Unprofessional Conduct Among U.S. Medical Students Linked to Burnout, Study Finds

Educators Call for Schools to Safeguard Students' Psychosocial Health

October 26, 2010 04:20 pm Barbara Bein

Like many residents and practicing physicians, U.S. medical students are prone to burnout. When they feel this distress, they're more likely to engage in unprofessional conduct. They rarely engage in academic dishonesty, such as cheating, but they may short-cut aspects of patient care, such as reporting a test result as normal when they actually omitted the test. These are among the findings presented in a Mayo Clinic study published in the Sept. 15 JAMA: Journal of the American Medical Association.

The survey of 2,682 medical students from seven U.S. medical schools also found that students experiencing burnout had less altruistic views about physicians' responsibility to society, including less desire to provide care for the medically underserved.

"Although students recognize cheating and dishonest clinical behaviors as unprofessional, feel guilty about engaging in these behaviors and believe that the behaviors make them a less trustworthy physician, a relatively high prevalence of unprofessional conduct related to patient care was reported by students in this study," said the authors, who include FP David Power, M.D., M.P.H., director of medical student education at the University of Minnesota Medical School in Minneapolis.

The students who responded to the electronic survey came from a wide-ranging cross-section of medical schools:

  • Mayo Medical School College of Medicine, Rochester, Minn.;
  • University of Washington School of Medicine, Seattle;
  • University of Chicago Pritzker School of Medicine;
  • University of Minnesota Medical School, Minneapolis;
  • University of Alabama School of Medicine, Birmingham;
  • University of California-San Diego School of Medicine, La Jolla, and
  • Uniformed Services University of the Health Sciences, Bethesda, Md.

According to the study(jama.ama-assn.org), more than half of the surveyed students were experiencing burnout, based on their measures of emotional exhaustion, depersonalization and sense of personal accomplishment as assessed by the Maslach Burnout Inventory.

Very few students reported academic dishonesty, such as copying from a "crib sheet" or taking credit for another person's work, the authors said. But many students reported dishonest clinical behaviors; for example, they reported a physical examination finding as normal when they had skipped it entirely.

Fourth-year Medical Student Says Burnout Comes as No Surprise

Kevin Bernstein, a fourth-year student at Drexel University College of Medicine, Philadelphia, and the student member of the AAFP Board of Directors, says he has "definitely observed emotional exhaustion and depersonalization" in the academic environment and has experienced these sensations himself.

"For me, it seems to trickle down from the attending to the resident/interns and infects the rest of the medical team," he told AAFP News Now.

Bernstein said the distress comes from the volumes of information medical students must learn, as well as the need for numerous tests and documentation that is part of practicing defensive medicine.

"If we took just half the amount of time we waste on defensive medicine and documentation and shifted that toward more time for teaching rounds and instructional time by attending physicians and residents, I believe medical students would feel more satisfaction with their educational and clinical experiences," said Bernstein.

"As it is, medical students spend most of their time trying to help the interns and residents with noneducational 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 toward 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 nonfactual clinical findings, lacking altruism and altogether becoming unprofessional throughout the process."

As a group, students with burnout were more likely to have engaged in one or more unprofessional behaviors than those without burnout, the study said.

"It was rare for any students to engage in clearly unprofessional activities like cheating or blatantly lying -- and, of course, this is reassuring for us all," Power told AAFP News Now. "Some of the more subtle behaviors, like documenting something that did not actually occur, are certainly of concern.

"However, as an educator and physician myself, I've had to check myself when, in the electronic health record, a preprinted template has all the elements that would be performed in a complete physical. It actually takes more diligence and time to go through this already-constructed template and cut and edit the template to reflect what actually occurred."

Family physician George Harris, M.D., M.S., of Lee's Summit, Mo., assistant dean for year 1 and 2 medicine at the University of Missouri-Kansas City School of Medicine and a professor of medicine in the school's department of community and family medicine, told AAFP News Now that he has observed burnout in students, noting that it usually seems to appear in the third year of a traditional four-year medical school curriculum.

He said the condition affects the intensity and thoroughness of how students perform a work-up of a medical condition on a patient and the number of differential diagnoses they consider, as well as how much time they spend with the patient taking a history and doing a physical exam.

"Students feel emotionally, physically and mentally worn down," Harris said. "They feel emotionally and mentally displaced from those around them. They are in survival mode.

"Fortunately, during the last year of medical school, most of them reconnect with their environment; and their underlying beliefs, values and attitudes re-establish themselves, and their altruistic views resurface."

Both family medicine educators said medical schools need to attend to noncognitive aspects of their students, including their personal lives, emotional well-being and overall psychosocial health.

"It is important to identify students early in their medical education who are experiencing signs of depression, unresolved parental separation, academic difficulty, limited peer interaction, poor coping skills and personal difficulties," Harris said.

Power agreed, explaining that the University of Minnesota Medical School has devised ways in which students can connect with faculty and with each other.

At the Minnesota medical school, entering classes of as many as 200 students are divided into smaller student groups, and each student connects with his or her own faculty adviser from the first day of medical school. In addition, students in the required family medicine clerkship participate in sessions in which they share a memorable positive or negative emotional reaction to a patient.

"This 'significant event reflection' has been very well received by students, and most wish there (was) more opportunity for this sort of sharing," Power said.

Indeed, now that the association between burnout and unprofessional conduct has been recognized, the study authors recommend that future research investigate whether interventions designed to reduce burnout help students cultivate professional values and behavior.