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Medical Education
August 9, 2021

The Learning Environment and Medical Student Burnout

Author Affiliations
  • 1Department of Internal Medicine, University of Kentucky College of Medicine, Lexington
  • 2Department of Pediatrics, University of Kentucky College of Medicine, Lexington
JAMA Netw Open. 2021;4(8):e2119344. doi:10.1001/jamanetworkopen.2021.19344

Physician burnout is a national epidemic, with many studies suggesting a prevalence of 50% or more in the United States.1 The causes are legion but include excessive clerical workload (especially as it relates to the electronic health record), inefficient work processes, lack of input or control by physicians of decisions made for patient care, and work-home conflicts.2 This epidemic has consequences for patient care (medical error, lower patient satisfaction and quality of care), the health system (increased physician turnover and early retirement, less patient access, increased costs), and physician health (poor self-care, substance abuse, depression, and suicide).2 The definition and measurement of burnout are a matter of debate, which in turn affect prevalence estimates3; however, the cri de coeur of writings on this topic leave little question that it is a source of great distress for physicians in this country. Indeed, some have equated the situation with moral injury,4 much deeper than burnout. Moral injury occurs when deeply engrained moral beliefs come into conflict and are violated by actions required for one’s job and duty (as can happen in combat situations).4 For physicians, reducing patients to a relative value unit in the name of productivity when their entire training has been to honor all patient needs and consider each and every patient of absolute, not relative, value is the essence of moral injury.

Nevertheless, if burnout was simply a function of physician practice, solutions would be confined to that arena. Unfortunately, burnout begins even in medical school and residency. Dyrbye and others have been at the forefront of the literature documenting that medical students at undergraduate matriculation have less burnout than peers who pursue other careers after college, but during the course of medical school and residency, these learners at some point achieve burnout even before embarking on independent physician practice.5 Therefore, any solutions to eventual physician burnout need to take into account this early burnout, and solutions cannot be confined to physician practice.

In JAMA Network Open, Dyrbye et al6 add to this important and growing literature by providing the first large-scale longitudinal study of a national sample of trainees that documents the association of mistreatment and perceptions of the learning environment in the second year of medical school with subsequent burnout, loss of empathy, and career regret by graduation. Strengths of the study include the large sample size, with the 14 126 responders included in the final analysis representing nearly 25% of all US medical school graduates from 2016 to 2018, and demographic distributions suggesting generalizability. Of these students, 22.9% reported some mistreatment by the second year of medical school, and career regret increased from 3.9% to 7.1% by graduation (in other words, 1 in 14 US medical school graduates already regret medicine as a choice of career even before their residency begins). On the positive side, some aspects of the learning environment were associated with less decline in student empathy and less increase in measures of burnout and career regret, including students’ perceptions of academic and nonacademic support and nurturing from faculty, as well as social and academic support from peers. This leads to the authors’ hopeful conclusion: “Our findings suggest that strategies to improve student well-being, empathy, and experience should include approaches to eliminate mistreatment, optimize faculty-student interactions, build peer support, and enhance students’ self-efficacy.”6 Indeed, findings from this study suggest that if medical schools can work to modify and improve aspects of the learning environment, student burnout, career regret, and the decline of empathy could be lessened.

Despite this hopeful conclusion, the policy relevance of the findings is limited. The challenge is that the analyses are performed at the student level, not the school level. The authors note that “the medical school campus explained the largest difference in MSLES [Medical School Learning Environment Survey] scores.”6 In this sample, some students in this study perceived mistreatment and did not believe the learning environment was supportive, but students from the same school believed the learning environment was indeed supportive. For a school considering change based on these findings, does the school focus on making global changes to aspects of the overall learning environment, or do they identify students not supported by the current learning environment to tailor support on an individual level rather than a macro level? For example, many students may feel supported by schools with house systems or pass/fail grading, but some students would prefer different systems or approaches. Is it plausible for a school to construct learning environments that meet individual student needs, or is the best we can do at the macro level? If the latter, a follow-up to the present study could be to compare schools in, for example, the top quintile of learning environment scores nationally (because this suggests that most of their students rate the environment highly) with the bottom quintile (assuming 60% of schools not in these quintiles are “average”). If there are differences on a macro level in the construction of the learning environment from these top compared with bottom schools, this would suggest that the problem and therefore the solutions lie mainly within the school, which would indeed provide policy relevance and guidance for medical schools.

Nevertheless, the present study adds to the literature in an important way—and as good research does, it stimulates more questions. For example, women in this study had fewer adverse outcomes than men, and a better understanding of the reasons for these findings would be of great interest. The authors note that US Medical Licensing Examination Step 1 scores are associated with student perceptions of the learning environment, but the current study has no measures of student academic performance.7 This begs the question: Do the students who are performing poorly and spiraling into burnout and despair formulate negative views of the school in general (including the learning environment), or does the unsupportive learning environment lead to adverse academic outcomes? A deeper understanding of this phenomenon would help schools as they consider the best approaches for student support and the learning environment. Despite these limitations, the present study by Dyrbye et al6 is intriguing in its findings that aspects of the learning environment could affect student burnout and other adverse outcomes, and future studies building on these findings should help medical schools mitigate student burnout, at least buffering them for the burnout challenges that await in residency and practice.

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Article Information

Published: August 9, 2021. doi:10.1001/jamanetworkopen.2021.19344

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Griffith CH III. JAMA Network Open.

Corresponding Author: Charles H. Griffith III, MD, Departments of Internal Medicine and Pediatrics, University of Kentucky College of Medicine, 800 Rose St, Room MN 143, Lexington, KY 40536 (cgrif00@uky.edu).

Conflict of Interest Disclosures: None reported.

References
1.
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2.
West  CP, Dyrbye  LN, Shanafelt  TD.  Physician burnout: contributors, consequences and solutions.   J Intern Med. 2018;283(6):516-529. doi:10.1111/joim.12752PubMedGoogle ScholarCrossref
3.
Rotenstein  LS, Torre  M, Ramos  MA,  et al.  Prevalence of burnout among physicians: a systematic review.   JAMA. 2018;320(11):1131-1150. doi:10.1001/jama.2018.12777PubMedGoogle ScholarCrossref
4.
Mantri  S, Lawson  JM, Wang  Z, Koenig  HG.  Prevalence and predictors of moral injury symptoms in health care professionals.   J Nerv Ment Dis. 2021;209(3):174-180. doi:10.1097/NMD.0000000000001277PubMedGoogle ScholarCrossref
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Brazeau  CM, Shanafelt  T, Durning  SJ,  et al.  Distress among matriculating medical students relative to the general population.   Acad Med. 2014;89(11):1520-1525. doi:10.1097/ACM.0000000000000482PubMedGoogle ScholarCrossref
6.
Dyrbye  LN, Satele  D, West  CP.  Association of characteristics of the learning environment and US medical student burnout, empathy, and career regret.   JAMA Netw Open. 2021;4(8):e2119110. doi:10.1001/jamanetworkopen.2021.19110Google Scholar
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Wayne  SJ, Fortner  SA, Kitzes  JA, Timm  C, Kalishman  S.  Cause or effect? the relationship between student perception of the medical school learning environment and academic performance on USMLE Step 1.   Med Teach. 2013;35(5):376-380. doi:10.3109/0142159X.2013.769678PubMedGoogle ScholarCrossref
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