Monday, November 8, 2010

Medical Student Burnout and Unprofessional Conduct

Recently, AAFP News Now released an article titled
Unprofessional Conduct Among U.S. Medical Students Linked to Burnout
It focused on an article recently released in JAMA entitled
Relationship Between Burnout and Professional Conduct and Attitudes Among US Medical Students

I had the opportunity to be interviewed for this article and was featured on an inset within the article that shared a minority of my interview. As I am currently rotating on inpatient medicine at a local community hospital, I am once again experiencing our health care system at its finest - a lot of wasteful spending and unnecessary testing. I am taking a look back at what I had wrote down for the interview and decided to paraphrase the majority of my response into the following blog post regarding the health care system and medical education.

When looking at the advances we have made in biochemistry, genetics, and molecular biology, we are being asked to know so much more information in much greater detail – and still within these 4 years worth of medical school.As more requirements are created and more scientific advances are brought forth, more time is needed in lecture and studying for tests like the USMLE and shelf exams. Most traditional programs are 4 years with 2 years of foundational science and 2 years of
clinical experience.

For one, I believe that medical school admissions do not do a good job
at identifying candidates that will provide an adequate workforce and/or will be good for medicine. It must be extremely difficult to screen applicants to figure out who is genuine about the profession – who is going into medicine because they truly want to go into medicine... on the other hand, who is going into medicine because they test well, and/or because their parents forced them into it throughout childhood. This is definitely a minority of students but nevertheless, takes away seats from other potential medical students who may choose to serve a better purpose and population within our health care system's needs.

Maybe we are not bringing enough students into medicine that come from
underserved areas; maybe we are not screening correctly in the
admissions process to accept students who display genuine altruistic views
and who do not fabricate an artificial personality in an interview
and/or on a personal statement. The 40 MCAT, 3.9 pre-med GPA and 5
publications may look good on paper but may fail miserably at
developing into an altruistic and compassionate physician.

It would be interesting to figure out specific determinants that make
students less altruistic and less likely to serve the medically
underserved. As medical students, we are molded by the experiences we
are faced with during clinical rotations. Were these students who had more
contact with patients who manipulate the health care system for
primary or secondary gain? In most cases, our attitude in respect to
patient populations trickles down from our attending physicians,
residents and interns.

With defensive medicine taking precedence in many situations, medical students take notice of the frustrations felt by our superior members of the team. Are these attitudes more likely to occur in underserved areas? If so, medical students are not only discouraged, but definitely overwhelmed at the amount of follow-up
required of the large volume of unnecessary testing that occurs. We spend so much time trying to cover our back that the amount of quality learning that actually occurs is dramatically reduced.

If we took just half the amount of time we waste on defensive medicine
and documentation and shifted that towards more time for teaching
rounds and instructional time by attending physicians and residents, I
believe medical students would feel more satisfaction with their
education and clinical experiences. As it is, medical students spend
most of their time trying to help the interns and residents with
non-educational work (what we refer to as “scut work”) so that we may
eventually have time at some point for educational purposes.

Additionally, because there is so much more hand-holding by attending
physicians towards the residents and all the way down to the medical
students, it is difficult for medical students to convince themselves
that they are actually contributing to the care of patients. Taking
all of this together, it does not surprise me that studies are showing
that medical students are burning out, documenting non-factual
clinical findings, lacking altruism and altogether becoming
unprofessional throughout the process.

The medical community as a whole needs a “face-lift” in regards to everybody’s attitude towards health care delivery. I do not think this will be possible until the health care system undergoes a much more meaningful reform to address the issues that attending physicians, residents, and medical students face due to the current clinical environment. The current political environment is not going to alleviate any of these issues because nobody is willing to commit to long-term changes in health care delivery and tort law.

Without meaningful tort reform, proper emphasis and payment for primary care, and population education about meaningful health care reform and personal responsibility, we will not peel through the layers and fix any of the intended and unintended consequences that have accumulated throughout years of failed policy and legislation.


  1. "it is difficult for medical students to convince themselves
    that they are actually contributing to the care of patients"

    Difficult indeed.

  2. Thanks for the good post, MDstudent31. A lot of important issues were introduced and discussed. Your comments generated a flashback for me to the VietNam conflict (we never declared war). Well trained, dedicated troops were available to fight as teams and committed to protect each other. A confused US Government wanted measurable indicators of successful warlike production (because former Ford president Robert McNamara was Secretary of Defense). The outcome measure chosen for success was dead bodies of enemy. The troops, who understood how to fight together to secure a military objective as an outcome measure of success, became demoralized when they were told to be killers to succeed. This lead to increased drug abuse and mental health problems as making and counting dead enemy bodies became the goal. Atrocities and dishonesty ensued, adding to the embarrassment experienced with the whole Viet Nam situation.
    Highly motivated medical students, as mentioned in your post, when misaligned with their values, goals and dreams by participating in wasteful quests for the wrong outcome measures of clinical success may be reacting with burnout and increased mental health problems, similar to our troops in Viet Nam. Good people when trapped with a betrayal of their values by revered leaders such as clinical service attending physicians, residents and interns, may become confused and disillusioned. We as practicing physicians owe more to the physicians of the future.
    Thanks for your stimulating comments.

  3. Since I can't find any direct contact information for you (plural; specifically the author of this post), I'd like to respectfully offer some blogging feedback on this post.

    You have five distinct topics here:
    1) more information to learn in the same short 4 years,
    2) the difficulty of selecting appropriate candidates for medical school,
    3) what defensive medicine looks like from the student perspective,
    4) the sense that the education of residents, not students, takes precedence in the clinical setting, and finally,
    5) a general call to arms/everyone needs an attitude adjustment.

    The best blog posts are those which cover a single topic in at least moderate detail. Ideally when one presents a problem, one tries to include something along the lines of a solution, however idealistic or problematic to actually implement (ie, perhaps the medical school application process should include time spent with actual clinicians, who then have input about who gets admitted; or whatever). Just plain ranting -- going on and on about things you don't like but have no idea how to fix -- can get boring.

    The nice thing about blogging is that there are no space limitations. You have enough material here for 4-5 quality posts. Go ahead and write them separately. The blog as a whole will be better for it.

  4. Thank you for the feedback and for reading our blog. The purpose of this post was to act as a supplement to the information presented in ANN. Future blog posts are definitely going to be shorter, simpler, and less complex. It just seemed fitting to put all of the responses for everybody to view, unedited.