Burnout and Suicidal Ideation among U.S. Medical Students

In a recent study, Dyrbye et al looked at burnout and suicidal ideation among medical students in the United States (1).

I am very interested to know if the rate of burnout varied amongst the students in different years of training. The Maslach Burnout Inventory (MBI) is based on the theory that in helping professions, frequent intense interactions with clients that are "charged with feelings of anger, embarrassment, fear, or despair and with solutions for the clients' problems that are not always obvious or easy to obtain. For the person who works continuously with clients under such circumstances, the chronic stress can be emotionally draining and can lead to burnout(2)."

Based on these considerations, one would anticipate that first and second year students, having very few interactions with patients, should have much less burnout using the MBI than other students. If the first and second year students do have a high level of burnout, then it may be a function of either a poor match between MBI questions and their experience or their burnout being driven by work-tedium rather than intense patient interactions. The MBI-general survey was developed for professions with "only casual contact with people" and evaluates work-tedium and performance and may be a useful instrument in these individuals(2). Third year students might have the highest level of MBI burnout since that is the most intensive clinical year. Burnout levels might decline in the fourth year as students have more autonomy, which has been associated with less burnout (3).

References:

1. Dyrbye L, Thomas M, Massie F et al. Burnout and Suicidal Ideation among U.S. Medical Students. Ann Intern Med. 2008;149:334-341.

2. Maslach C and Jackson SE. Maslach burnout inventory manual. 3rd Ed. Palo Alto, Ca: Consulting Psychology Press; 1986.

3. Shirom A, Nirel N, and Vinokur A. Overload, Autonomy, and Burnout as Predictors of Physicians' Quality of Care. Journal of Occupational Health Psychology. 2006, Vol. 11, No. 4, 328"“342

Conflict of Interest:

None declared

To the Editor: I was astounded to read that the suicide rate of medical students and physicians in our country is so high. When I attended medical school there were far fewer places available for aspiring physicians than currently exist. I believe that the motivation to be a physician was therefore greater; and perhaps as a result, the will and ability to survive the strain was stronger. Additionally, there was far less to learn at the time, and medicine has taken great leaps forward since 1956, when I graduated. My non-scientific observation is that of the hundreds of medical students, house physicians, and colleagues that I have known in the past 56 years, I've known none that have committed suicide.

Conflict of Interest:

None declared

We commend Dyrbye and colleagues (1) on their important work linking burnout to suicidal ideation among medical students. To assist educators in addressing this issue, we wondered if there were any observable differences between students who reported "chronic burnout" and those who "recovered from burnout." For example, do more resilient students have marital support or lower educational debt? We also found it especially noteworthy that higher levels of educational debt were associated with increased suicidal ideation in this study (1). It is plausible that high educational debt may act as a chronic stressor, contributing to the persistent nature of burnout in certain students. In support of this hypothesis, another recent study observed an association between anticipated debt and perceived financial stress suggesting that anxieties about future debt also contribute to student stress (2). This highlights the need to consider how to prepare students with higher debt to address this mental stressor.

In addition to exploring these factors, it is also important to understand how much of recovery from burnout is a natural part of completing the stressful, and predominantly clinical third year. Indeed, students in their third year had increased suicidal ideation than those in other years (1). In an insightful review, three of the authors of this study discuss the myriad of causes leading to medical student moral distress (3). During the clinical years, however, moral or ethical distress may play an especially subtle but substantial role in student well-being (4). Using the cardiac stress test as an analogy, clinical clerkships may inadvertently act as an "ethical stress test" that "risk-stratifies" those students who are particularly susceptible to poor resilience, cynicism, and burnout as future resident physicians. Given the new accreditation requirement to "periodically assess the learning environment" at U.S. medical schools (5), the extent of burnout and resilience among students might serve as useful proxy to "risk-stratify" even medical schools"”particularly those schools with learning environments that are at high-risk for eroding student well-being and promoting burnout.

This study therefore raises the importance of further research that investigates the specific contributions of financial and moral stress in promoting burnout. Through more work like this, medical educators will be better able to target those students burdened with high educational debt or those exhibiting poor resiliency from burnout. Indeed, early interventions are particularly important before high-risk students become burned-out residents responsible for patient care.

References:

(1) Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149:334-41. [PMID: 18765703]

(2) Morra DJ, Regehr G, Ginsburg S. Anticipated debt and financial stress in medical students. Med Teach. 2008;30:313-5. [PMID: 18484459]

(3) Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: causes, consequences, and proposed solutions. Mayo Clin Proc. 2005;80:1613 -22. [PMID: 16342655]

(4) Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students' perceptions of their ethical environment and personal development. Acad Med. 1994;69:670-9. [PMID: 8054117]

(5) Liason Committee on Medical Education. Accreditation standards. Chicago, IL and Washington, DC: American Medical Association and Association of American Medical Colleges; 2007. Accessed http://www.lcme.org/standard.htm on 23 September 2008.

Conflict of Interest:

None declared

We thank Drs. Yoon and Arora for their thoughtful letter. We agree that debt is a substantial source of stress for today's medical student. As reported, students reporting >$100,000 of educational debt had a 1.47 greater odds of suicidal ideation during the previous year than students with <$50,000 in reported debt on univariate analysis. Despite this association, debt was not independently associated with suicidal ideation during the previous year on multi-variate analysis. The amount of debt students reported was associated with other factors such as age, relationship status, parental status, year in school, and burnout (all p <0.02). This observation suggests the relationship between debt and suicidal ideation may be mediated through interactions between debt and burnout or other characteristics rather than directly. This possibility is worthy of further study. We also believe it is important to identify what personal and professional characteristics are associated with recovery from burnout. It is hoped this information can inform efforts to assist struggling students. We are in the process of performing a comprehensive formal analysis of this aspect which will be the subject of a future manuscript.

Conflict of Interest:

None declared