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The journey toward becoming a physician can be an arduous one, with each stage of training bringing new challenges that can threaten an individual’s personal wellness. Even prior to the COVID-19 pandemic, demands and expectations from the specialty have been increasing exponentially with medical advancements over the past few decades. Focusing on the mental well-being of health care workers and equipping trainees with the right tools to prevent burnout are more important than ever. Although many positive changes have been made toward emphasizing student wellness in recent years, the data suggest they are not working.

“These are the duties of a physician: first, to heal his mind and to give help to himself before giving it to anyone else.” —Epitaph of an Athenian physician, 2 AD 

One notable systematic review and meta-analysis using data from 47 countries identified that a staggering 27.1% of medical students have depression or depressive symptoms and another 11.1% have suicidal ideation.¹ Additionally, about 400 medical students or physicians commit suicide each year in the United States.² Across their lifetime, physicians experience levels of depression similar to those of the general population. However, rates of suicide in this population are substantially higher, with male physicians being 1.5-3.8 times more likely and female physicians being 3.7-4.5 times more likely to commit suicide than the general population.^3-5

Evidence suggests that certain specialties may be at higher risk of suicide, including anesthesiologists, psychiatrists, general practitioners, and general surgeons.⁶ These physicians experience higher rates of suicide attempts and successful suicides, ⁷ possibly due to their added knowledge of toxicology and understanding of the techniques for suicide.⁸ In particular, anesthesiologists have access to drugs in their workplace.⁹ Shanafelt et al found that physician burnout increased by around 10.0% from 2011 to 2014 to an average rate of 54.4%, whereas the average burnout rate in the general working population remained steady at 28.0%.^10,11 The prevalence of burnout differed across medical specialties as well, with emergency medicine physicians experiencing the highest levels of burnout, followed by anesthesiologists, and preventive/occupational medicine physicians experiencing the least.¹⁰

Additional Challenges from the COVID-19 Pandemic

The COVID-19 pandemic has seen a shift in practice for nearly all physicians, with anesthesiologists experiencing some of the most extensive changes. According to a report from the American Society of Anesthesiologists (ASA), many anesthesiologists “pivoted from working in the operating room to treating COVID-19 patients in critical care units, making the most of their expertise in intubation, ventilation strategies, and critical care medicine, which includes all aspects of resuscitation with multiorgan failure.” ¹² Suddenly, responsibilities included unusual and mentally draining tasks such as participating in the decision-making process with grieving families not permitted to visit their loved ones due to isolation restrictions.¹³ Not surprisingly, insomnia, burnout, and depression incidence among medical staff escalated substantially during the pandemic.¹⁴

The pandemic also posed unprecedented challenges to the health and wellness of all medical learners. Some of the ways in which the pandemic threatened mental health for medical students were through:

• Forced virtual learning and social isolation
• Technological difficulties in remote delivery and exam taking
• Missed class time due to illness
• Reduced opportunities for social bonding and peer support
• Limitations in clinical exposure
• Limited access to public gyms and other recreational spaces for physical activity
• Limitations on in-person extracurricular activities
• Inability to participate in away rotations
• Virtual interviews for residency placement.

Statistics showcase an alarming reality that, although more emphasis has been placed on wellness in recent years, students, residents, and staff physicians are not all doing “well.” As is the case with many transgenerational issues, we suggest starting at the source – specifically, at medical schools.

Factors That Contribute to Burnout

“These are the duties of a physician: first, to heal his mind and to give help to himself before giving it to anyone else.” —Epitaph of an Athenian physician, 2 AD ¹⁵

The fundamental role of medical professionals is to help patients return to or improve upon their baseline of health, which encompasses physical, mental, and spiritual dimensions. The success of the physician in this eternal pursuit extends beyond their clinical knowledge and expertise. To pave the path of wellness, one must understand the contributors to burnout.

It is well understood that both burnout and depression can negatively impact the wellness of physicians, which can consequently lead to patient harm.^16-19 This can be a vicious cycle. As symptoms of physician burnout (eg, emotional exhaustion or depersonalization) progress, work performance declines and the likelihood of errors increases, which can have a negative impact on wellness.^20,21 In the past, it was believed that burnout was primarily the result of personality traits; however, this now appears inaccurate, given that more than half of U.S. physicians struggle with burnout.²² Recent evidence suggests that burnout is a consequence of the unique experiences, influences, and health care interactions of each physician. ²² The modern-day health care system has been enriched with technology in an effort to lighten the load on the health care team. However, the adoption of electronic records, orders, and test results, along with virtual hospital visits, has led to increased workloads and reductions in work-life balance.²²

Increased workforce demands and the labor shortage also contribute to increased levels of burnout. The COVID-19 pandemic further increased the demand for health care, already at high levels because of the aging population and wider insurance coverage. At the same time, the workforce continues to shrink as many anesthesiologists decided to reduce their working hours or retire altogether during the pandemic.²³ ASA predicted in 2013 that, by 2025, there would be a shortage of 3,000 anesthesiologists.²⁴

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With our continued efforts to explore mental health in medicine, there is reason to be hopeful that we will be equipped to face our old habits head-on, and in turn nurture our trainees so they are successful and happy in their medical careers.

Caring for COVID-19 patients has not been the sole reason for increased stress during the pandemic. Physicians in the United Kingdom have reported increased incidences of discrimination (reported by Black, Asian, and other minority staff).²³ In addition, many physicians were forced to find living arrangements away from their families, and many parents struggled to find childcare services for children who had to stay home from school. These factors forced many physicians to stay home themselves and transition from full-time to part-time work, particularly women. About 40% of anesthesiologists under 36 are women, and women are three times more likely than their male colleagues to work part time.²⁵ Finally, COVID misinformation may be responsible for an increased prevalence of patient aggression, and even assault, toward health care providers, leading some providers to implement “panic buttons.'' Misinformation-driven anger and frustration may be a notable driver of burnout among health care providers.²³

The Traditional Medical Education Curriculum

Armed with an understanding of some of the factors that contribute to burnout in medicine, medical schools are an ideal place to start addressing the problem. To appropriately reflect on where we are headed, it is useful to evaluate progress over the years. Kassebaum et al²⁶ provided an in-depth look at the culture of student abuse/mistreatment at medical schools in the 1990s. The following were described as occurring regularly.

• Verbal abuse in the form of public belittlement, humiliation, and berating
• Educational abuse in the form of excessive workload, sleep deprivation, and inappropriate grading
• Sexual and racial harassment
• Physical abuse
• Requests to perform personal services such as grocery shopping or babysitting

The article described a culture in which many of these behaviors were seen as entrenched in the educational curriculum and rites of passage, often interpreted as unavoidable parts of the educational process and medical culture. The acceptance of such destructive behavior led to a “transgenerational legacy” of abuse that continued to be passed down, the authors reported.²⁶ However, more than 15 years later, a systematic review and meta-analysis concluded that 59.4% of medical trainees continued to experience at least one form of harassment or discrimination during their training, with verbal harassment being the most common.²⁷

This likely reflects a traditional culture that is still ingrained in the medical system. Greater awareness of wellness across the medical profession is urgently needed from top to bottom to make impactful change. Medical students are future doctors who will continue to be exposed to stressful lifestyles and remain at high risk for burnout. Therefore, promoting wellness, modeling good behavior, providing students with coping strategies such as mindfulness, and building resilience will be advantageous for their future careers. Maintaining good mental health will be key for both their own well-being and that of their future colleagues.

Recommendations for Change in the Medical School Curriculum

Numerous studies have provided recommendations on how to improve the wellness of students, residents, and staff physicians.^28-31 These revolve around increasing education, recognizing wellness and its role as an important part of personal and professional lives, creating a safe space for learning and working, destigmatizing mental health, and making confidential counseling services more accessible so that people can seek help early. Specific recommendations for medical students focus on examining and condensing the medical curriculum into more digestible and less redundant materials. As medical school is already a competitive environment, replacing the granular grading system with a pass/fail grading system will reduce stress levels. Establishing a well-structured mentor/mentee program will encourage “checking in” and obtaining early access to help if necessary. Creating and promoting a wellness committee also encourages a sense of community and helps to build a safe space to open communications and report problems (Figure 1).

Figure 1. Venn Diagram showing recommendations on how to improve the wellness of students, residents, and attending physicians

These are certainly welcome changes, and a top-down approach may increase compliance. Other recommendations to minimize resident and physician burnout and promote wellness include implementing duty-hour limits, providing communication skills and leadership training, creating flexible work schedules, and focusing on aspects of work that are most meaningful to specific individuals.^28-31 Some of these may be challenging if there are not enough people within the workforce. With the pandemic, certain specialties like anesthesiology have had difficulty recruiting and retaining workers, which further impacts the overall workload on anesthesiologists and, in turn, their wellness. Strategies at the management level are needed to increase recruitment, express appreciation to existing staff for their work and efforts, eliminate undesirable elements in the workplace or workforce, and provide adequate resources for frontline staff. It is also important to understand the workload limits among the existing staff while paying attention to feedback and needs from staff members. Otherwise, existing staff will become more burned out, thereby reducing workplace satisfaction and leading to aforementioned challenges.

One notable suggestion that aims to prevent burnout is for physicians to devote 20% of their work time toward a part of their practice that is especially meaningful to them and best aligns with their core values.³¹ Evidence also supports the notion that physician wellness is tied to the leadership that they receive. For example, for every 1% increase in leadership composite score (the higher the score, the better leadership qualities of their immediate physician supervisor), there is a subsequent 3% decrease in burnout and a 9% increase in satisfaction.³²

Although most medical schools currently implement some form of wellness training, one study suggests that only 22% are focused on evaluating program effectiveness while the remainder are focused solely on student participation without evaluating effectiveness.³³ This suggests that more effort is required to evaluate the wellness strategies implemented at medical school and to make necessary adjustments to improve the program.

Personal Experience

The leading theory that student wellness will translate to resident and subsequently physician wellness is a promising method to combat the transgenerational impacts of an abusive medical culture. I (DH) can attest firsthand that many of the proposed initiatives to combat levels of medical student burnout and depression are currently being deployed. First and foremost, the pass/fail grading system used by Canadian medical schools retains the focus on learning and removes much of the anxiety driven by a grade-focused curriculum. In addition, a focused mentorship program is being used in several capacities. One such example is mandatory periodic wellness check-ins paired with academic mentorship for any students struggling with the learning material. Longitudinal mentors also have been paired with students for routine check-ins regarding academic performance, study strategy, and overall wellness. Lastly, many student-led groups are working to improve access to mental health resources, organizing self-care workshops, and attempting to destigmatize mental health challenges among students.

Unlike many other fields of study that see a notable portion of each class either voluntarily drop out or fail out of the program, medical schools enjoy a comparatively high graduation rate. As a result of this, the inter-class competitiveness seen in other fields is generally not present, giving way instead to an environment of support, comradery, and a feeling of community.

One example of an extracurricular activity geared toward this sense of community is an initiative that I (DH) co-lead called the Mental Health Advocates. This group organizes a “Mental Health Week” containing lunch talks and events aimed at promoting wellness and destigmatizing mental health challenges. Our premier event is known as the “Mental Health Monologues,” where students come gather at a venue and enjoy an evening listening to and sharing student stories of mental health challenges and triumphs. Creating a safe space to share these experiences goes a long way in breaking down the stigmatization that has existed surrounding mental health struggles and shows students firsthand that they are not alone facing these challenges.

In addition to student-lead initiatives, the faculty of medicine and dentistry at the University of Alberta has an entire department dedicated to advocacy and well-being. This group does an outstanding job from day one of medical school by educating students on healthy wellness practices, providing timely counseling and therapeutic services, and increasing awareness of all things relating to wellness and mental health. Speaking earlier to the fact that an increased emphasis on wellness should begin in medical school, it is imperative that these services and increased educational resources extend beyond medical school and support residents and staff physicians to reduce levels of burnout and abusive behavior at the attending level.

Conclusion

Although some of the provided statistics suggest that student, resident, and physician wellness levels are lower than that of the general population, there is room for optimism. Suboptimal wellness training for physicians and trainees is a transgenerational problem with many factors. Although recent trends do not demonstrate obvious improvement in rates of burnout, depression, or suicide, concerted effort toward action is evident.

It is imperative that the medical education curriculum continues to adapt to the evolving challenges facing today’s students such as remote learning, an increasing role of technology and responding to a global pandemic. With our continued efforts to explore mental health in medicine, there is reason to be hopeful that we will be equipped to face our old habits head-on, and in turn nurture our trainees so they are successful and happy in their medical careers.

Dylan Hollman, BSc, is a medical student CR2 at the University of Alberta Faculty of Medicine & Dentistry in Edmonton, Canada.

Vivian Ip, MBChB, FRCA, is a clinical professor at the University of Alberta Hospital in Edmonton, Canada.

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