Daniel W. Szydlo

Burnout and Suicidal Ideation among U.S. Medical Students

Death by suicide is a major occupational hazard for physicians (1). The suicide rate among male physicians is more than 40% higher than among men in the general population, whereas that of female physicians is a staggering 130% higher than among women in the general population (1, 2). The increased risk for suicide among physicians may begin during medical school (3). Available studies suggest that the suicide rate among medical students is higher than in the age-matched population (35). Other small, single-institution studies (610) have reported that 3% to 15% of medical students have suicidal ideation during medical school training. Suicidal ideation is a well-established predictor of suicidal planning and attempts. The National Comorbidity Survey found that 34% of individuals in the general population with suicidal ideation develop a suicide plan and, of those who plan, more than 70% will attempt suicide (11). Notably, 26% of individuals with suicidal ideation progressed directly to an unplanned suicide attempt (11). Suicide is at the extreme end of the personal distress continuum, and it is critical for medical schools to identify students at greatest risk for suicide in the hope of intervening before a tragic outcome. Several multi-institutional studies (1214) reveal that medical students have a substantially lower mental quality of life than similarly aged individuals in the general population and that burnout affects up to 50% of U.S. medical students. We hypothesized that burnout would relate to suicidal ideation among medical students. We used a mixed longitudinal and cross-sectional study design to evaluate the prevalence of suicidal ideation among U.S. medical students and to evaluate the relationship between suicidal ideation and burnout, symptoms of depression, and quality of life. Our objective was to assess the frequency of suicidal ideation among medical students and explore its relationship with burnout. Methods Participants In the spring of 2006 (baseline) and 2007 (1-year follow-up), we invited all medical students at the Mayo Medical School, University of Washington School of Medicine, University of Chicago Pritzker School of Medicine, University of Minnesota Medical School, and University of Alabama School of Medicine to complete Web-based surveys. Students at the University of California San Diego School of Medicine and Uniformed Services University of the Health Sciences also participated in the 2007 survey. Participation was elective, and responses were anonymized. We included all students who responded to the 2007 survey in the cross-sectional analysis and those who responded in both 2006 and 2007 in the longitudinal analysis. Each institutions institutional review board approved the study before participation of their students. Data Collection Participants returned the surveys electronically. Preserving student confidentiality was an essential feature. We linked individual responses on the 2006 and 2007 surveys for longitudinal analysis by using unique identifiers and stripped all data of identifiers before forwarding them to study statisticians for analysis. Study Measures We used established instruments to measure burnout, symptoms of depression, and quality of life on both the 2006 and 2007 surveys. These surveys also included questions about demographic characteristics, and the 2007 survey included questions about suicidal ideation. Suicidal Ideation We assessed suicidal ideation by asking students: Have you ever had thoughts of taking your own life, even if you would not really do it?, During the past 12 months have you had thoughts of taking your own life?, and Have you ever made an attempt to take your own life? These questions, which originated from an inventory developed by Meehan and colleagues (15) that has been used to assess suicidal ideation among medical students (9), are similar to questions used in large U.S. epidemiologic studies intended to assess suicidality (11, 1618). Burnout, Symptoms of Depression, and Quality of Life The Maslach Burnout Inventory is a 22-item instrument that is considered the gold standard for measuring burnout (1921). This instrument has separate subscales to evaluate each domain of burnout: emotional exhaustion, depersonalization, and low personal accomplishment. Tests of discriminant and convergent validity have been acceptable, construct validity of the 3 dimensions has been demonstrated (22, 23), and predictive validity has been suggested by burnout score predicting risk for future sick leave absences (24). The Maslach Burnout Inventory has also been used extensively in studies of both physicians (20,21, 25) and medical students (13, 14, 2628). According to convention, a score of 27 or higher on the emotional exhaustion subscale or 10 or higher on the depersonalization subscale was considered an indicator of professional burnout for medical professionals (19). Health professionals are considered to have a low score on the personal accomplishment scale if their score is 33 or less. Normal scores for health care professionals, including physicians, are 22.19, 7.12, and 36.53 on the emotional exhaustion, depersonalization, and personal accomplishment subscales, respectively (19). We identified symptoms of depression by using the 2-item Primary Care Evaluation of Mental Disorders (29), a screening tool which performs as well as longer instruments (30). This instrument has a sensitivity of 86% to 96% and a specificity of 57% to 75% for major depressive disorder (29, 30). With a reported positive likelihood ratio of up to 3.42 for the diagnosis of major depression (30) and an estimated 25% prevalence of depression among medical students (12), a positive result implies a 50% probability of current major depression. We measured mental and physical quality of life by using the Medical Outcomes Study Short Form-8 (SF-8) (31, 32), an alternate version of the SF-36. Norm-based scoring methods of responses on this instrument are used to calculate mental and physical quality of life summary scores (31). The mean mental and physical quality of life summary scores for the U.S. population are 49.2 (SD, 9.46) and 49.2 (SD, 9.07), respectively (31). Previous research has demonstrated acceptable reliability and testretest reliability (31). Several studies (31) have demonstrated content, construct, and criterion-related validity for the SF-8, and other studies (33) have demonstrated high convergent validity and good discriminate validity. The SF-8 has also been used in samples of residents (32) and medical students (14, 27, 28). Statistical Analysis Our primary analysis involved descriptive summary statistics for estimating the prevalence of suicidal ideation, burnout, a positive depression screen, and mental and physical quality of life for medical students. We evaluated differences by reported suicidal ideation in the previous year by using the WilcoxonMannWhitney test (for continuous variables) and the Fisher exact test (for categorical variables). We used the Wilcoxon rank-sum test rather than parametric tests to account for the interval level nature of the psychological tests. All tests were 2-sided, with a type I error rate of 0.05. We performed collinearity testing to determine whether multiple-way collinearity existed among the independent variables (34). No variables had achieved a level of collinearity that would bias the modeling process. We performed forward stepwise logistic regression to evaluate independent associations of the independent variables with suicidal ideation. We used a saturated model and backward stepping to confirm results of the initial stepwise regression. In all cases, backward stepping produced the same model as the stepwise approach. All analyses were done by using SAS, version 9 (SAS Institute, Cary, North Carolina). Role of the Funding Source This work was supported by an Education Innovation award from the Mayo Clinic. The Mayo Clinic played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation of the manuscript or decision to publish the manuscript. Results Cross-Sectional Survey A total of 2248 (52.4%) of 4287 medical students responded to the 2007 survey. Responders were less likely than the overall population to be male (51.6% vs. 54.9%), between 25 and 30 years of age (55.4% vs. 62.4%), or nonwhite (25.8% vs. 31.0%) (all P< 0.02). Table 1 shows the demographic characteristics of cross-sectional survey respondents. Table 1. Participant Characteristics, 2007 Table 2 shows the percentage of responders reporting suicidal ideation, burnout, and symptoms of depression and the mean quality-of-life scores. Of the 2230 responders on the 2007 survey who responded to questions on suicidal ideation, 249 (11.2% [CI, 9.9% to 12.6%]) reported considering suicide in the previous year and 43 (1.9% [CI, 1.4% to 2.6%]) had made a suicide attempt at some point in the past. On sensitivity analysis, assuming that all nonresponders did not have suicidal ideation, the prevalence of suicidal ideation in the past 12 months would be 249 (5.8%) of 4287 students. Table 2. Burnout, Quality of Life, and Depression Symptoms, 2007 Overall, 1069 (49.6%, [CI, 47.5%51.8%]) of 2154 students met the criteria for burnout (94 students did not answer enough Maslach Burnout Inventory questions to be included in this analysis). Among these students, 860 (40.1%) of 2142 had high emotional exhaustion, 648 (31.8%) of 2037 had high depersonalization, and 595 of 1945 (30.6%) had a low sense of personal accomplishment. Compared with age-comparable individuals and the general U.S. population, medical students had lower mental quality-of-life scores (mean, 43.5 [SD, 11.0] vs. 47.2 [SD, 9.9] for age-comparable individuals [P< 0.001] and 49.2 [SD, 9.5] for the general U.S. population [P< 0.001]) but higher physical quality-of-life scores (mean, 52.2 [6.9] vs. 51.4 [SD, 7.9] for age-comparable

Burnout and serious thoughts of dropping out of medical school: A multi-institutional study

Purpose Little is known about students who seriously consider dropping out of medical school. The authors assessed the severity of thoughts of dropping out and explored the relationship of such thoughts with burnout and other indicators of distress. Method The authors surveyed medical students attending five medical schools in 2006 and 2007 (prospective cohort) and included two additional medical schools in 2007 (cross-sectional cohort). The survey included questions about thoughts of dropping out, life events in the previous 12 months, and validated instruments evaluating burnout, depression symptoms, and quality of life (QOL). Results Data were provided by 858 (65%) students in the prospective cohort and 2,248 (52%) in the cross-sectional cohort. Of 2,222 respondents, 243 (11%) indicated having serious thoughts of dropping out within the last year. Burnout (P < .0001), QOL (P < .003 each domain), and depressive symptoms (P < .0001) at baseline predicted serious thoughts of dropping out during the following year. Each one-point increase in emotional exhaustion and depersonalization score and one-point decrease in personal accomplishment score at baseline was associated with a 7% increase in the odds of serious thoughts of dropping out during the following year. On subsequent confirmatory multivariable analysis, low scores for personal accomplishment, lower mental and physical QOL, and having children were independent predictors of students having serious thoughts of dropping out during the following year. Conclusions Approximately 11% of students have serious thoughts of dropping out of medical school each year. Burnout seems to be associated with increased likelihood of serious thoughts of dropping out.

The learning environment and medical student burnout : a multicentre study

Objectives  Little is known about specific personal and professional factors influencing student distress. The authors conducted a comprehensive assessment of how learning environment, clinical rotation factors, workload, demographics and personal life events relate to student burnout.

Factors associated with resilience to and recovery from burnout: a prospective, multi-institutional study of US medical students

Medical Education 2010: 44: 1016–1026

Patterns of distress in US medical students

Background: How multiple forms of psychological distress coexist in individual medical students has not been formally studied. Aim: To explore the prevalence of various forms of distress in medical students and their relationship to recent suicidal ideation or serious thoughts of dropping out of school. Methods: All medical students at seven US schools were surveyed with standardized instruments to evaluate burnout, depression, stress, mental quality of life (QOL), physical QOL, and fatigue. Additional items explored recent suicidal ideation and serious thoughts of dropping out of medical school. Results: Nearly all (1846/2246, 82%) of medical students had at least one form of distress with 1066 (58%) having ≥3 forms of distress. A dose-response relationship was found between the number of manifestations of distress and recent suicidal ideation or serious thoughts of dropping out. For example, students with 2, 4, or 6 forms of distress were 5, 15, and 24 fold, respectively, more likely to have suicidal ideation than students with no forms of distress assessed. All forms of distress were independently associated with suicidal ideation or serious thoughts of dropping out on multivariable analysis. Conclusions: Most medical students experience ≥1 manifestation of distress with many experiencing multiple forms of distress simultaneously. The more forms of distress experienced the greater the risk for suicidal ideation and thoughts of dropping out of medical school.

Development and preliminary psychometric properties of a well-being index for medical students

BackgroundPsychological distress is common among medical students but manifests in a variety of forms. Currently, no brief, practical tool exists to simultaneously evaluate these domains of distress among medical students. The authors describe the development of a subject-reported assessment (Medical Student Well-Being Index, MSWBI) intended to screen for medical student distress across a variety of domains and examine its preliminary psychometric properties.MethodsRelevant domains of distress were identified, items generated, and a screening instrument formed using a process of literature review, nominal group technique, input from deans and medical students, and correlation analysis from previously administered assessments. Eleven experts judged the clarity, relevance, and representativeness of the items. A Content Validity Index (CVI) was calculated. Interrater agreement was assessed using pair-wise percent agreement adjusted for chance agreement. Data from 2248 medical students who completed the MSWBI along with validated full-length instruments assessing domains of interest was used to calculate reliability and explore internal structure validity.ResultsBurnout (emotional exhaustion and depersonalization), depression, mental quality of life (QOL), physical QOL, stress, and fatigue were domains identified for inclusion in the MSWBI. Six of 7 items received item CVI-relevance and CVI-representativeness of ≥0.82. Overall scale CVI-relevance and CVI-representativeness was 0.94 and 0.91. Overall pair-wise percent agreement between raters was ≥85% for clarity, relevance, and representativeness. Cronbachs alpha was 0.68. Item by item percent pair-wise agreements and Phi were low, suggesting little overlap between items. The majority of MSWBI items had a ≥74% sensitivity and specificity for detecting distress within the intended domain.ConclusionsThe results of this study provide evidence of reliability and content-related validity of the MSWBI. Further research is needed to assess remaining psychometric properties and establish scores for which intervention is warranted.

Efficacy of a brief screening tool to identify medical students in distress

Purpose To determine whether the Medical Student Well-Being Index (MSWBI) can serve as a brief assessment tool to identify medical students in severe psychological distress. Method The authors used data from 2,248 medical students at seven U.S. medical schools who responded to a 2007 survey to explore the accuracy of the MSWBI in identifying medical students with three outcomes: low mental quality of life (QOL; defined by having a Medical Outcomes Study Short-Form Health Survey mental component summary score ≥1/2 standard deviation below that of the age- and gender-matched population norm), suicidal ideation, or serious thoughts of dropping out. The authors confirmed their analyses using data from a separate sample of 2,682 students evaluated in 2009. Results Students with low mental QOL, suicidal ideation, or serious thoughts of dropping out were more likely to endorse each individual MSWBI item and a greater number of total items than were students without such distress (all P < .001). The likelihood ratio for low mental QOL among students with MSWBI scores <4 was 0.47 as compared with 4.79 for those with scores ≥4. At an MSWBI threshold score of ≥4, the MSWBIs sensitivity and specificity for identifying students with low mental QOL or recent suicidal ideation/serious thoughts of dropping out were both ≥90%. On multivariable logistic regression, all MSWBI items were independently associated with at least one outcome. Conclusions The MSWBI is a useful brief screening tool to help identify students with severe distress.

Factors associated with resilience to and recovery from burnout

Medical Education 2010: 44: 1016–1026

Factors associated with resilience to and recovery from burnout: a prospective, multi-institutional study of US medical students: Resilience in medical students

Medical Education 2010: 44: 1016–1026