Medical students' mental health is a topic of great interest as it has implications not only for medical students but also for the patients of these future doctors. Medical students face many academic pressures and burnout is one possible consequence of these stressors with some studies suggesting that burnout affects up to 50% of medical students. Our own study of American students in a medical programme located outside of the U.S. showed that student perceptions of the medical learning environment were linked with burnout suggesting that reducing burnout requires a pedagogical approach that addresses academically related stress factors. This chapter contends that one institutional strategy to prevent problems such as burnout is to adopt a theory-based approach to instructional design that addresses the causes of medical student stress and burnout from the instructional side.
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Burnout has been described as ‘a psychological syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with other people in some capacity’ (Galan et al., 2011). Grounded in the realities of people’s experiences Maslach’s Burnout Inventory, which has been recognized for more than a decade as the leading measure of burnout, defines three dimensions of burnout. The three dimensions, Emotional Exhaustion, Depersonalization and Personal Accomplishment are related to environmental variables in different ways. Exhaustion and cynicism tend to emerge from school overload and social conflict while a sense of inefficacy arises from a lack of resources within a situation (Maslach, 2003). Maslach’s theory states that burnout occurs when people lose a sense of positive connectedness with others and have a loss of shared values among peers (Maslach, Schaufeli, & Leiter, 2001).
Medical student burnout can be a predictor of depression, low self-esteem, school attrition and suicidal ideations (Chang, Eddins-Folensbee, & Coverdale, 2012) and has also been associated with intention to leave medical school and unprofessional behaviour (Dyrbye, et al., 2010). In a study conducted by the Mayo Clinic, with participants from seven U.S. medical schools, 53 percent of medical students, had symptoms of burnout. In a series of studies Drybye and her colleagues (Dyrbye, et. al, 2009, 2010, 2012) showed how burnout was associated with self-reported unprofessional conduct and less altruistic professional values among other problems.
Emotional exhaustion may lead to physical neglect, which decreases empathy and can directly affect patient care. Emotional exhaustion and loss of focus may also be the reason doctors have a higher suicide rate than the general population (Dyrbye et al., 2010). Lupo and Strous (2001) showed higher levels of anxiety among medical students in the preclinical years than the clinical years. Alternately, conflicting research cited by Rosenthal and Okie (2005) showed higher levels of anxiety in the clinical years. The conflicting data can be attributed to different types of stress factors making each phase a new learning opportunity to reflect on stressors and acknowledge symptoms.
A current thread in medical education research has examined clinical empathy and its relationship with burnout (Dyrbye et al., 2010; Hojat et al., 2004). Empathy is a universal foundation of the future physician-patient relationship (Matthews, Suchman & Branch, 1993) that promotes diagnostic accuracy, patient adherence to treatment plans and physician satisfaction (Derksen, Bensing & Largo-Janssen, 2013). Research into empathy and professional burnout has demonstrated that physicians tuned into the psychosocial needs of their patients were less likely to experience burnout (Anfossi & Numico, 2004), that empathy levels are negatively correlated with burnout (Wilczek-Ruzyczka, 2011) and that burnout is a factor with significant influence on self-assessed empathy among medical students (DiLalla, Hull & Dorsey, 2004). It has also been shown that self-perceived empathy declines significantly during the course of medical school as a result of increased contact with patients in the clinical phase of training (Neumann et al., 2011).
The capacity for empathy is important for establishing interpersonal relationships, which is crucial in the medical field where clinicians need to establish both general interpersonal relationships and doctor–patient relationships (Park et al., 2006). Within an empathetic relationship, patients talk more about their symptoms enabling the physician to collect more data and determine a more accurate diagnosis (Derksen, Bensing & Largo-Janssen, 2013). By finding a common ground between doctor and patient, trust is built, the emotional experience is recognized and the patient is able to become an active participant in the treatment (Gelhaus, 2012). Empathic communication enables patients to talk more comfortably which leads to a more accurate diagnosis and an agreeable treatment plan between physician and patient (Coulehan, et al., 2001).