:461–485.
9. Chen AK, Kumar A, Haramati A. The effect of Mind Body Medicine course on medical student empathy: A pilot study. Med Educ Online. 2016;21:31196.
10. Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. National Academy of Medicine website. https://nam.edu/burnout-among-health-care-professionals-a-call-to-explore-and-address-this-underrecognized-threat-to-safe-high-quality-care/. Published July 5, 2017. Accessed March 3, 2018.
11. Johnson JP. Salary trend among medical professionals: 1998–2013. Economic Research Institute website. https://downloads.erieri.com/pdf/TrendsAmongMedicalProfessionals.pdf. Published 2013. Accessed February 23, 2018.
12. Stanford Graduate School of Business. MBA program career support. https://www.gsb.stanford.edu/programs/mba/career-impact/career-support. Accessed March 5, 2018.
13. Green M. Business schools help alumni over career bumps. Financial Times. May 11, 2017. https://www.ft.com/content/1de87b98-2c3f-11e7-bc4b-5528796fe35c. Accessed March 5, 2018.
14. Clinite KL, Reddy ST, Kazantsev SM, et al. Primary care, the ROAD less traveled: What first-year medical students want in a specialty. Acad Med. 2013;88:1522–1528.
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