Burnout alarmingly high in medical students and young doctors

On 27 July 2018, news broke that world-renowned cardiologist and Dean of the Health Sciences Faculty at the University of Cape Town, Prof. Bongani Mayosi, had taken his life. Shockwaves rippled through the global medical society. How was it possible that mental illness – reportedly depression - overcame such a giant? Prof. Mayosi’s impeccable career saw him contribute to the isolation of a genetic mutation that increases risk of heart attack in otherwise healthy people and to ground-breaking, multinational research into the management of pericarditis and rheumatic heart disease. He also received South Africa’s highest honour, the Order of Mapungubwe in 2009.

His suicide may shock us – but should it surprise us? Depression is a common mental disorder. Globally more than 300 million people of all ages, suffer from depression. Depression is a major contributor to the overall global burden of disease. The World Health Organisation reports that around 800 000 people take their lives every year. 

It's a fact that, like Prof. Mayosi, thousands of outwardly functional medical students and professionals think daily of ending their lives. The 2018 Medscape National Physician Burnout & Depression Report - a survey of some 15 000 physicians from 29 specialities - found 42 % of physicians feel burnout (half of these on a regular basis), while 15% reported feeling depressed. Their reasons included financial pressures, bureaucracy and admin pressures linked to their work, long work hours and lack of respect from colleagues or staff. But the roots of burnout have long enveloped these doctors.  Research published in the August 2018 issue of the American Journal of Medicine - a comparison of data from 2011 to 2014 - found that physician burnout measures highest in emergency medicine, family medicine, internal medicine, and paediatrics. 

In a recent article written for the prestigious New England Journal of Medicine, fourth-year student Leo Eisenstein writes, ‘In medical school, we are led (and allow ourselves) to believe that we as individuals have more power than we do. Despite a shift toward team-based care, the image of physicians as singular heroes, as saviours, remains deeply embedded in medical culture.  As a newcomer to medicine, I feel intimidated by it all.” 

Burnout starts in medical school. Here a significant academic workload, long hours and sleep deprivation, pressures of social isolation, stress of caring for patients in resource-constrained environments, stress of paying off student loans, financial obligation to provide for extended family, as well as other everyday stressors, combine to create a perfect storm that negates young doctors’ physical and mental health. Society expects that doctors will be all-knowing, well-rounded, high-achieving individuals. Doctors expect this of themselves. But at what cost? 

Multiple studies show international, growing alarm and urgency to develop preventive strategies to improve wellbeing and mental health in medical students:

• A recent, systematic review estimated the prevalence of depression or depressive symptoms among medical students at 27.2% and suicidal ideation at 11.1%.
• A meta-analysis of more than 16,500 medical students, presented at European Psychiatric Association 2018 Congress, found that almost 46% of students suffer from burnout, with emotional exhaustion the most common symptom.
• A study of 4287 medical students at seven US medical schools, reported burnout in 49.6% of students, and suicidal ideation in 11.2%.
• A review of published literature from 1974 to 2011 revealed that at least half of all medical students may be affected by burnout during their medical education. 
• A cross-sectional study conducted at the Barretos School of Health Sciences, Dr Paulo Prata in Brazil found a high level of burnout in a total of 330 students in the first four years of medical school. Authors note: 'The mental health of medical students has been a cause for concern on the part of medical schools in several countries: in addition to their study-related burdens, many demands and responsibilities are placed on these students because the profession is dedicated to the health care of people and has very little tolerance for mistakes, favouring the development of stress and anxiety.'

Quantifying young doctor burnout in South Africa

The extent to which mental illness affects medical students across South African universities and young doctors is not well known. Based at the University of Stellenbosch’s Faculty of Medicine and Health Sciences, Dr Alex Parsons* is one of a number of people at universities country-wide currently completing studies to establish the dynamics. “Fears of humiliation and being labelled ‘weak’, ‘incapable’, ‘unprofessional’ or ‘a failure’, prevent medical students asking for help in the face of anxiety, depression and burnout. This vein continues into established medical careers and sets the tone for catastrophic burnout,” says Dr Parsons, whose current MPhil looks into how medical schools should structure their curriculum to prevent student burnout.

“I experienced burnout at end of the second year of internship and took off four weeks of mental health leave as a result. My burnout was, in part, the result of sleep deprivation. This is an area where we can make a significant impact - shortening the 36-hour shifts that doctors are mandated to work and preventing the hospital mismanagement that abuses intern work hours. ” His burnout also emanated from frustration with the system within which he worked. “Young doctors are not afraid of working hard. They are afraid of frustration - needing resources to practice medicine and being without them, as is so often the case in South African state healthcare facilities.” His research is also looking into systems that train empathy into doctors – as a form of resilience to stress. “The unspoken rule in medicine is ‘Don’t get involved too much, don’t carry patient’s burdens. You will burnout.' But, studies show that empathy is protective against developing burnout.”

Discovery and SADAG Helpline offers students and young doctors anonymous support

“Medical students and young doctors are high-achieving, service-oriented people, accustomed to excelling and aware of the privileged degree they have been accepted to do,” says Dr Maurice Goodman, Chief Medical Officer of Discovery Health and Trustee of the Discovery Foundation and Fund. “Society sees young and established doctors as infallible, almost super-human. Many doctors suffer in silence. We need to break stigmas around doctors asking for help. That starts with medical students feeling free to access emotional support,” adds Dr Goodman. “That’s what the Young Doctors and Medical Students Helpline is all about - assisting medical students, interns and trainee doctors to cope with personal stress, mental illness and any other issue that could affect their wellbeing.”

In October 2017, The South African Depression and Anxiety Group (SADAG) and Discovery launched the 24-hour Young Doctors and Medical Students Helpline - an anonymous, free of charge, independent service aimed at reducing the number of medical school dropouts, assisting in crisis situations and preventing medical student and young doctor suicides. Dr Goodman adds: “Given the huge shortage of doctors in this country and our significant disease burden, it is a national imperative to invest in our future doctors. Discovery sees our support of this vital initiative as an important part of our investment in our country’s healthcare system.”

Cassey Chambers, Operations Director of SADAG, who works at the Helpline coalface, explains: “The Helpline has not only helped medical students but also students in the Health Science departments at various medical schools across South Africa.” During the day, the easy-to-remember number, 0800 323 323, gets callers through to three counsellors trained specifically to assist medical students. After-hours the line diverts to the counsellor on night-duty. 

Dr Kim Motloung, a Mental Health Champion on the Discovery Young Doctor programme adds: "The Discovery/SADAG Helpline is one of the greatest contributions made towards improving the mental health of medical student and young doctors. It’s become a talking point for many young doctors and there is growing awareness of the need to ensure doctors know how to protect themselves from burnout, and more. We are very happy about the initiative.”

“SADAG counsellors offer a solutions-focused approach,” explains Chambers. “Trained helpline counsellors provide follow-ups, educational material about mental illness plus referrals to other medical professionals if necessary. For students in crisis, follow up calls are made to track their situations and ensure that they are making positive progress. We also provide crisis intervention, especially in the instance of a suicide attempt that requires emergency treatment,” adds Chambers. “Medical students also worry about maintaining anonymity while accessing on-campus walk-in services. They feel more comfortable sharing their symptoms if they don’t have to worry about their professors, peers, patients or the medical board finding out. Our call rate data clearly shows that we are making strides in removing students’ fears of being discriminated against if they have a mental illness or suicidal ideation,” she adds.

SADAG counsellor Minda Kruger adds: “Our data show that callers access our resources far too late in the burnout process, rather than in the earliest days of severe stress. We are working to change this through active marketing of our support services on university campuses.” Chambers adds:  “We have developed referral guides for every university’s essential services – in that way our counsellors are able to go beyond support on the phone, to referring students on and finding solutions.”

Medical student callers report avoiding local clinics and hospitals for fear of their mental illness being exposed to colleagues. Tumi Mashaba*, a fourth-year medical student adds: “I found the Helpline provided me with such a relevant service. At our university, students wait up to six months to access the campus psychologist and the services are only available from 08:00 to 17:00 while we are in lectures.” 

SADAG counsellor Timmy Joji: “Anonymised Helpline data is shared with universities to show that there could be, say, a four-week waiting period to consult with a psychologist on campus. That’s far too long. We’re linked in with various university departments and on-campus supportive groups and ensure that students access as much help as they can get in their environment.”

Counsellors discuss the causes of depression with callers, as well as potential options that the student has to improve their situation. “The importance of a healthy lifestyle and diet are often emphasized, and students are encouraged to be active and explore hobbies and interests outside of their studies. We also offer advice on calming techniques like meditation as well as structured planning and study schedules.”

Discovery/SADAG Helpline data reveal extent of medical student distress

Where female callers have in the past been in the majority, recent stats show male callers gaining in prominence and this could indicate a change in stereotypical ideas against seeking help in male students. “Efforts to raise awareness of the helpline across campuses have also assisted in these dynamics,” adds Chambers. 

A breakdown of the 236 students’ calls to the Helpline during June 2018 shows data typical of other months also.  Reasons for calls:

• Depression (33%)
• Anxiety (19%)
• Academic stress (19%)
• The remainder relate to stress in personal relationships, suicidal thoughts, substance abuse, experiences of sexual abuse and financial distress.

“Anxiety is often linked to insomnia and some callers use alcohol to help them sleep. Callers report weight loss or gain, loss of interest in activities previously enjoyed, lack of hygiene, self-harming and an inability to focus on studying, which heightens stress around exam time, when we see calls spike,” says Chambers. Very few of the Helpline callers reported having had a diagnosis of a previous mental health disorder or take medication prescribed to assist them to deal with their depressive symptoms.”

Financial constraints remain a pressing theme with some students losing bursaries and finding themselves in debt. “Student funding often does not provide for the December period and students have been left without accommodation, food allowance or money to travel home to their families. We see that circumstances have been so extreme that students have resorted to sleeping on campus or considered shelters and feeding schemes,” adds Chambers. Counsellor Joji adds: “Depressed students report a low mood, lack of motivation and desire to socialize or interact with others, find it difficult to focus on their studies, and spend a large portion of the day in bed. Many are unable to wake up in the morning and attend lectures.”

Counsellor Thabo Lephoto describes a typical call: “We recently spoke to a University student in her 2^nd year who was diagnosed with depression after attempting to jump off a window ledge. Her roommate pulled her back. She has no siblings and supports her unemployed mom. She feels academia has taken over all aspects of her life. She drinks and smokes both cigarettes and marijuana.” Many students resort to self-medication through marijuana, alcohol and prescription drugs such as Ritalin. “This self-medication brings relief in the short term, but worsens their coping skills in the long-term,” explains Lephoto. 

Mashaba’s experience as a student: “I’ve encountered fellow students addicted to prescription medications. We know that all universities experience suicide on campuses but we are not sure of the extent of the problem as its often kept quiet. Medical school is such a competitive environment. You look around you and everyone ‘seems’ to be coping. So, most people isolate themselves and turn to substance abuse, pretending everything is okay.”

Medical student Tom Slabbert* adds: “Our biggest fear is that our insecurity will be unmasked. Substance abuse is rife among medical students in general. We have easy access to scheduled drugs. A fellow student carefully planned his suicide using anaesthesia drugs and took his life via lethal injection.”

Mashaba continues: “Our stress also emanates from the fact that bullying and intimidation are part of our teaching process. We are trained by senior doctors – who have been through a system indifferent to their burnout - who teach by humiliating junior doctors in front of colleagues and patients, so fuelling the cycle of abuse. We are daily faced with the reality of life and death. We counsel patients, see traumas and experience the worst side of humanity. Suddenly you look around you and you’re surrounded by colleagues who have become very disconnected. Who do you turn to? Saying, ‘I am not coping’ means you are not strong enough to be a doctor.”

Slabbert adds that self-care is frowned upon: “Our timetables and hospital shifts leave little free time for relaxation or exercise. Any free time must be spent on studies. There is no time for self-development. You sacrifice all your passions for the degree and delay all gratification. I would love to see a mental-health element included in the first year of medical studies, both telling us what to expect and how to look after ourselves so that we don’t have to find out the hard way.”

Is building resilience the key to preventing doctor burnout?

“Expectations of medical students and young doctors grow with each passing year, and so too does our responsibility to help these students to help themselves,” says Dr Goodman. “In the USA, At Stanford Medicine, the WellMD Centre - a national coalition of medical schools – aims to better understand burnout. St Louis University School of Medicine is making alterations to the curriculum to encourage resilience in students,” says Dr Goodman. At Vanderbilt University medical students have established a Wellness programme to support students in five ways – physical emotional/spiritual, interpersonal, academic/professional and environmental/community.”

Resilient doctors really matter. Suzy Jordache - a Senior Medical Educator with the Medical Protection Society (MPS – the UK-based providers of medical malpractice insurance to doctors all over the world), attended the Johannesburg leg of the Risky Business Congress held in March 2018. There, she explained to delegates that the MPS is heavily focussed on research and systems that promote resilience among doctors. “Studies show that burnt out doctors make poor medical decisions that increase their medico legal risk. This is linked to     sub-optimal listening on the part of a doctors, and decreased empathy and communication of therapeutic choices with patients. So, doctor burnout means decreased patient safety. And, guilt on the part of bunt out doctors only adds to occupational distress,” says Dr Jordache. “Burnout causes erosion of a sense of calling in a doctor with adverse consequences for physicians and patients. The polar opposite of burnout is ‘engagement’, which resilience fosters. Resilience feeds a sense of calling – the notion that a doctor has dedicated their lives to something meaningful and pro-social.”

What is good for a doctor’s brain is good for their heart and good for their body. So says Psychiatrist Dr Jonathan Moch - Brain Health consultant on the Discovery Young Doctor Program. He has recently begun work to build resilience in young doctors through reconnection with the inner self. “Medical schools teach students how to heal others and assume students will learn how to heal themselves in the process. This is a very poor assumption. It’s said that up to 30% of medical students wish to leave the profession after completing their community service,” says Dr Moch, adding: “The best way to face life’s challenges – especially those beyond one’s control - is to build resilience in an individual.” Dr Moch’s programme offers medical students and young doctors a non-pharmacologic, non-technological solution for wellbeing. “We offer ‘Mindfulness in the Park’ events, opportunities to connect with the inner self in nature – in a park, forest on the beach or other spaces, where art, yoga, silent walks, tai chi and other such activities will provide mental nourishment. Our online teaching programme also guides participants through optimal nutrition, sleep and exercise. We aim to switch off the incessant information and stress overload that young doctors face by temporarily removing students from the medical context and allowing them to heal.”

Dr Moch’s ‘resilience prescription’ for doctors includes daily practices such as:

• At least seven hours sleep every night
• Brisk walking - or another aerobic equivalent
• Eating whole, natural foods and ensuring a good intake of green and non-starchy veggies
• Challenge your brain
• Relax for 10 to 20 minutes
• Make space for friendships
• A one-hour, digital detox for stillness experiences and mindfulness practices.

Helping doctors to ask for help – the future of medicine

“In life, Prof. Mayosi’s courage saw him shed light on many unchartered areas of medicine. And, in death, he has done the same and given people who suffer from depression - his medical colleagues in particular – license to reject the stigma that surrounds coming forward and saying, ‘I need help!' He’s started a chain reaction that might well save many others in his profession from the same fate,” says Dr Goodman. “We’re well aware that these dynamics start at medical school, and that’s where we’ve invested our efforts to make a difference at the very start of a healthcare professional’s career. Ultimately we hope that the Young Doctors and Medical Students Helpline will become a safety net allowing individuals in the early stages of burnout to seek support and access the protection and guidance that they need. We hope that our investment in the Helpline and partnership with Dr Moch’s FLIP365 optimal brain health coaching programme will go some way to alleviating burnout in young doctors. We are confident that, working together, we can drive down the number of calls to the helpline over time and provide our universities with the support they need to deliver a healthy generation of future doctors.”

*Names changed to protect identities

The dedicated Medical Student Helpline will assist all medical students, interns and young doctors with any mental health issue. This 24-hour service provides free telephonic counselling via a toll-free helpline 365 days a year. Contact 0800 323 323 or visit www.sadag.org .