Sindromul de epuizare profesională la studenții la medicină

Similarities and differences between the undergraduate student status and the employee status

The undergraduate student status is often compared with the employee status. The parallel between these two roles becomes increasingly relevant in the current educational landscape, where the evolution of labor market demands, competencies-driven training, clear requirements regarding targeted performance levels, and clear provisions in educational contracts shape the responsibilities of both students and higher education providers. Therefore, a comparative overview of similarities and differences between these two roles refines the understanding of academic burnout through the lens of responsibility and performance standards⁽¹⁾.

The complex workload and responsibilities of the undergraduate student status support the idea that being a student is similar to a workplace. Students have a mandatory level of attendance to lectures, practical activities and skills training, they are also required to complete and present individual and team portfolios, projects, to study for complex theoretical and practical exams, to acquire a specific minimal level of knowledge, skills and autonomous performance, in order to pass the exams. The cognitive, psychological and social strain involved in the student status may be equated with the workload undertaken by an employee⁽¹⁾. Moreover, objective workload is associated with perceived stress and fatigue, both in students and employees; discipline, responsibility and entrepreneurship skills are similarly required from students and employees⁽²⁾.

Training for the labor market economics of supply and demand underlines a further similarity between students and employees. Critical thinking, communication and teamwork, problem solving, generating creative solutions to product demands, flexibility and other transversal competencies carry an increasing weight in undergraduate training. Studies show that clear training objectives for these key skills during undergraduate studies enhance both identification with the future professional role and employability, hence the perception of student role as the first part of – or the investment in – the professional role⁽³⁾.

Nevertheless, relevant differences between undergraduate studies and workplace stand out. Firstly, the financial reward of being employed differs from the rewards of studying. It is true that undergraduate students may benefit from scholarships, reduced fees for housing, transportation and meals, and also from exchange programs and research opportunities with expenses paid by the university. However, most of these financial benefits are based on performance levels, not equally accessible to all students, and students mostly depend on external financial support for their cost-of-living expenses. Additionally, some students pay study fees, while some services provided by universities also require paying a fee. These render financial benefits of students significantly different from an employee’s salary. Moreover, an employee signs a work contract with clear rights and responsibilities, monitored by the labor authorities, according to labor laws. Students do sign a study contract with rights and responsibilities; however, the study contract entails mostly training and learning targets that prepare for future professional opportunities, not performance targets that would translate to immediate financial benefits, penalties or rewards^(4,5).

Another major difference between student status and professional status involves the level of flexibility of the schedule. Students have a higher level of flexibility in organizing their daily schedule based on class schedule, preferences and individual pace of learning. Certain activities do not require 100% attendance, and universities offer – besides mandatory study topics – a portfolio of optional study topics to choose from, based on personal interests. The perception of academic workload and academic stress widely varies and depends on the context and strategies of teaching and learning. On the flipside, employees have 100% attendance requirements, stricter work schedules, less flexibility, clear job description, workload with stricter deadlines and quality requirements. Therefore, the structure of student role differs from the formal employee role^(4,5).

The aforementioned pros and cons underline that, despite the similarities between students and employees, the two roles overlap only partially, and contain relevant differences in objectives, rewards and responsibilities⁽⁵⁾. These differences carry a higher relevance when we compare medical students and doctors. Medical students perform tasks and practice medical procedures with the purpose of learning and under strict supervision; they have not reached the full level of training, therefore they benefit from plenty of room for error, with very limited direct consequences for the patients’ health. Also, they do not have board certification to practice, to establish diagnosis and treatment plans; they do not have the legal responsibility for their interaction with patients, their main source of stress is academic evaluation, progress and training, not the patients’ management plan and health outcome. Conversely, doctors have the full qualifications and board certification to practice, full legal responsibility for errors and malpractice – despite some degree of oversight. Doctors are acknowledged as essential for the healthcare system; they benefit from financial rewards according to their level of expertise and relevance for the medical institution where they work. However, this comes with a high cost; they need to make quick critical decisions about patient diagnosis, assessment, treatment and monitoring, medical team management, under a high level of stress and unpredictability, during night shifts, emergencies, in underfunded, understaffed medical facilities⁽⁶⁾.

Burnout: definitions, dimensions and extent in medical students

Burnout as a complex psychological construct entails chronic stress which is directly linked with academic or professional workload. The concept of burnout was coined in order to ascertain the wear and tear of professions with an intense and complex level of human interaction – i.e., the cost of caring. The commonly used definition of burnout includes emotional depletion, depersonalization and decreased perceived achievements. Emotional depletion reflects the intense fatigue generated by the academic or professional role, leading to depletion of psychological resources, empathy and emotional investment. Depersonalization outlines distancing from (and cynical attitudes towards the work role) work demands and workplace interactions. Decreased perceived achievements entail an objective and perceived decrease in workplace level of performance and efficiency, leading to the downward spiral of significantly decreasing amounts of sub-par workload management⁽⁷⁾.

Academic burnout stems from intense academic requirements, elevated performance standards and increasing pressures associated with academic performance, such as an increased cost of studying, added fees, an increased delay of employability, limited access to institutional facilities, scholarships, research grants and academic exchanges. Students who experience burnout lose cognitive focus and motivation for studying and feel overwhelmed and burdened by the complex level of information, skills and human interactions. The study of medicine per se is acknowledged as one the most strenuous and exhausting academic tracks available. The burden of medical students in particular is enhanced by the interaction with the complex biological, psychological, social and spiritual spectrum of human suffering, the perception of limited agency and control over the result of medical care, the constantly looming risks of aggression, illness, patient death, ethical and legal pressures, which are not properly addressed by the training curriculum. Moreover, students learn within a narrow spectrum of medical facilities, very different from the actual landscape of medical labor market^(8-11).

Medical students experience a significantly higher level of mental health struggles compared with the general undergraduate student population^(12,13). Epidemiological studies report a 37% prevalence of burnout in medical students, or even higher – i.e., almost half of medical students are reported to have experienced burnout throughout their study years^(8,9,11). Some studies even contextualize burnout as an epidemic – i.e., a systemic issue, of medical higher education⁽⁹⁾. Pandemic and post-pandemic studies show an increasing level of burnout in medical students⁽¹⁴⁾. Burnout and the subsequent mental health struggles have a different impact on medical students, depending on gender and race⁽¹⁵⁾, with an extensive spectrum of short- and long-term detrimental consequences. More specifically, burnout can lead to decreased empathy towards patients, which affects in the long term the quality of doctor-patient relationship. Also, it generates decreased academic satisfaction and even drop out from medical studies, which in turn affects in the long term the quality and functioning of the entire healthcare system^(16-19). Therefore, both providers of higher medical education services and the healthcare system have the responsibility to understand and mitigate risk factors for burnout in medical students and actively implement appropriately – tailored burnout prevention strategies^(20-22). Moreover, due to the high prevalence of physician burnout revealed by post-pandemic studies⁽²³⁾, the scope of these strategies should include medical trainees/early career physicians⁽²⁴⁾.

Risk factors for the development of burnout in medical students

Burnout in medical students involves three main types of risk factors:

Academic factors

The medical curriculum comprises a vast array of knowledge and skills directly linked with frequent complex evaluations. These strenuous tasks underscore significant levels of academic stress, and may contribute to the development of burnout^(8,9,11). Increased pressure to achieve a high level of academic performance and a highly competitive academic environment for students can increase perceived stress and the risk for burnout^(17,18). Moreover, early, poorly-prepared exposure to clinical environment, severely ill patients and extreme human suffering may contribute to compassion fatigue burnout^(25,26).

Individual factors

Personal characteristics of students can influence the vulnerability for burnout. Substance and alcohol use, increased levels of perfectionism, impostorism, self-criticism and, also, ineffective coping strategies are associated with higher risk of burnout^(27,28). Moreover, unhealthy lifestyle habits and poor sleep hygiene predict higher levels of risk for developing burnout in medical students⁽²⁹⁾. Older age, female sex and increased cognitive empathy are also identified as individual risk factors for burnout in medical students^(8,30).

Institutional factors

The academic environment plays a key role in the development of burnout. Medical students who self-fund their education experience institutional mistreatment⁽³¹⁾, sexual victimization⁽³²⁾, humiliation^(32,33) or conflicts with teachers or colleagues⁽³³⁾, reporting higher levels of burnout and other mental health issues. Also, medical students report demanding educational environments with fixed, competitive learning mindsets and hierarchical structures as factors associated with burnout^(34,35).

Burnout prevention and management strategies in medical students

Burnout prevention in medical students encompasses a complex, multi-layered approach. In order to appropriately address the risk factors for burnout, prevention and management strategies require individual-level and institutional-level interventions⁽²¹⁾.

Individual-level interventions include self-care, self-compassion, setting SMART academic goals, seeking mentorship, taking advantage of available institutional and noninstitutional support⁽³⁶⁾, resilience and stress management training^(11,37), or mindfulness practices⁽³⁸⁾.

Institutional-level interventions include curricular restructuring^{(2,4,18,36,39)}, new methods of teaching^(40,41), mentorship programs, institution-provided workshops aimed at developing emotion regulation, problem solving and goal setting⁽³⁶⁾, institutional policies that include flexible training, mental health support, safeguards against excessive workload, abuse, bullying and unhealthy competition⁽⁴²⁾ and, last but not least, institutional reframing of academic failure and quitting as a learning experience and a step toward more realistic goals and future success⁽³⁶⁾.