This piece is part of in-Training Mental Health Week.
In the fall of my first year, barely a week into my new life as a medical student, I met an old friend from college who had recently started her residency in New York. It was still warm enough for ice cream, and we sat with our dripping cereal milk cones in Central Park — it had been four years since we last saw each other in college. She seemed upbeat and largely caught up on sleep after finishing her rough rotation the previous week. “How’s life?” I asked generically. As the ice cream diminished we caught up on my post college work and travel, and about my decision to apply to medical school after a few detours along the way. I ask her if she has any advice, now that I sat at the beginning of one journey, and she another.
Beyond the practical tips on how to study effectively and seeking out the right mentors, there was also the oft-repeated refrain to “take care of yourself” and to avoid “burning out.” I was prepared to tuck this into my back pocket along with the other warnings that medical school would be hard and that self-care is of great importance until she quietly mentioned that earlier that same week, a colleague in her intern class had committed suicide. She was still struggling to make sense of it. “And,” she added, “as much as being a doctor is the greatest job in the world, depression and burnout are real problems — problems that I’m not sure we know yet how to come to terms with.”
The data on the matter is certainly less than encouraging. A review of the literature reveals that burnout is prevalent in medical students (28%–45%), residents (27%–75%, depending on specialty), as well as practicing physicians. It’s worth saying that burnout is not unique to medicine. However, the challenges within medical practice and training are unique in poignancy, and worth understanding to better inform how trainees can inoculate against them.
First coined in 1974 by psychologist Herbert Freudenberger, burnout has broadly been defined as long-term exhaustion and diminished interest in work resulting from a long-term exposure to stressful working environments. The social psychologist Christina Maslach developed the commonly used instrument for assessing burnout, known as the Maslach Inventory, which describes the condition as composed of three dimensions: (1) emotional exhaustion, characterized by lack of energy and general negative affect, (2) cynicism or depersonalization, involving an uncaring response to others, and (3) reduced personal accomplishment, whereby individuals believe they will not be able to do their jobs adequately.
Burnout is defined in the World Health Organization’s ICD-10 (International Classification of Diseases) as a “state of vital exhaustion.” Although burnout is not recognized as a distinct disorder in the DSM-V, it has been shown to be associated with depression and even increased rates of cardiovascular disease and inflammatory biomarkers.
Burnout in medical school
Medical school is a notoriously challenging experience during which students undergo tremendous personal change and professional growth. Though the stressors that come along with this are varied and unique to each student’s context and experience, they may be categorized within a few common themes. Harvard psychiatrist Raymond Laurie has previously described the concept of “role strain” with respect to negotiating relationships with their families, friends, partners, peers, attending physicians and patients. Additionally, with regard to students’ concept of themselves, individuals who have high achievement may be challenged in new ways both intellectually and emotionally.
Stress levels are known to be particularly high in the third year, as students make the transition from classrooms to clinical wards. The medicine that is taught is no longer in abstract or in theory, and the consequences of the care given are directly observable in the lives of patients. As such, the clinical experiences that students encounter may at times be tremendously rewarding, but also challenging when patients’ conditions decline or when they eventually pass away.
In a 2009 study of Mount Sinai third-year medical students, a research team led by Haglund, Charney and Southwick assessed the impact of trauma — as stipulated by the criteria defined in the DSM-V — on medical student well-being. While the study confirmed that trauma exposure is indeed common at this juncture in training, the study notably found that students who encountered more traumatic events also experienced more personal growth, suggestive of resilience.
What is resilience and how can it help us?
Dr. Charney didn’t originally set out to study resilience in medical students. In fact, as a neuroscience researcher at Yale in the late 1980s, he first became interested in studying post-traumatic stress disorder (PTSD) in veterans after he and colleague Steve Southwick noticed that PTSD did not strike veterans indiscriminately. “We decided that there was a lot we could learn about people who were traumatized, but didn’t develop PTSD. In other words, people who were resilient.”
As is described by Charney and Southwick, materials and objects are termed resilient within the physical sciences if they resume their original shape upon being bent or stretched. In people, resilience refers to the ability to “bounce back” or “bending but not breaking” after encountering stress or trauma, sometimes even growing from the experience. Charney and Southwick’s work has since explored the biology of stress and its impact on the brain through the study of groups who have faced uniquely challenging circumstances — ranging from navy seals and former Vietnam prisoners of war to individuals born with congenital diseases — to determine whether there were traits that were protective against PTSD, or predictive of resilience.
After over two decades of research, the traits that were found in individuals who seemed able to “bounce back” even after facing significant trauma converged around a number of common themes.
To take one example, the importance of role models is of particular relevance for medical students because of the apprenticeship model in which training programs are structured. The results from the 2009 study showed that support from team members was instrumental to increasing levels of personal growth following exposure to trauma. At the same time, the study also echoed previous findings that poor role modeling by superior physicians correlates with increased student cynicism as well as rates of anxiety and depression. As such, these results emphasize the importance of positive faculty-student dynamics to facilitate a supportive training environment.
Notably, this framework suggests that resilience is more than a concept and is in fact an approach to living. It submits that these traits are not fixed in our personalities, but changeable, with the possibility for improvement — even if it likely won’t be easy. Building resilience requires practice and consistent effort over a sustained period of time. Rather than trying to implement all of the strategies at once, Charney suggests choosing one or two ideas that feel natural and doable.
In her 2004 memoir The Year of Magical Thinking, Joan Didion reflects on growing up the daughter of a geologist. “A hill is a transitional accommodation to stress and ego may be a similar accommodation. A waterfall is a self-correcting maladjustment of a stream to structure and so, for all I know, is technique.” Ultimately, we all need to discover the strategies that best address our own structural stresses and maladjustments — whether it be reflecting upon difficult situations with trusted mentors, friends or family, or utilizing the various resources available to us, ranging from student mental health tools to student led organizations. As medical students, it is upon all of us to proactively pursue our best selves.
Indeed, our future patients will be counting on it.