David V. Power

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.

Relationship of pass/fail grading and curriculum structure with well-being among preclinical medical students: A multi-institutional study

Purpose Psychological distress is common among medical students. Curriculum structure and grading scales are modifiable learning environment factors that may influence student well-being. The authors sought to examine relationships among curriculum structures, grading scales, and student well-being. Method The authors surveyed 2,056 first- and second-year medical students at seven U.S. medical schools in 2007. They used the Perceived Stress Scale, Maslach Burnout Inventory, and Medical Outcomes Study Short Form (SF-8) to measure stress, burnout, and quality of life, respectively. They measured curriculum structure using hours spent in didactic, clinical, and testing experiences. Grading scales were categorized as two categories (pass/fail) versus three or more categories (e.g., honors/pass/fail). Results Of the 2,056 students, 1,192 (58%) responded. In multivariate analyses, students in schools using grading scales with three or more categories had higher levels of stress (beta 2.65; 95% CI 1.54–3.76, P < .0001), emotional exhaustion (beta 5.35; 95% CI 3.34–7.37, P < .0001), and depersonalization (beta 1.36; 95% CI 0.53–2.19, P = .001) and were more likely to have burnout (OR 2.17; 95% CI 1.41–3.35, P = .0005) and to have seriously considered dropping out of school (OR 2.24; 95% CI 1.54–3.27, P < .0001) compared with students in schools using pass/fail grading. There were no relationships between time spent in didactic and clinical experiences and well-being. Conclusions How students are evaluated has a greater impact than other aspects of curriculum structure on their well-being. Curricular reform intended to enhance student well-being should incorporate pass/fail grading.

A multi-institutional study exploring the impact of positive mental health on medical students' professionalism in an era of high burnout.

Purpose Although burnout is associated with erosion of professionalism and serious personal consequences, whether positive mental health can enhance professionalism and how it shapes personal experience remain poorly understood. The study simultaneously explores the relationship between positive mental health and burnout with professionalism and personal experience. Method The authors surveyed 4,400 medical students at seven U.S. medical schools in 2009 to assess mental health (categorized as languishing, moderate, and flourishing) and burnout. Additional items explored professional behaviors, beliefs, suicidal ideation, and serious thoughts of dropping out. Results A total of 2,682/4,400 (61%) responded. Prevalence of suicidal ideation (55/114 [48.2%], 281/1,128 [24.9%], and 127/1,409 [9.1%]) and serious thoughts of dropping out (15/114 [13.2%], 30/1,128 [2.7%], and 14/1,409 [1.0%]) decreased as mental health improved from languishing, moderate, and flourishing, respectively (all P < .0001); this relationship between personal experience and mental health persisted independent of burnout (all P < .001). As mental health improved, the prevalence of unprofessional behaviors (i.e., cheating and dishonest behaviors) also declined, whereas students’ altruistic beliefs regarding physicians’ responsibility toward society improved. For example, 33/113 (29.2%), 426/1,120 (38.0%), and 718/1,391 (51.6%) of students with languishing, moderate, and flourishing mental health endorsed all five altruistic professional beliefs (P < .0001). The relationship between professional beliefs and mental health persisted among students with burnout, whereas fewer relationships were found among students without burnout. Conclusions Findings suggest that positive mental health attenuates some adverse consequences of burnout. Medical student wellness programs should aspire to prevent burnout and promote mental health.

Suitable screening tests for cognitive impairment and depression in the terminally ill- a prospective prevalence study

Although confusional states and depression are common accompaniments of advanced cancer, few objective data are available concerning the prevalence of these clinical states or what methods are most suitable for their accurate detection. We decided that a 10-question Abbreviated Mental Test Score (AMTS) and a semistructured application of modified DSMIII-R (Diagnostic and Statistical Manual of Mental Disorder, third edition - revised) criteria for a major depressive illness were the most suitable screening tests for a terminally ill population. Thirty of 87 patients (34%) displayed significant cognitive impairment. The AMTS rating declined with approaching death and also correlated negatively with age. Of 81 patients, 21 (26%) were depressed when screened using DSMIII-R criteria for depression. One-third of patients with impaired AMTS scores also satisfied DSMIII-R criteria for depression. Of cognitively impaired patients, 90% had at least two possible causes for their confused state. We have found that both the AMTS and semistructured interview using DSMIII-R criteria for depression are useful routine screening tests in the terminally ill.

Are medical students comfortable with practicing physical examinations on each other

Purpose To assess medical student attitudes toward, and comfort with, taking turns practicing peer physical examinations (PPEs) on fellow classmates. Method A questionnaire with 25 Likert-scaled questions was administered to 164 end-first-year medical students at the University of Minnesota, Minneapolis. Topics assessed included: (1) comfort with various aspects of PPEs; (2) attitudes regarding the professionalism, appropriateness, and perceived value of PPEs; (3) attitudes toward peer breast, genital, and rectal exams; and (4) the effects of age and gender on response. Results Of the 164 students surveyed, 124 (76%) responded. Almost all (98%) agreed that PPEs are appropriate, valuable, and a comfortable experience. Fewer students were comfortable with performing inguinal examinations and conducting PPEs with students of the opposite gender. Twelve percent of the students expressed difficulty in setting limits with peers, and 48% felt exposed when undressed as an examination model in front of a group of peers. The majority of students were opposed to peer breast, genital, and rectal examinations. Some statistically significant gender differences and age/gender interactions were observed. Conclusion Results suggest that this sample of medical students was very comfortable with PPEs and willing to participate in PPEs, although a few students were uncomfortable with these examinations. No extensive curricular change appears warranted, though steps can be taken to maximize overall student comfort and to accommodate the few students who do not favor PPEs.

Comparing rural-trained medical students with their peers: Performance in a primary care OSCE

Background: Although it is well-established and considered successful, there is limited data on how the graduates of a Minnesota rural medical education program (Rural Physician Associate Program [RPAP]) compare with their peers. Purpose: To compare the performance of RPAP students with their peers on a primary care observed structured clinical examination (OSCE). Methods: The performances of RPAP students and a group of non-RPAP Year 4 medical students were compared on the same OSCE. Results: RPAP students performed at least as well as their peers on stations assessing performance on common primary care clinical scenarios but not as well on a small number of stations that assessed applied knowledge of specific content taught in the traditional clerkship curriculum. Conclusions: We provide evidence that rurally trained students at this institution performed at least as well as their peers on OSCE stations testing performance in common primary care scenarios. The broader implications of this study are that medical students may receive high-quality training in rural communities, as documented by their performance on an objective structured clinical examination.