Burnout in medical school: signs and prevention

The semester began with goals: review every week, get back to the gym, sleep eight hours. In October, the student opens the summary and reads the same paragraph three times. The patients from the clerkship became tasks, the exams became threats, and the question "why did I choose this?" shows up every day. She thinks it is just tiredness and that vacation will fix it.

NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.

Sometimes it does. Sometimes it is burnout, a syndrome with known signs, common among medical students and linked to serious risks. This guide explains what burnout is, how many students it affects, how to recognize the signs and what studies show about prevention, for the student and for the school.

Key points

• Burnout has three dimensions: emotional exhaustion, depersonalization and a sense of low accomplishment.
• Meta-analyses estimated that more than a third of medical students have burnout before residency.
• In a US longitudinal study, burnout predicted suicidal ideation in the following year, and recovery was associated with less ideation.
• Medical students had more burnout than people of the same age in other careers.
• Individual interventions and changes in organization reduced burnout in physicians, and the two fronts complement each other.

What burnout is

Three dimensions

Burnout is a syndrome linked to chronic stress from work or study. The most used questionnaires measure three dimensions: emotional exhaustion, which is tiredness that does not go away with a night of sleep; depersonalization, which is cynical detachment from patients, colleagues and tasks; and a sense of low accomplishment, which is feeling that nothing you do has value.

Different from tiredness and from depression

Tiredness after a week of exams improves with rest. Burnout persists and affects the relationship with the course. Depression affects all areas of life, while burnout starts linked to work or study; the two conditions, however, often overlap, and only a professional assessment separates one from the other.

Close neighbors

Two topics in the series touch on this one. The distress after an error with a patient, called the second victim, is an acute event. Impostor syndrome is the persistent feeling of being a fraud. Both can feed burnout and have their own guides.

How many students are affected

What the meta-analyses say

A meta-analysis with 24 studies and 17,431 students estimated the prevalence of burnout before residency at 44.2% (Frajerman et al., 2019). Emotional exhaustion reached 40.8%, depersonalization 35.1% and low accomplishment 27.4%, with no significant difference between sexes (Frajerman et al., 2019).

Another meta-analysis, with 42 studies and 26,824 students, estimated the global prevalence at 37.23%, with variation between countries and between questionnaires (Almutairi et al., 2022). In that analysis, older age and female sex were significant predictors of burnout (Almutairi et al., 2022).

The two estimates differ, and heterogeneity between studies was high. The common message is that burnout is frequent enough to be treated as a collective issue, not as an individual weakness.

Compared with other careers

A US national survey compared medical students, residents and early-career physicians with people of the same age range in other professions (Dyrbye et al., 2014). The three medical groups had more burnout than the comparison population, and students and residents had more symptoms of depression (Dyrbye et al., 2014). The authors concluded that training seems to be the peak of distress in the medical career (Dyrbye et al., 2014).

Why burnout matters

The link with suicidal ideation

A study with 4,287 students from seven US schools, with part of them followed for a year, found burnout in 49.6% and suicidal ideation in the last year in 11.2% (Dyrbye et al., 2008). At follow-up, burnout and low mental quality of life were independent predictors of suicidal ideation in the following year (Dyrbye et al., 2008).

Of the 370 students with burnout at the start, 26.8% recovered, and recovery was associated with far less suicidal ideation (Dyrbye et al., 2008). The finding is a concrete reason to take burnout seriously and a reason for hope: recovery is possible and it makes a difference.

Risk factors for suicidal ideation

A meta-analysis of 25 studies on medical students found depression, burnout, other mental illnesses and stress as the factors most strongly associated with suicidal ideation (Seo et al., 2021). For burnout, the odds ratio was 6.29 (Seo et al., 2021).

If you have thoughts of hurting yourself or of not wanting to live, seek help today: your school's psychological support service, a health service or someone you trust, and get the help you need without waiting.

Warning signs

In yourself

• Exhaustion that does not go away with a weekend or a holiday.
• Detachment: patients become tasks, colleagues become an annoyance, and your mood turns cynical.
• A sense of uselessness: studying a lot and feeling that nothing sticks.
• Changes in the body: poor sleep, pain, appetite changes, getting sick often.
• Escape: putting everything off, missing commitments, increasing the use of alcohol or other substances.

In colleagues

Isolation, unusual irritation, a sudden drop in performance and comments of hopelessness deserve attention. A direct, non-judgmental question, such as "you seem tired lately, do you want to talk?", usually opens more doors than advice.

When to seek help

When the signs last for weeks, get in the way of studying and personal life, or come with persistent sadness and thoughts of death. A professional assessment also helps separate burnout from depression and anxiety, which require specific care.

Prevention: what works

What studies with physicians show

A meta-analysis of 15 randomized trials and 37 cohort studies assessed interventions against burnout in physicians, without including students (West et al., 2016). Overall burnout fell from 54% to 44%, and high emotional exhaustion fell from 38% to 24% (West et al., 2016). The authors concluded that both individual strategies and structural ones, tied to work organization, brought benefit (West et al., 2016).

The data come from practicing physicians, and applying them to undergraduate study should be done with care. The general lesson, that the individual and the institution need to act together, holds for both contexts.

What the student can do

• Protect your sleep: it is the first thing to go and the one that weighs most in recovery.
• Plan with slack: a schedule with no room for the unexpected fails in the first hard week. The guide on how to study during the clinical rotation with little time offers a model.
• Study actively: active learning methods deliver more in less time than rereading summaries.
• Keep ties outside medicine: friends, family and activities that do not involve exams.
• Move your body regularly, at the pace you can manage.
• Ask for help early, before you reach your limit.

What the school can do

The structural part includes reviewing the volume of course hours, offering accessible and confidential psychological support, training preceptors to recognize signs and fighting teaching by humiliation. Measuring burnout periodically and anonymously helps show whether the changes are working.

Beware of individual-only solutions

Teaching breathing and organization is useful, but not enough when the problem lies in the structure of the course. If half the class has burnout, the cause is rarely only in each student.

Class representatives and student organizations

Student centers, class representatives and student organizations can bring the coordination data on exam load, overlapping activities and access to psychological support. A simple anonymous survey, repeated every semester, gives concrete arguments for requesting changes and shows whether they worked.

Studying, breaks and NEXO

NEXO was designed to fit into a full day: one case of the day, fictional and with a real clinical presentation, arriving in up to six clues. The round is short and has an end, which helps those who need practice without opening yet another endless study front.

The game is a study tool, and mental health care comes from people and services. If the case of the day has become just another obligation, take a break without guilt. The guide what NEXO is explains the whole match, and the release of modes is on the NEXO economy page.

If you coordinate a medical school, a student league or a residency and want to use cases in light activities with a set time, meet NEXO Closer. Researchers in medical education can propose studies through NEXO Researcher. Doctors who review cases take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.

Frequently asked questions

How many medical students have burnout?

Meta-analyses estimated between 37.23% (Almutairi et al., 2022) and 44.2% (Frajerman et al., 2019) before residency.

What are the symptoms of burnout?

Emotional exhaustion, cynical detachment from patients and tasks, and a sense of low accomplishment, often with poor sleep and physical complaints.

Is burnout the same as depression?

They are different conditions that often overlap. A professional assessment helps to tell them apart.

Does burnout go away?

It can. In an American study, 26.8% of students with burnout recovered within a year, with less suicidal ideation (Dyrbye et al., 2008).

What works for prevention?

Individual strategies and changes in organization reduced burnout in doctors (West et al., 2016).

Where to seek help?

At the psychological support service of your school or at a health service. In a crisis, seek the help you need immediately.

Prevention checklist

1. Protect your sleep above all.
2. Plan with slack for the unexpected.
3. Study actively and in short blocks.
4. Keep ties outside medicine.
5. Watch for the signs in yourself and in your colleagues.
6. Ask for help early at your school's service.
7. Demand structural changes from the institution.

Want to practice in a short time? Play the case of the day on NEXO.

References

1. Frajerman A, Morvan Y, Krebs MO, Gorwood P, Chaumette B. Burnout in medical students before residency: A systematic review and meta-analysis. Eur Psychiatry. 2019. https://pubmed.ncbi.nlm.nih.gov/30384110/
2. Almutairi H, Alsubaiei A, Abduljawad S, Alshatti A, Fekih-Romdhane F, Husni M, et al. Prevalence of burnout in medical students: A systematic review and meta-analysis. Int J Soc Psychiatry. 2022. https://pubmed.ncbi.nlm.nih.gov/35775726/
3. Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014. https://pubmed.ncbi.nlm.nih.gov/24448053/
4. Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008. https://pubmed.ncbi.nlm.nih.gov/18765703/
5. Seo C, Di Carlo C, Dong SX, Fournier K, Haykal KA. Risk factors for suicidal ideation and suicide attempt among medical students: A meta-analysis. PLoS One. 2021. https://pubmed.ncbi.nlm.nih.gov/34936691/
6. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016. https://pubmed.ncbi.nlm.nih.gov/27692469/