Burnout in Health Professions Education

by Karli Kurwicki, Pharm.D., PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Burnout among healthcare students and professionals has been studied for many years. Burnout is typically caused by stress that builds over time and can cause students to have damaging thoughts about themselves, anger, frustration, and even depression. A student experiencing burnout might also develop paranoia and skepticism about their future, and this may lead to distrust in colleagues or mentors. Burnout contributes to poor mental health.

There are three dimensions of burnout: emotional exhaustion; depersonalization and cynicism; and a lost sense of personal accomplishment. Emotional exhaustion occurs when a student feels indifferent towards the outcome of school work. Students may feel apathy toward studying so they perform poorly on tests and other assignments. Depersonalization and cynicism typically occur after the student has developed emotional exhaustion. Cynicism causes the student to have negative feelings towards school work and their profession. A decreased sense of personal accomplishment causes the student to feel incompetent. These feelings can ultimately lead to depression and impact the student’s emotional well-being. Many healthcare professionals and students feel a stigma with admitting they are depressed because there are negative connotations towards mental illness, even among those who work in the medical field. Students often see depression or anxiety as a weakness.¹

Marshall et al² investigated stress, quality of life, and burnout among pharmacy students attending a US pharmacy school. Third-year pharmacy students filled out a questionnaire that asked about stressors, how the students handle stress, and health-related quality of life over the previous four weeks. Female students had higher perceived levels of stress than males and the mean mental health score was significantly lower for the female students. A majority (56.9%) of the students admitted to feeling nervous or anxious, ranging from fairly often to very often, over the previous four weeks. The investigators also compared perceived stress levels between the graduate students and undergraduate students. The graduate students were significantly more stressed than the undergraduate students. The most common stress trigger for students was not examinations and tests (23.9%) but family and relationships (36.7%). They also asked students to suggest ways the college could help address their stress. The most common recommendation was to move Monday examinations to another day (67.9%) so that they could enjoy their weekends with family and friends. These results remind faculty that school is not the only stressor students face and that to have better learning outcomes and reduce the risk burnout, asking student opinions is important.

A survey of medical students at 7 medical schools across the United States examined the correlation between burnout and suicidal ideation. The authors report that 49.6% of students experienced symptoms of burnout and 11.2% experienced suicidal ideation. Burnout and low mental quality of life were strong predictors of suicide ideation. They also noted that students who recovered from burnout later were less likely to report suicidal ideation.³ This study serves as a good reminder that burnout can be so mentally taxing that it may cause a student to have suicidal thoughts.

Another study done in Portugal compared stress and burnout between students in the first two years of pharmacy school to students in the last two years.⁴ The results of this study are similar to the study done in the United States. Female students were significantly more likely to report emotional exhaustion compared to male students (p=0.017). Students in the last two years of pharmacy school experienced more depersonalization (p=0.006) meaning that they felt less connected to those around them. They found that students with more anxiety and higher personal accomplishment had higher scores on the Maslach Burnout Inventory. Burnout was associated with higher rates of dissatisfaction with school.

Lastly, a study performed in Australia aimed to measure burnout and engagement of nursing, occupational therapy, social work, and psychology students.⁵ The students were sent a survey to fill out. The investigators assessed burnout using the Maslach Burnout Inventory. The majority of the students who completed the survey were nursing students (53.5%). They found that burnout increased and engagement decreased as students progressed through the curriculum. However, they did not find a difference in burnout rates among the different health profession students. The authors speculated that improving student resources to help with exhaustion and burnout may be beneficial.

Burnout among students in health profession programs is higher in female students, high achievers, and increases as students progress through the curriculum. Faculty at all health profession schools must consider the negative effects stress has on students. Faculty should be able to recognize signs of burnout and should be prepared to help students by talking about burnout. Providing resources to students so that they can recognize the signs of burnout is a must. Faculty should encourage students to reach out to school counselors, mentors, and faculty if they are experiencing these symptoms, and they should help the students to understand that burnout is something that happens to many students. They should not be ashamed. It is also important to provide mental health counseling to those who are experiencing burnout. Offering free services to help students such as free tutoring could potentially decrease student stress and ultimately burnout. Lastly, schools should perform annual student opinion surveys to try to find ways to help students in terms of mental health and adding more resources to help students.

References

1. Bridgeman PJ, Bridgeman MB, Barone J. Burnout syndrome among healthcare professionals. Am J Health-Syst Pharm. 2018;75:147-52.
2. Marshall LL, Allison A, Nykamp D, et al. Perceived stress and quality of life among doctor of pharmacy students. Am J Pharm Educ. 2008;72(6): Article 137.
3. Dyrbye LN, Thomas MR, Massie MF, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149(5):334-341.
4. Silva RG, Figueiredo-Braga M. The roles of empathy, attachment style, and burnout in pharmacy student’s academic satisfaction. Am J Pharm Educ. 2018: in press. DOI 10.5688.
5. Robins TG, Roberts RM, Sarris A. Burnout and engagement in health profession students: the relationships between study demands, study resources and personal resources. Australian Journal of Organisational Psychology. 2015;8(e1):1-13.

Spiral Integration in Pharmacy Education

by Hanson Walker, Pharm.D., PGY1 Community Pharmacy Resident, University of Mississippi School of Pharmacy

As new medications, therapies, and healthcare practices are constantly evolving, there is an increasing need to develop a curriculum that allows students to not only acquire foundational knowledge but also learn how to most effectively put this knowledge into practice.  Pharmacy and other health professional schools must constantly evaluate and adapt their curricula to best fit both the volume and breadth of information that must be disseminated and the changing learning preferences of each new generation of learners.  Changing an entire curriculum is certainly a major undertaking; however, it can be accomplished using principles of curricular design.

While learning often occurs by starting with the most foundational information and building towards the full scope of knowledge needed by a practitioner, when designing a curriculum one must start with the end in mind and reverse the process (aka backward design).  If we start with a long list of all the discrete bits of knowledge a healthcare professional needs to know and attempt to incorporate them as we move forward in the curriculum, the result will be a disheveled mess with no demonstrable flow and likely poor learning outcomes. On the other hand, if the overall structure is established at the inception of the curriculum, deciding first what the practitioner must be able to do, and then assembling the bits and pieces that together form the profession’s knowledge base, it can then be integrated throughout the curriculum.  But how? How can we best integrate the plethora of information into a cohesive whole that prepares students for their future careers?

Integration of knowledge has long been a goal of curriculum developers, and this integration has historically occurred across two dimensions.  The first, horizontal integration, includes multiple topic areas (for example, pharmaceutics, pharmacology, medicinal chemistry, pharmacotherapeutics) whereby instructors deliver material related to the topic (e.g. a disease state) in parallel.  Thus similar-level material in each of the subjects is taught concurrently.  This approach can take many forms ranging from multidisciplinary (each discipline works separately), to interdisciplinary (commonalities between disciplines are leveraged to reach a common understanding of a topic), and transdisciplinary (disciplines are so interwoven as to be nearly indistinguishable).  The second, vertical integration, involves the introduction of increasingly complex material across time, where students are presented with basic, foundational knowledge and concurrently introduced to related clinically-oriented foundational experiences in order to bridge the gap between theory and practice.  The complexity of theory and practice experience build over time.  Spiral integration fuses these two concepts together.

In spiral integration, horizontal and vertical integration are merged to form a metaphorical spiral.  In theory, basic concepts are revisited with increasing complexity at various touchpoints throughout the curriculum.  This allows new knowledge and ideas to be correlated with previously learned concepts.  But, there are challenges to the implementation of such an approach. Overcoming these challenges requires both foresight by the curriculum designers and effective implementation by the faculty.

Let’s take a look at a concrete example of how spiral integration might be implemented.  At its core, spiral integration is basically a curriculum structure that involves the layering of concepts from multiple disciplines, with the complexity of the information increasing with each passing year.  In this type of curriculum, basic and clinical sciences are interwoven from the beginning, allowing the student to understand the relationships between pharmaceutics, medicinal chemistry, pharmacology, pharmacotherapeutics, as well as the social and administrative sciences.   Let’s take a closer look at how a specific instructional approach could be spirally-integrated.  Problem-based learning (PBL) is a common teaching methodology within healthcare education, and, like many other educational strategies, it can be used throughout a spirally-integrated curriculum.  PBL cases would be used beginning in the first year of pharmacy school, yet these cases would not focus heavily on therapeutic knowledge that the students have yet to develop but rather on social determinants of health, nonadherence, and healthcare communication.  In this way, students are introduced to some foundational concepts without being overwhelmed by the breadth of knowledge expected of a pharmacist.  Once students progress to the second year, concepts related to therapeutics would be included in patient cases, while reinforcing previously covered concepts learned within the curriculum.  During the third year, students would be given increasingly complex cases with greater emphasis on more complicated aspects of care.  Finally, in the last year of the curriculum, students progress from the fabricated cases to the real-world experiences (aka advanced practice experiences), where all of the knowledge they have gained is put into practice.

Given the seemingly clear benefits of a spirally-integrated curriculum, it would seem that this type of structure would basically be educational canon, but it is not without controversy.  Detractors may argue that while there is significant theoretical value for spiral integration, there is little evidence to support its effectiveness.  This is at face value a true statement, but it is nonetheless a misleading one, as the lack of evidence is in large part due to the difficulty of performing such a study rather than any substantial reasoning or evidence against the concept.  On the other hand, evidence shows that students in an integrated curriculum exhibit heightened retention of foundational information and improved application of learned material to real-world practice.  Due to this combination of theoretical soundness and evidence (albeit limited), integration across domains of knowledge with increasing complexity over time increases our chances of producing graduates ready to enter the workforce as well-informed, competent practitioners.

References

Rockich-Winston N. Toward a pharmacy curriculum theory: spiral integration for pharmacy education. International Journal of Medical Education 2017;8:61–2.

Husband AK, Todd A, Fulton J. Integrating science and practice in pharmacy curricula. Am J Pharm Educ 2014;78(3):Article 63. 

Pearson ML, Hubball HT. Curricular integration in pharmacy education. Am J Pharm Educ 2012;76(10):Article 204.

Schwartz AH, Daugherty KK, O’Neil CK, et al. A curriculum committee toolkit for addressing the 2013 CAPE outcomes. Curriculum SIG Writing Group. 2014.