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Medical Student

Stress and Burnout


Committee on Physician Health and Wellness  Providing Education for Medical Students
Authors: Committee on Physician Health and Wellness Representatives  Cheryl L. Hurd, MD and Bethany E. Powell, MD
Original Release Date: February 2000 • Review Date: September 2015

Learning Objectives Focus about beginning medical school, as


Upon completion of this activity, This activity discusses how to cope he sees all of his hard work, studying,
medical students should be able to: effectively with many of the stresses and dedication come to fruition in his
encountered in the practice of medicine. lifelong dream. However, he is also
1. Recognize factors that contribute
It offers self-assessment tools, prevention nervous.
to stress and burnout in the
strategies, and treatment options.
medical profession; David realizes that everyone who
2. Describe the continuum attends medical school is intelligent,
associated with stress; Target Audience diligent, and hard-working. Many of
Medical students his new fellow students may even be
3. Assess personal risk for burnout;
very competitive regarding grades.
4. Analyze the expectations and He worries that this could lead to a
risk factors for students that
increase risk for burnout; I. Introduction less supportive and more stressful
school environment. Being an astute
5. Identify and apply healthy individual who also likes to prepare,
coping skills that improve David is unsure of what he should do
ethical behavior, enrich personal Case Study: David to help himself succeed in medical
resilience, manage stress, and • 23-year-old male student school.
prevent burnout; and
• Graduated magna cum laude from We will return to this case later in the
6. Recognize when medical course.
students need professional help. well-known university
• Accepted to medical school to
begin in the fall Elements of Medical Ethics
• Nonmaleficence
• Excited about new opportunities
• Beneficence
Table of Contents • Nervous about expectations • Autonomy (student and patient)
I. Introduction....................................1
• How will he succeed? • Justice
II. Reality of Stress............................2
III. Burnout...........................................3 Let’s begin with a case example. Medical students are an integral part of
David is a 23-year-old medical student society, bound by medical ethics. This
IV. The Process of Stress...................4 adds stress to each student’s life. Medical
who has known that he wanted to be
V. Symptoms of Burnout..................4 a physician since he was young. He
VI. Preventing Burnout.......................6 is very bright and an eager learner, Continued on page 2

VII. Asking for Help..............................7 graduating magna cum laude from


Princeton.
VIII. Summary........................................8
IX. Bibliography...................................9 He performed well on the MCAT, and
was accepted to medical school to
begin that fall. David is very excited

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students have an ethical obligation to take three criteria are the main components
care of patients optimally. Case Study: David (cont’d.) of the Maslach Burnout Inventory, the
Nonmaleficence. “Primum Non Nocere” standardized instrument used to measure
Stress — Burnout
“First, Do No Harm” burnout.
Beneficence. Take positive steps to help • Performs well academically during Burnout is characterized by decreased
others, not just refrain from harm his first year of medical school mental energy or emotional exhaustion.
Autonomy. Personal rule of self free from In this state, medical students feel unable
• Adapts to rigors of medical
controlling interference from others that to give of themselves, which can cause
education cynicism and detachment from patients,
prevents personal choice
• Beginning to have headaches as which is defined as depersonalization. The
Justice. Fair, equitable, and appropriate
second year commences other component is diminished personal
distribution of a service; medical students
accomplishment related to negative self-
begin to realize disparity and have an • Studying longer hours than during appraisal. Two theories postulate that for
obligation to promote justice his first year and missing social medical students, “unsatisfactory aspects of
Medical students are expected to manage activities as a result the learning environment and a feeling that
stress so that it does not interfere with one’s efforts are meaningless or irrelevant”
ethical principles. They must recognize David is now in medical school,
also may lead to burnout.
doing no harm begins with one’s self. This and has done well with his studies
and grades. He is in the top quarter (Anne 2014; Cook 2014; Enoch 2013; Jennings 2009;
self-awareness involves being attentive to Lee 2013; Mazurkiewich 2012; Shanafelt 2014)
the moment, the person, the task at hand, of his class and seems to have
and being fully present, balancing all four adapted well to the rigors of medical
elements of medical ethics. school. However, as he begins his What Are Stressors?
second year, with the addition of Physical Stressors result from internal,
learning clinical skills, having outside physical symptoms, such as headaches,
II. Reality of Stress preceptorships, and even more stomach problems, and so on; external
rigorous material to learn, he begins to physical stressors include heat, cold,
Stress is the reality of life and must be have headaches on a regular basis. At excessive noise, and the like.
recognized and managed. times, he feels tired. He has to study Psychological Stressors arise from time
Feeling stressed? This is one of many even more than he did during his pressures or the unrealistic expectations
experiences incoming medical students first year. To fit in study time, and still we place on ourselves or allow to be
face that for some, may be their first have adequate sleep, he is declining placed on us by others, such as, “you must
exposure to life-and-death situations. social invitations and outside activities. be perfect,” “you must know everything,”
These experiences, which are physically, He is doing this more and more, to or “you must suppress your feelings at all
mentally, and emotionally demanding, the point that he seldom sees anyone costs.” An irrational belief, for example
often test the limits of our coping skills. outside of class/clinicals. is “doctors don’t get sick with illnesses
Recognizing our limitations and seeking such as: anxiety, depression, psychiatric
help is not only important to our patients, disorders.” Fatigue and time demands can
but also to ourselves. lead to anxiety, depression, and substance
This course will help identify common
Definition of Burnout abuse.
causes for stress in the lives of medical • Burnout is a state of mental and/ Familial Stressors can arise from
students and offer healthy ways of coping or physical exhaustion caused by relationship problems with parents,
with that stress. excessive and prolonged stress. spouses, and children. Medical students
• Burnout syndromes are characterized face competing time demands for family
by three features: and education. Family problems can tax
Definition of Stress important resources like time and money,
o Emotional exhaustion, and often require immediate attention.
Stress is an internal process that occurs
when a person is faced with a demand o Depersonalization (cynicism), and Financial Stressors are common for medical
that is perceived to exceed the resources o Diminished sense of personal students. Most students carry the burden
available to respond to it effectively, and accomplishment. of a student loan, and often do not have
where failure to deal with the demand time to get jobs. Medical students thus
effectively has important and undesirable Burnout is defined as “a state of mental must decide whether they can survive with
consequences. and/or physical exhaustion caused by current funds or acquire another student
Stress also is defined as “our reaction to excessive and prolonged stress.” Research loan.
events, environmental or internal, that tax studies have found that some of the major Spiritual Stressors arise when basic
or exceed our adaptive resources.” Each causes of burnout in medical students are spiritual values or beliefs are reformulated,
of us has a certain number of coping student mistreatment, sleep deprivation, called into question, disregarded, or when
resources, and when they are strained or and residency choice. time constraints impede on spiritual
exhausted, stress usually results. Stress The burnout syndrome is characterized growth or attendance at services. Neglect
reactions consist of both physical and by losing enthusiasm for work (emotional of spiritual needs contributes to higher
emotional responses. Stress can be a exhaustion), treating people as if they were levels of stress and impairment.
motivator toward change and growth or a objects (depersonalization), and having a
cause of impairment. sense that work is no longer meaningful
(low personal accomplishment). These

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Social Stressors are abundant and can
arise in any context where interpersonal
For example, medical students have even
less free time than premed students,
III. Burnout
relationships exist, like school, work, due to the greater volume of material
church, and community. The loss of and the increase in total hours spent Burnout is defined as “a psychological
contact with friends and family contributes in class and lab. In the clinical years, syndrome in response to chronic
to feelings of loneliness among busy students are assigned large numbers interpersonal stressors on the job,”
students. Stress can come from continued of seriously ill, complex patients. All which creates a feeling of exhaustion,
forced contact with individuals with whom medical schools are competitive, and the depersonalization (i.e., feeling emotionally
they may not share the same values or culture is that one must excel to obtain detached), and a diminished sense of
beliefs. a high-quality residency. Students have accomplishment.
Academic Stressors change as the no control over the information thrown While individual traits may factor as risks
student progresses through school. at them in the preclinical years, and no for developing burnout, situational factors
The first two years, the student faces control over the types of patients, or the play a more predominant role. When a
competition and fear of failure. As quality of supervision or role modeling work environment does not correlate with
the student moves into the later years from interns, residents, and attendings. an individual’s value system, burnout is
of education, stressors the student The responsibility of patient care can be likely.
experiences are fears of increasing enormous and can challenge a student’s For medical students, potential causes
responsibility, death of patients, fear of coping mechanisms. The risk of exposure for burnout include: heavy workloads,
infection or bodily harm, and discomfort to serious infections, such as hepatitis C situations in which their control is limited,
with discussing sexual issues. and MRSA, can create anxiety and stress. and exposure to new ethical and moral
Clinical Stressors include difficulties Due to the lack of free time, students may dilemmas. Two theories postulate that for
in dealing with the chain of command/ not feel they can establish or maintain medical students, “unsatisfactory aspects
pecking order common for students. adequate support systems, or may feel of the learning environment and a feeling
Coping with hierarchy and the authoritative they are showing weakness if they seek one’s efforts are meaningless or irrelevant”
environment is troubling for students. support. Students receive a great deal of may lead to burnout.
One student compares medical training to science their first two years, but limited (Brazeau 2010; Jennings 2009; Shanafelt 2009; West
military training. She says they both recruit exposure to the art of medicine, including 2009; Girdano 1996)
young people full of leadership potential communication with patients and families,
setting limits, and maintaining healthy
and essentially break their autonomous
boundaries. Burnout Survey Results
will through a rigorous hierarchy. The first
The fast pace of medical school can be • International residents report less
two years are boot camp, the last two,
relentless, but at the same time, some burnout than American residents.
during which students are thrown into the
hospital wards are definitely front-line duty. clinical rotations may include repetitive • Psychiatry residents report less burnout
tasks and duties that are normally than family medicine residents.
(Coombs, R. Surviving Medical School. Sage
Publishing: Thousand Oaks, 1998. p. 22) performed by others in the health delivery • Fifty percent of all medical students
field. were assessed with significant burnout
Many patients are difficult to diagnose, in a large multicenter study.
Stressors in Medical School cannot be cured, or may not respond to • Physician burnout has a negative
• Dramatic lifestyle changes therapies; thus, the student experiences impact on patient outcomes.
• Heavy academic workload/clinical problems without solutions. Although
caseload students may receive lectures on death and Various surveys demonstrate that medical
• Perceived need to excel at all costs dying, being present at the death of the students, residents, and a variety of
first patient is an event medical students medical specialties are experiencing what
• Lack of control/autonomy
remember the rest of their lives. appear to be high rates of stress and
• Responsibility for patients burnout.
Students never have enough time to study
• Exposure to infections all the material in the preclinical years, (Woodside 2008; Brazeau 2010; Halbesleben 2008)
• Limited support systems and never have enough time to be fully
• Inadequate training for working with prepared for the interrogation they often
patients and families receive on rounds in the clinical years.
• Frenetic, intense pace of training Students are frequently exposed to
• Repetitive single tasks/scut-work cynicism and fatalism, and may become
• Problems without solutions disillusioned with their career choice.
• Death and dying
• Time pressure and demands
• Disillusionment

Premedical studies pressure students


to obtain a high GPA, score high on
the MCAT, earn exemplary letters of
recommendation, and participate in
extracurricular activities. But dramatic
changes occur in all medical students’ lives
the day they start medical school. Continued on page 4
3
Case Study: David (cont’d.)
Personal Factors — Burnout to put their studies first. It is often difficult
for physicians and students to accept help
• Financial pressures (medical school for themselves, or reveal that they are
Stress — Burnout debts) facing personal challenges.
• First night on call in critical care • Work-life balance (family/parenting) During times of extreme stress, such as
unit (CCU), takes part in a code • Lack of time for self-care (sleep, marital strife, grief from a major loss, or
where patient dies exercise) financial difficulties, there is greater risk of
• Complex personal relationships burnout and unethical behavior.
• Witnesses death of several other
patients during four-week CCU Any of these factors can contribute to
rotation stress of the medical student. However, the IV. The Process of Stress
• Exposed to ridicule by housestaff exponential rise of multiple factors places
and attending for not knowing even the most resilient student at high risk
trivia for burnout. The Process of Stress
(Anne 2014; Bell 2013; Shapiro 2011) 1. Stress leads to arousal.
David began his third-year clinical
2. Person selects a coping response.
rotations in July. He witnessed death
on his first night on call, for which he Personality Traits 3. If effective, arousal decreases.
was not prepared. He was exposed to • Perfectionism and need to control 4. If ineffective, arousal increases,
“teaching by intimidation” on rounds, • Overachievers: Type A personality resulting in escalation of stress level.
providing additional stress, along with • To reveal emotions equals weakness 5. Unresolved stress leads to burnout.
the long hours of work and sleep
• “Patients should always come first” 6. Burnout leads to unethical behaviors.
deprivation.
• Inability to recognize personal needs
Edgar P. Nace, MD, a board-certified
• Reluctance to ask for help/Inability to
Burnout Facts recognize personal needs
psychiatrist in Dallas and past chair of the
PHW Committee, states, “I think every
• Influence on specialty choice • Self-sacrifice physician experiences stress, and most of
• Lack of sense of accomplishment the time, it’s normal stress and is managed
• Early preclinical onset The qualities that enable medical students
effectively.
to excel often are the same qualities that
• Fifty-five percent of all medical can lead to burnout, such as perfectionism, “But if stressors increase or if the person’s
students were assessed with significant workaholism, and a Type A personality. capacity to deal with stress decreases,
burnout in a large multicenter study then that physician is subject to burnout,
The culture of medicine has created an
• Men and women report comparable which is a situation that develops before
unrealistic expectation for physicians to
burnout rates diagnosable conditions emerge, such as
always put the patient first and to deny
depression, anxiety disorders, or substance
their own needs. This also applies to
In one study, students reporting burnout abuse.”
medical students in that they are expected
tended to choose specialties for training (Franke 1999)
where they could control lifestyle. Higher
burnout symptoms, such as emotional
exhaustion and depersonalization,
occurred in the final years of medical
school. However, increased sense of
personal accomplishment decreased
burnout. One cross-sectional study pointed
out that an increased level of burnout
occurs prior to the clinical years.
(Enoch 2013; Mazurkiewich 2012; Williams 2015)

Burnout Statistics
• Burnout experienced in:
o Fifty-six percent of medical students
o Sixty percent of residents
o Fifty-one percent of mid-career
physicians
• Mid-career physicians report greatest
burnout compared with early- and late-
career physicians
• Twenty-four percent of physicians
consider their leaving practice in the
next one to three years
(Dyrbye 2014; Reese 2012)
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Stress in medical school adds to the for ethical violations. For physicians, these • Up to 9 percent of students reported
normal baseline stress that all individuals violations may lead to loss of licensure if suicidal ideation.
experience. Stress can be cumulative and/ not managed appropriately. • Prevalence of depression increases
or traumatic. over the course of medical school,
(Gunderman 2014)
Stress is not inherently bad. The result of with a higher risk of stress/depression
stress depends on what kind of coping associated with transition to clinical
mechanisms an individual chooses. In the Negative Outcomes care rotations (third year).
face of stress, a person selects a coping • Relationship distress
response. If it is an effective coping Medical education is associated with
• Emotional exhaustion
mechanism, stress is reduced. If ineffective, greater increases in stress and symptoms
• Academic consequences compared with other types of training.
this can result in an escalation of stress.
Over time, this unresolved stress leads to • Suicide These stressors often exert negative effects
burnout. Burnout can lead to unethical on students’ and residents’ academic
Depersonalization, which refers to performance, physical health, and
behavior.
treating people like objects, may arise psychological well-being, making them
as a protective mechanism in human more susceptible to depression. Students
services professionals to minimize
V. Symptoms of Burnout emotional involvement that could interfere
often react by making personal sacrifices,
which may create a loss of control and
with functioning in crisis situations. In result in the student incorporating less time
• Fatigue moderation, “detached concern” toward for the leisure activities that may alleviate
• Irritability patients by physicians may be appropriate stress.
• Headaches and necessary, but when excessive, it may
The transition from didactic to clinical
lead to callousness and cynicism with
• Gastrointestinal disorders training can be associated with anxieties
subsequent negative effects on the patient-
• Anxiety/Depression related to giving incorrect treatment,
physician relationship.
becoming infected by patients,
• Difficulty sleeping Emotional exhaustion is caused by inadvertently harming patients, loss of
• Decreased sex drive excessive psychological and emotional control over sleeping hours, and the
• Poor concentration demands made on people helping performance of clinical skills.
• Possible suicidal thoughts people that leave individuals drained
Medical students seem to have higher
and depleted. Low morale, reduced
rates of depression than individuals in the
(Fralick 2014) effectiveness, burnout, and health
general population, but are no more likely
problems are often the result.
to be treated. Only 22 percent of depressed
Behaviors Resulting From Feelings of diminished personal students seek care due to concerns about
accomplishment are reflected in symptoms
Burnout of stress, depression, and a sense of
confidentiality, stigma associated with
using mental health services, cost, fear of
• Increased use of substances (alcohol, inefficiency and diminished competence. documentation in the academic record,
prescription drugs) With such feelings, the individual believes and fear of unwanted intervention.
• Social withdrawal that his or her actions no longer can or do
Depressive symptoms affect students’ lives,
• Cynicism make a difference. This adversely affects
academic performance, and patient care.
• Lateness/Procrastination the patient-physician relationship, patient
satisfaction, and perhaps, ultimately, health Suicidal ideation was predicted by
• Unethical behaviors (boundary outcomes. perceived lack of control, certain
violations, disruptive behavior) personality traits, single marital status,
In one survey, 50 percent of approximately
• Preoccupation with alternatives to negative life events, and anxiety and
2,200 medical students from seven medical
clinical practice depression. Students reporting suicidal
schools reported burnout while 11 percent
ideation are more likely to use tobacco,
Increased use of tobacco, alcohol, reported they considered suicide in the
alcohol, and illicit drugs and to engage in
prescription medications, and/or illicit past year. Medical student suicide rates are
other risky health behaviors.
substances to help cope with stress places inconsistent and poorly reported. However,
400 physicians (equivalent to two medical Suicide remains one of the top causes of
the individual at great risk for physical and early death in practicing physicians.
psychological dependence. school classes) are lost to suicide yearly.
(Dyrbye 2008; American Foundation for Suicide (Compton 2008; Goebert 2009; Smith 2007)
Medical students experience a myriad
Prevention. www.asfp.org [accessed 5/15/15];
of symptoms and behaviors when their Tomaselli 2008 www.amednews.com [accessed
coping mechanisms are overwhelmed. 5/15/15]).
A wide range of burnout manifestations
can be seemingly mild, such as irritability
and fatigue. However, with ongoing stress,
Susceptibility to Depression
physicians and students can develop • More than 20 percent of medical
anxiety disorders, depression, and students have symptoms of depression
substance use disorders, and be at risk (12 percent — probable major
depression and 9 percent — probable
mild/moderate depression).

Continued on page 6
5
Self-Assessment Exercise indicates a high stress level, one that could studies in medical students, learning
be psychologically and physiologically mindfulness-based techniques led to a
Take the following self-assessment exercise
debilitating. reduction in mood disturbances, stress,
to assess your own personal stress level.
and anxiety.
This exercise is for your own use and does (Girdano 1996)
not need to be returned to TMA. Nurturing your creative abilities is
important to your overall well-being.
How often do you…
(a) almost always VI. Preventing Burnout Maintaining a sense of balance will enable
you to be more optimistic and, as a result,
(b) often able to study and comprehend the work
(c) seldom After attending stress management being asked of you more effectively and
(d) almost never workshops, many people worry about efficiently. If your mind, heart, soul, and
1. Find yourself with insufficient the stress in their lives. In reality, no one body are clear, you will be able to think
can eliminate all of the stress in his or better and make better judgments, treat
time to do things you really enjoy?
her life. Stress is not inherently bad, it is others with respect, and gain respect in
2. Wish you had more support/ how one responds to stressful events that return.
assistance? determines the effect individually. Develop and nurture relationships by
3. Lack sufficient time to complete The key is to not try to avoid stress bringing focus to two special people in
your work most effectively? altogether, but to recognize and manage your life. Most women in America have a
4. Have difficulty falling asleep the stress in our lives in such a way that close female friend and male friend, their
because you have too much on your we avoid the negative consequences of husband or significant other. Men need
mind? stress. bonds like these as well. Special people
5. Feel people simply expect too in our lives are not just friends; they are
intimates. With them, we can let down our
much from you? What the Student Can Do guard and show the less desirable sides
6. Feel overwhelmed? • Recognize symptoms of burnout. of ourselves. These people, too, require
7. Find yourself becoming forgetful • Find meaning in career choice/promote special care and nurturing.
or indecisive because you have too professional fulfillment. Peer support systems help students reach
much on your mind? • Choose residency wisely. out to others and feel part of a community.
8. Consider yourself to be in a high- • Set boundaries based on core values. Students can learn from each other about
pressure situation? • Maintain a healthy diet/Exercise. various issues, such as study techniques
9. Feel you have too much and social networks, as well as share
• Obtain a preventive care/personal
responsibility for one person? leisure and enjoyable activities.
physician.
10. Feel exhausted at the end of the Keep a sense of humor. A sense of humor
• Take regular vacations.
is one of the most important elements of
day? • Take scheduled breaks from a healthy life. There is no question that
Calculate your total score as follows: electronics. people who lack a sense of humor have
(a) = 4 points; • Journal. great difficulty coping with the vicissitudes
(b) = 3 points; • Have a retirement plan. of everyday living. Try to keep stressors in
(c) = 2 points; • Address spiritual needs. perspective.
(d) = 1 point • Ask for help/Seek counseling if (Williams 2015)
needed.
Total = Take regularly scheduled vacations and
Believe you can change. Students weekends away from medical school
This exercise was designed to assess your frequently say, “I’m too set in my ways activities. Make appropriate arrangements
level of stress due to overload. Overload, to do anything about it.” This negative then turn off your pager and/or cell phone;
or over-stimulation, refers to the state in attitude belies the truth: Everyone can unplug your work communications such as
which the demands around you exceed change. email or electronic health record.
your capacity to meet them. Some aspect(s) Identify and prioritize activities based on Plan for retirement. Many students seem
of your life are placing excessive demands personal core values. Setting appropriate to think they will be practicing medicine
on you. When these demands exceed limits and pursuing meaningful life forever. It is commonly accepted in
your ability to comply with them, you activities outside of medical school are psychiatric circles that school teachers are
experience distress. necessary for students to have balance, the most successful retirees because they
The four major factors in overload are (1) emotional support, and buffers against the have practiced retiring for a few months
time pressures, (2) excessive responsibility stresses of medicine. every summer. Since physicians often have
or accountability, (3) lack of support, and Healthy lifestyles benefit students as very little experience with vacations, they
(4) excessive expectations from yourself much as they do the general population. tend to make poor retirees. It is never too
and those around you. Any one or a Simple things, such as getting enough early to think about how you will spend
combination of these factors can result in sleep, exercising, and seeing a physician your leisure years.
stress from overload. for regular medical care (rather than self- Additionally, there is evidence that
Your total number of points on this treatment), appear logical. spirituality may have a buffering effect
exercise will help you assess how stressed Mindfulness allows one to live in and on stress, and a positive effect on coping.
you are by overload. A total of 25-40 points enjoy the present. According to two recent

6
Studies show that daily experiences reduce
burnout and lead to higher satisfaction with
Hope for the Future VII. Asking for Help
• Physician well-being programs
life.
• Code Lavender • Professional assistance
Help is available. Talk with a trusted
colleague or faculty member. Seek • Physician Healers Track at The o Private provider in community
professional help (counseling/medication) University of Texas Medical Branch at
o Student health services
through the student assistance program, Galveston (UTMB)
• PHW committees
support groups, or at the student health • Providing workshops, counseling
center. services, employee assistance o TMA PHW committee
programs, mentoring, coaching, o CMS PHW committees
(Bell 2013; Fralick 2014; Gregorie 2013; Shanafelt
2012; Wachholtz 2013) financial advice, peer support groups • Peer mentors and coaches
The Mayo Clinic Physician Well-Being • Support systems
What the Medical School Program researches causes of, and
Students have many options in getting
strategies for, preventing burnout.
Can Do The Adventist Health Care System founded help. A primary care physician can
• Make a commitment to student well- a coalition for physician well-being that make referrals to private physicians in
being. offers individual and family counseling, the community, protecting one’s privacy.
• Measure student satisfaction. seminars, retreats, and peer support Student services staff also may have a list
groups. The system sets an expectation for of community physicians.
• Provide onsite exercise and child-care
facilities. all new physicians to attend orientation to Most medical schools have student
this program. health services and/or student counseling
• Hold workshops/training in conflict
The Cleveland Clinic implemented “Code services that can provide assessments
resolution.
Lavender,” a program to respond rapidly and treatment. These services are usually
• Incorporate mindfulness techniques in provided for little or no cost.
medical education. when health care teams need intensive,
emotional, and spiritual support. During The TMA PHW Committee is a resource
• Consider converting to pass-fail for general inquiries, as well as help
emotionally troubling or exhausting times,
grading. with specific needs, referrals, and in the
the response team arrives with holistic
nursing support, including massage advocacy role.
While the student can adopt many
strategies to reduce the risk of burnout, therapy, healthy snacks, water, and a caring Most medical schools are located in
medical schools have an ethical presence. counties where the county medical society
responsibility to do all they can to prevent UTMB implemented the Physician Healers has a PHW committee. The committee can
and manage student burnout, and to Track in 2013, teaching mindfulness and provide general information, referrals, and
promote optimal patient care. communication skills to medical students. function in an advocacy role.
Medical schools can make a commitment (Bell 2013; Gregoire 2013; Rosenstein 2012; Remember that you have a choice about
to student well-being by encouraging StuderGroup 2012) burnout. You can actively choose to do
student wellness and learning to identify things differently and take care of yourself.
symptoms of student stress and burnout. It is important to take regular inventory
Schools can provide support to students of your stressors and initiate appropriate
Case Study: David (cont’d.)
with burnout either through institutional action to avoid burnout. It is an ethical
support systems or other resources such • Recognized his burnout dilemma to balance your own life with the
as the TMA physician health and wellness demands of the profession.
• Spoke with friends
(PHW) hotline. With appropriate intervention and
Institutions can measure student • Sought counseling professional help, medical students can,
satisfaction and, if needed, make changes and do, recover and ultimately practice
• Utilized spiritual coping medicine safely.
to increase student satisfaction.
mechanisms
In a meta-analysis of burnout interventions
in medical students, several studies showed • Improved social functioning and Potential Barriers
significant reduction in stress, emotional clinical performance • Stigma
exhaustion, and depersonalization. One
David completed medical school. He • Residency
particular study showed more cohesion
between students and reduced perception was encouraged and excited about • Licensure
of stress and burnout. his career in medicine. Recognizing
and implementing healthy coping Seeking treatment has often been avoided
(StuderGroup 2012; Williams 2015) skills prevented a negative outcome to due to the perceived stigma of mental
David’s stress and burnout. health issues. In addition, concerns for
effects on post-graduate training and
licensure also have prevented students
from getting help.
Although there is still some bias, mental
illness does not carry the same stigma
it once did. This is due to increased

Continued on page 8
7
public awareness of mental illness and Letting yourself experience strong
improvements in effective treatments. emotions, and realizing when you may
It also is evidenced by media coverage need to minimize them to continue
of well-known individuals who have functioning, is important. Stepping forward
completed treatment successfully. to take action, and stepping back to rest,
Applying for residency is an exciting, also is important.
stressful process, and unless one’s medical It is healthy to spend time with others to
training was extended or interrupted due gain support and encouragement, as well
to mental illness, it should have no impact as nurture yourself. Relying on others, as
on his or her application and interview well as yourself, is a significant coping
process. strategy.
Many state medical boards require The PHW Committee hopes this activity
reporting only major mental illness. is useful educational information and
Examples of major mental illnesses in welcomes your suggestions regarding these
Texas would be schizophrenia or other or other educational materials you think
psychotic disorders. Other examples should be made available to Texas medical
include Substance Use Disorders and students.
bipolar disorder. Issues of stress and
burnout in training are not usually
reportable. Disclaimer
NOTICE: The Texas Medical Association
(Dyrbye 2015) provides this information with the express
understanding that 1) no attorney-client
relationship exists, 2) neither TMA nor its
VIII. Summary attorneys are engaged in providing legal
advice and 3) that the information is of a
general character. This is not a substitute
• Stress is inevitable.
for the advice of an attorney. While every
• Burnout is preventable, treatable, and effort is made to ensure that content is
manageable. complete, accurate and timely, TMA cannot
• Identify coping strategies that work guarantee the accuracy and totality of the
best for you. information contained in this publication
and assumes no legal responsibility for
Self-Assessment • Help is available.
loss or damages resulting from the use of
Questions Accept the fact that there will be a certain
level of stress in your life and work to
this content. You should not rely on this
1. Is this activity a normal, information when dealing with personal
manage it in a way that you avoid or legal matters; rather you should seek legal
expected part of practice for minimize the negative consequences of the advice from retained legal counsel.
members of my profession? stress, and prevent it when you can.
2. Might engaging in this
activity compromise my
relationship with this patient?
With other patients? With
my colleagues? With this
institution? With the public?
3. Could this activity cause
others to question my Silence Is Not Always Golden
professional objectivity?
4. Would I want my other
If you or a classmate feel overwhelmed or depressed, call for help
patients, other professionals,
or the public to know that I
today.
engage in such activities? (800) 880-1640
The ethical physician will be
PHW Hotline
totally honest when answering
these questions.

8
IX. Bibliography
American Foundation for Suicide Prevention. Physician Enoch, L, Chibnall, JT, et al. Association of Medical Student
and Medical Depression and Suicide. www.afsp.org/ Burnout with Residency Specialty Choice. Med Educ
preventing-suicide/our-education-and-prevention- 47(2): 173-81, 2013.
programs/programs-for-professionals/physician-and-
Fralick, M and Flegel, K. Physician Burnout: Who Will
medical-student-depression-and-suicide (accessed
Protect Us from Ourselves? CMAJ Epub: June 2014.
5/15/15).
Girdano, DA, Everly, GS, and Dusek, DE. Controlling Stress
Anne, S. Burnout: Recognize and Reverse. Otolaryngol
and Tension: A Holistic Approach. Needham Heights,
Head Neck Surg Epub May 13, 2014.
MA: Allyn & Bacon, 1996.
Babbott, S and Manwell, LR. Electronic Medical Records
Goebert, D, Thompson, D, et al. Depressive Symptoms in
and Physician Stress in Primary Care: Results from the
Medical Students and Residents: A Multischool Study.
MEMO Study. J Am Med Inform Assoc Epub Feb. 2014.
Acad Med 84(2): 236-41, 2009.
Bell, H. The Burn Out Busters: How Thee Mayo Clinic
Gregoire, C. The Amazing Way this Physician is Fighting
Physicians Became Experts on Physician Well-Being.
Physician Burnout. The Huffington Post, 12/2/13.
Minn Med 96(11): 14-8, 2013.
Gunderman, R. The Root of Physician Burnout.
Brazeau, CM, Schroeder, R, et al. Relationships Between
The Atlantic 2012. www.theatlantic.com/health/
Medical Student Burnout, Empathy, and Professionalism
archive/2012/08/the-root-of-physician-burnout/261590/
Climate. Acad Med 85(10 Suppl): S33-6, 2010.
(accessed 3/23/15).
Compton, MT, Carrera, J, et al. Stress and Depressive
Jennings, ML. Medical Student Burnout: Interdisciplinary
Symptoms/Dysphoria Among U.S. Medical Students:
Exploration and Analysis. J Med Humanit Epub, 29
Results from a Large, Nationally Representative Survey. J
October 2009.
Nerv Ment Dis 196(12): 891-7, 2008.
Krasner, MS, Epstein, RM, et al. Association of an
Cook, AF, Arora, VM, et al. The Prevalence of Medical
Educational Program in Mindful Communication with
Student Mistreatment and its Association with Burnout.
Burnout, Empathy, and Attitudes Among Primary Care
Acad Med 89(5): 749-54, 2014.
Physicians. JAMA 302(12): 1284-93, 2009.
Drolet, BC and Rodgers, S. A Comprehensive Medical
Lee, RT, Hladkyl, S, et al. Correlates of Physician Burnout
Student Wellness Program—Design and Implementation
Across Regions and Specialties: A Meta-Analysis. Hum
at Vanderbilt School of Medicine. Acad Med 85(1): 103-
Resour Health Sept 28, 2013.
10, 2010.
Mazurkiewich, R, Korenstein, D, et al. The Prevalence and
Dunn, LB, Iglewicz, A, et al. A Conceptual Model of
Correlations of Medical Student Burnout in the Pre-
Medical Student Well-Being: Promoting Resilience and
Clinical Years: A Cross-Sectional Study. Psychol Health
Preventing Burnout. Acad Psychiatry 32(1): 44-53, 2008.
Med 17(2): 188-95, 2012.
Dyrbye, LN, Eacker, A, et al. The Impact of Stigma and
Meldrum, H. Exemplary Physicians’ Strategies for Avoiding
Personal Experiences on the Help-Seeking Behaviors of
Burnout. Health Care Manag 29(4): 324-31, 2010.
Medical Students With Burnout. Acad Med Feb 3, 2015.
Paro, HB, Silveira, PS, et al. Empathy Among Medical
Dyrbye, LN, Sotile, W, et al. A Survey of U.S. Physicians
Students: Is There a Relation with Quality of Life and
and Their Partners Regarding the Impact of Work-Home
Burnout? PLoS One 9(4): Apr 4, 2014.
Conflict. J Gen Intern Med 291): 155-61, 2014.
Reese, SM. Tired of Being a Doctor? Choices for Opting
Dyrbye, LN, Thomas, MR, et al. Burnout and Suicidal
Out of Medicine. Medscape 2012. www.medscape.com/
Ideation Among U.S. Medical Students. Ann Intern Med
viewarticle/757765 (accessed 3/23/15).
149(5): 334-41, 2008.
Rosenstein, AH. Physician Stress and Burnout: What Can
Dyrbye, LN, Varkey, P, et al. Burnout Among U.S. Medical
We Do? Physician Exec 38(6): 22-6, 2012.
Students, Residents, and Early Career Physicians Relative
to the General U.S. Population. Acad Med 89(3): 443-51, Shanafelt, TD. Enhancing Meaning in Work: A Prescription
2014. for Preventing Physician Burnout and Promoting Patient-
Centered Care. JAMA 302(12): 1338-40, 2009.
Dyrbye, LN, West, CP, et al. Burnout Among U.S. Medical
Students, Residents, and Early Career Physicians Relative
to the General U.S. Population. Acad Med 89(3): 443-51,
2014.
9
Shanafelt, TD, Boone, S, et al. Burnout and Satisfaction With Texas Medical Board Physician Online Application. www.
Work-Life Balance Among US Physicians Relative to the tmb.state.tx.us/page/renewal-physician-online-registration-
General US Population. Arch Intern Med 172(18): 1377-85, registration (accessed 3/23/15).
2012.
Texas Medical Board Physician in Training Online
Shanafelt, TD, Kaups, KL, et al. An Interactive Individualized Application.
Intervention to Promote Behavioral Change to Increase
www.tmb.state.tx.us/page/renewal-physician-online-
Personal Well-Being in US Surgeons. Ann Surg 259(1): 82-
registration-registration (accessed 3/23/15).
8, 2014.
Tomaselli, KP. Medical Student Stress and Burnout Leave
Shanafelt, TD, Oreskovich, MR, et al. Avoiding Burnout:
Some with Thoughts of Suicide. www.amednews.com/
The Personal Health Habits and Wellness Practices of US
article/20081020/profession/310209967/6/ [10/20/08]
Surgeons. Ann Surg 255(4): 625-33, 2012.
(accessed 5/15/15).
Shapiro, J. Astin, J, et al. Coping With Loss of Control in the
Wachholtz, A and Rogoff, M. The Relationship Between
Practice of Medicine. Fam Syst Health 29(1): 15-28, 2011.
Spirituality and Burnout Among Medical Students. J
Smith, CK, Peterson, D, et al. Depression, Anxiety, and Contemp Med Educ 1(2): 83-91, 2013.
Perceived Hassles Among Entering Medical Students.
West, CP, Dyrbye, LN, et al. Single Item Measures of
Psychol, Heath & Med 12(1): 31-9, 2007.
Emotional Exhaustion and Depersonalization are Useful
StuderGroup. Physician Burnout: Preparing for a “Perfect for Assessing Burnout in Medical Professionals. J Gen
Storm.” Straight A Review Feb 2012. www.studergroup. Intern Med 24(12): 1318-1321, 2009.
com/getmedia/fea54126-168b-4ba3-9866-8f584e4e7fa8/
Williams, D, Tricomi, G, et al. Efficacy of Burnout
physician_burnout_straight_a_review.pdf.aspx (accessed
Interventions in the Medical Education Pipeline. Acad
3/23/15).
Psychiatry 39(1): 47-54, 2015.

BURNOUT is
Preventable
• You have a choice.
• It is important to take regular
inventory of your stressors and
initiate appropriate action to
avoid burnout.
• It is an ethical dilemma
to balance your own life
with the demands of the
profession.

10
Committee on Physician Health
and Wellness
Providing Health and Wellness Education for Medical Students

History texmed.org for additional information. The drug screen program for physicians
The Texas Medical Association House Speakers who participate in the PHW provides a statewide, consistent method
of Delegates established the Committee Committee’s regional education teams are for random drug screening of physicians
on Physician Health and Wellness in knowledgeable about physician health under agreement with county medical
November 1976. The committee’s charge and wellness issues. The committee offers society PHW committees, district
is to “promote healthy lifestyles in Texas training annually for new team members, coordinators, and hospital-based peer
physicians and to identify, strongly urge which also serves as a refresher course for assistance committees.
evaluation and treatment of, and review other team members. Through the PHR Assistance Fund,
rehabilitation provided to physicians financial assistance is available to
Services
with potentially impairing conditions physicians who cannot afford treatment
As advocates, the PHW Committee helps for depression, SUDs, or other problems.
and impairments.” (TMA Bylaws, Section
with: Financial assistance also is available
10.621).
Composed of physicians who are • Intervention; for short-term living expenses while a
concerned about the health and well-being • Referral for evaluation and treatment, if physician receives treatment. Donations
of their colleagues, the PHW Committee necessary; to the fund are appreciated and are tax-
endeavors to provide help and assistance. • Monitoring upon return from deductible.
The function of the committee is three- treatment; and The committee also offers assistance,
fold: 1) to promote physician health and education, and literature to help medical
• Education for physicians, family
well-being, 2) to ensure safe patient students and resident physicians who may
members, and support staff regarding
care by identifying physicians who may know of a peer who needs assistance or
possible impairments.
have a potentially impairing illness, and who may need assistance themselves.
3) to advocate for the physician while The PHW Committee seeks to rehabilitate, The PHW Committee developed resources
maintaining confidentiality and the highest rather than punish, physicians who available to hospitals to help them respond
ethical standards. are impaired. All referrals made to the to the Joint Commission requirement
committee are confidential — both for the related to physician health.
physician who has a potentially impairing
Educational Materials illness and for the individual making the Types of Referrals
The PHW Committee offers several referral. The committee is interested in the • Substance Use Disorders
ongoing courses on a wide range of topics health and well-being of the physician, • Mood disorders
to educate physicians, TMA Alliance patient, and families of all constituents. • Sexual boundary violations
members, hospital administrations,
Activities • Disruptive behavior
and others. PHW activities encourage
physicians to promote and maintain • 24-hour hotline: (800) 880-1640 • Personality disorders
their health and wellness, which fosters • Continuing medical education • Cognitive disorders
healthy lifestyles in patients. The PHW programs • Ethical misconduct
Committee is committed to providing • Drug screen program for physicians
ongoing education of all physicians and The majority of cases referred to Texas
• Physician Health and Rehabilitation county medical society PHW committees
medical students regarding physician
(PHR) Assistance Fund have involved SUDs. However, as hospitals
health and wellness as well as services for
health-related conditions that may affect a • Outreach to medical students and and medical societies are more aware
physician’s ability to practice medicine with resident physicians of physician impairment, disruptive and
reasonable skill and safety. • Hospital/Joint Commission Standard dysfunctional behaviors of all types are
re: Licensed Independent Practitioner being reported. A psychiatric illness may
Speakers’ Bureau Health be at the root of the behavior. Psychiatric
PHW Committee courses can be given illnesses can be diagnosed with a proper
upon request as live presentations at A 24-hour toll free number is available that
evaluation and most often respond to
meetings of county medical societies, anyone may call if he or she is concerned
treatment.
hospitals, and other entities. An about a physician who may have a
potentially impairing illness. Stress management and boundary
administrative fee is charged to offset issues also are referred to the PHW
speaker travel and administrative expenses. The PHW Committee provides CME
Committee, as well as mood disorders,
To ensure that we can secure a speaker for activities on a wide variety of topics related
sexual boundary violations, and cognitive
your program, please make your request to physician health and well-being. In
disorders.
at least one month before the scheduled addition, the committee offers statewide
conferences and local workshops each Ethical misconduct does not only include
presentation. Contact Sasha Toj at TMA at
year. sexual misconduct, but can include
(800) 880-1300, ext. 1343, or sasha.toj@
things such as sexual harassment in the
Continued on Back Cover
11
workplace. There are many institutional Table: Recent Statistics
guidelines laid down by hospitals,
large medical groups, as well as the
federal government that spell out sexual Type Percentage of Cases
harassment. Other forms of ethical Substance Use Disorders 69%
misconduct can include such things as
double billing and overcharging for services.
Disruptive behavior 8%
Cognitive impairment 4%
Stress/overwork 3%
Sexual misconduct 3%
Depression 1%
Physical disabilities 1%
Other psychiatric disorders 17%
PHW Hotline
(800) 880-1640 (TMA PHW Hotline Calls and Quarterly Reports 2014)

Physicians, residents, and students may be referred to the TMA


PHW Committee 24 hours a day by calling the toll-free hotline number,
(800) 880-1640. The direct line to committee staff is (512) 370-1342.

Committee on Physician Health and Wellness


401 W. 15th Street, Austin, TX 78701
(512) 370-1300
www.texmed.org W002121.10-15

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