Potential causes

The practice of medicine can be very stressful whatever the discipline. Molodynski and colleagues suggested that high levels of stress when dealing with life and death situations can contribute to a poor sense of self-accomplishment on a daily basis (Molodynski et al. 2019). Increased administration tasks that eat into patient contact time can add to frustration and stress. Anxiety can follow and the alternation of high risk and high intensity work with mundane bureaucracy can create substantial tension in some individuals. This in turn can lead to physical and psychological symptoms of anxiety. Burnout itself may manifest with symptoms of anxiety, but sufferers are also likely to be in despair and have low mood. As the stress diathesis hypothesis describes, cumulative stress can lead to depression. This can feed into a vicious cycle where no praise is forthcoming and students and doctors may face complaints and abuse, especially in public healthcare systems.

Changing patient expectations can add stress as constrained resources may not allow optimal care. Unrealistic expectations of the therapeutic encounter from the media and internet can ‘turbocharge’ such dissonance. If medical students see their seniors under pressure, they may feel disenchanted. Technical developments, such as Artificial Intelligence (AI), may be extremely helpful in some medical specialties but create more problems in others. Anecdotal evidence suggests that medical students often feel challenged by technical advances. The increasing use of simulation is clearly positive in many ways but may result in issues by limiting ‘fully genuine’ contacts during medical school. Algorithm-based clinical decisions can be equally helpful but patients of course do not behave in the same way or like their algorithms so they are certainly not a solution for all.

Mundane routine work interspersed with complex urgent tasks can contribute to an increased likelihood of burnout, especially if the individual feels they have little autonomy. The individual may feel trapped and under constant pressure without facilities or opportunities to wind down, creating a ‘perfect storm’ to increase the risk of illness. Certain personality traits such as obsessive and perfectionistic traits (which are relatively common among doctors and medical students) can also contribute to burnout. A particularly difficult challenge for doctors and medical students is that of being supportive and empathic while also being technical and professional.

Stages of burnout

Three stages of burnout have been identified, though in reality they merge. The first stage of stress arousal can be identified by poor concentration, memory lapses, irritability, and anxiety. This may be followed by the second stage with avoidance, lateness, and social withdrawal when students do not attend their classes or wards. The third stage is characterised by anxiety, depression, apathy, and suicidal ideation.

Rates of burnout

Studies from different parts of the world using fairly similar methods have shown unexpectedly high rates of burnout among medical students. These countries included Brazil (Casteldelli-Maia et al. Reference Castaldelli-Maia, Lewis, des Santos, Picon, Kadhum, Farrell, Molodynski and Ventriglio2019), Canada (Wilkes et al. Reference Wilkes, Lewis, Brager, Bulloch, MacMaster, Paget, Holm, Farrell and Ventriglio2019; Wilkes et al. Reference Wilkes, Lewis, Paget, Holm, Brager, Bulloch, Macmaster, Molodynski and Bhugra2021), England (Farrell et al. Reference Farrell, Kadhum, Lewis, Singh, Penzenstadler and Molodynski2019b), India (Farrell et al. Reference Farrell, Kar, Valsraj, Mukherjee, Kunheri, Molodynski and George2019a), Italy (Volpe et al. Reference Volpe, Ventriglio, Bellomo, Kadhum, Lewis, Molodynski, Sampogna and Fiorillo2019), Jordan (Masri et al. Reference Masri, Kadhum, Farrell, Khamees, Al-Talar and Molodynski2019),Morocco (Chellieh et al. Reference Chellieh, Kadhum, Lewis, Molodynski, Abouqal, Belayachi and Bhugra2019, New Zealand (Farrell et al. Reference Farrell, Moir, Molodynski and Bhugra2019c), Nigeria (Esan et al. Reference Esan, Folasire and Oluwajulugbe2019; Ayinde et al. Reference Ayinde, Akinnuoye, Molodynski, Battrick and Gureje2021), Paraguay (Torales et al. Reference Torales, Kadhum, Zarate, Barrios, Gonzalez, Farrell, Ventriglio and Arce2019), and Portugal (Almeida et al. Reference Almeida, Kadhum, Farrell, Ventnglio and Molodynski2019). In a more recent series of surveys from more countries, similar findings have emerged from Georgia (Berdzenishvili et al. Reference Berdzenishvili, Kadhum, Molodynski and Bhugra2021), India (Phillip et al. Reference Philip, Molodynski, Barklie, Bhugra and Chaturvedi2021), Indonesia (Kloping et al. Reference Kloping, Citraningtyas, Lili, Farrell and Molodynski2021), Iran (Ashrafi et al. Reference Ashrafi, Kadhum, Molodynski and Bhugra2021), Nepal (Kafle et al. Reference Kafle, Bagale, Kadhum and Molodynski2021), and Russia (Chumakov et al. Reference Chumakov, Petrova, Mamatkhodjaeva, Ventriglio, Bhugra and Molodynski2021). A note of caution is indicated as these studies are based on online surveys for which it is possible that those suffering are more likely to respond introducing potential selection bias. Reassuringly, systematic reviews by Chunming (Chunming et al. Reference Chunming, Harrison, MacIntyre, Travaglia and Balasooriya2017) and IsHak (IsHak et al. Reference IsHak, Nikravesh, Lederer, Perry, Ogunyemi and Bernstein2013) have also suggested high rates of burnout among medical students.

Causative factors

The surveys mentioned earlier described four broad types of causative factor: relationships (with peers and parents), financial pressures, accommodation, and studies. Although overall reported stress was high in all countries, the exact nature of stressors did show variation.

In a qualitative study from the UK, the following five factors for burnout among doctors and medical students were identified (Bhugra et al. Reference Bhugra, Sauertig, Bland, Lloyd-Kendall, Wijesuriya, Singh, Kochhar, Molodynski and Ventriglio2019):

1. 1. Systemic factors: These included problems with structures and systems. Medical students felt that they were not seen as part of a team and felt that they were a burden on already over-burdened staff thus adding to a sense of low self-worth.

2. 2. Occupational: Repeated brief rotations added to stress as well as not getting enough time to become embedded in teams.

3. 3. Interpersonal factors: Difficulties in forming relationships as short rotations created difficulties and became stressors.

4. 4. Environmental factors: Practical issues such as lack of workspace or base and poor access to rest and nutritious diet contributed to feeling unwanted and uncared for.

5. 5. Sociocultural: Working out of context and not being aware of the culture of a ward or team added to the stress.

There are ongoing academic stressors throughout the whole of the medical student period with an ever increasing scholastic workload, competition to achieve high scores in order to get the right career pathway, multiple high stake examinations, and expectations of teachers and parents. In clinical years, unfamiliar environments, poor teaching, limited supervision and mentoring, and poor role models all affect functioning and engagement. As mentioned earlier, contributory personal factors include leaving home and consequently existing support systems with friends, siblings and parents. Lack of support and friendships in a new place can lead to isolation and loneliness and create a sense of alienation. Excessive use of alcohol and/or cannabis to cope with anxiety and exhaustion is common, though very variable across countries.

Consequences

Feeling exhausted and tired can lead to a number of negative outcomes such as medical errors that cause harm to patients (Dyrbye et al. Reference Dyrbye, Massie, Eacker, Harper, Power, Durning, Thomas, Moutier, Satele, Sloan and Shanafelt2010, West et al. Reference West, Tan, Habermann, Sloan and Shanafelt2009, Shanafelt et al. Reference Shanafelt, Balch, Bechamps, Russell, Dyrbye, Satele, Collicott, Novotny, Sloan and Freischlag2010). This can leave the individual feeling guilty and depressed and even suicidal (Dyrbye et al. Reference Dyrbye, Thomas, Massie, Power, Eacker, Harper, Durning, Moutier, Szydlo, Novotny, Sloan and Shanafelt2008, Shanafelt et al. Reference Shanafelt, Balch and Dyrbye2011). It has been suggested that burnout affects clinicians’ empathy (Wilkinson et al Reference Wilkinson, Whittington, Perry and Eames2017). It can lead to medical students' missing activities completely or them showing up late for ward rounds and teaching (Stevens Reference Stevens2016). There may be bursts of temper and clinical rage. Internalisation of anger and frustration may lead to depression and suicidal ideation. In addition, those affected may react poorly to criticism or negative feedback (Brotheridge and Grundy Reference Brotheridge and Grandey2002). Burnout thus may alienate them further, and unless clinical and educational supervisors are aware of the condition and its impact, the issues can worsen and may lead to students leaving their courses.

What can we do?

Bargagliotti (Reference Bargagliotti2012) and Spence-Laschinger et al. (Reference Spence-Laschinger, Wilk, Cho and Greco2009) have described the concept of engagement and contrasted it to burnout. Their argument is that engagement is a state of vigour and dedication. Engagement and resilience go hand in hand, with resilience being the ability of an individual to adapt to change and stress and manage it in a way that does not cause harm to themselves or others.

Strategies to prevent burnout and deal with it need to be seen at three levels: personal, organisational, and institutional and governmental.

At the governmental level, there must be clear policies to support students and staff. Medical schools must be supported in looking after medical students’ mental health needs and well-being. Appropriate occupational health services should be adequately and sustainably funded. Regulatory bodies must also play a role. Educational authorities must ensure that their resources for student support are sufficient and appropriate and easily accessible.

At the organisational level, it is important that support systems are both readily available and advertised widely. Confidentiality in these services is crucial. Institutional policies must recognise and prioritise the well-being and mental health of students, and staff and students should be empowered to set up well-being programmes and offices. Well-being guardians may be appointed and better communication must be encouraged. Prevention of bullying, harassment, and discrimination is a must both in policy and in action. Zero bullying policies and actions must be implemented. Many universities and medical schools have departments of education and occupational medicine, and these could (and often do) form the core of any programme to develop and deliver mental health and well-being support.

At an individual level, medical students must be helped to understand how to look after themselves, their health, and their mental well-being as part of their curriculum. The importance of basic things such as good sleep, exercise, and good nutritious food cannot be over-emphasised. Access to decent food and rest facilities are a crucial responsibility of medical schools and NHS providers who train students and have been long neglected. Students can be encouraged to be aware of and develop their own strategies for preventing burnout such as physical exercise, listening to music, reading books, yoga, meditation, spending time in nature, and mindfulness. Time and space must be carved out for students to recognise and identify their stress and then manage it before it becomes a problem. Recognising one’s own weaknesses and vulnerabilities as well as strengths can only help an individual to become a better and more empathic doctor. Peer support and belonging to professional organisations to gain a collective voice can help. Career advice and encouraging students to develop a portfolio of interests can help. These can be a mixture of academic, teaching, political, managerial, or policy development activities.

It is important to bear in mind that solutions will have to be modified according to cultural variations and resources. It is important that medical students' well-being is an essential part of their curriculum and that they are taught to look after themselves so that they can look after others.