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 Table of Contents  
INVITED PERSPECTIVE/VIEWPOINT
Year : 2021  |  Volume : 37  |  Issue : 2  |  Page : 162-167

Stress, distress, and burnout among medical trainees: An institutional approach


Department of Psychiatry, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission27-Apr-2021
Date of Decision17-Jun-2021
Date of Acceptance17-Jun-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Dr. Susanta Kumar Padhy
Department of Psychiatry, All India Institute of Medical Sciences, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_106_21

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  Abstract 


In the recent changes in medical education and health-care systems, stressful work condition and concurrent destabilizing psychosocial dynamics can result in adverse consequences of medical trainee's mental health. This can range from the usual stress in a medical school to distress and long-term burnout emerging into psychological disorders often underrecognized and ill managed. Stigma and poorly integrated available mental health services, administration, peers, and families can be roadblocks to implement an effective campus mental health services. This article also provides a template of student mental health service model in our institution and suggested measures for a holistic professional grooming during medical curriculum.

Keywords: Campus, stigma, stress, trainees


How to cite this article:
Mishra S, Padhy SK, Sinha AK. Stress, distress, and burnout among medical trainees: An institutional approach. Indian J Soc Psychiatry 2021;37:162-7

How to cite this URL:
Mishra S, Padhy SK, Sinha AK. Stress, distress, and burnout among medical trainees: An institutional approach. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Sep 29];37:162-7. Available from: https://www.indjsp.org/text.asp?2021/37/2/162/320210




  Introduction Top


As the health services are gearing up for patient-centeredness, medical training requires competency-based and holistic assessment of the trainees. A parallel system of exhaustive curriculum but poor support for nonacademic issues can convert a productive stress to distress and burnout, leading to mental health morbidity.

This article attempts to understand the various contributing factors, vulnerability, and practical approaches to enhance positive mental health for an enriching professional contribution.


  Stress during Medical Schooling: An Inevitable Construct Top


Stress is an universal experience during medical training, which can be a combination of intrinsic and extrinsic factors and to some extent is productive. Beyond one's coping reserve a protracted multifactorial stress may lead to distress, burnout and further psychological issues in trainees.[1]

The transition from an adolescent brain marked by impulsivity, poor problem-solving, and decision-making to early adult prosocial and executive cognitive capacities can vary between individuals. This age group is prone to many mental health disorders as well.[2]

A common misconception regarding medical trainees being pre-equipped with these skills overlooks the nidus of a poor psychological outcome in vulnerable students.[3]

The stress coupled with unhelpful coping strategies such as avoidance, dissociation, disengagement, substance use, and withdrawal can set in a learned helplessness mode. However, problem-focused coping, networking, seeking constructive feedback, and cultivating healthy self-care can further enhance their resilience.[4],[5]

The stress mindset in medical education

A given “stressful” situation goes through the lens of primary and secondary cognitive appraisal of threat perception. A resourceful and resilient individual might appreciate medical training as “challenging.” The salience allocated to the role of stress in modifying the outcome of any event in either productive or debilitating manner shapes the cognitive appraisal, threat perception, performance, and resultant mood state. This “stress mindset” can be amplified by adverse life experiences, poor resources at hand, and individual's vulnerability for a negative or distorted appraisal of any event.[6]


  Stressed Students, Stressed Teachers Top


Unaddressed chronic stress can impact a wide range of medical workforce. Mental health as an alien concept can make students reluctant to seek help. When students become teachers, the help seeking may be further reduced. Sudden transition from academics to real-world clinics, lack of experience, and difficulty in team-based care can make younger physicians more vulnerable to burnout compared to their seniors. Changing doctor–patient dynamics, rampant litigations, and growing incidences of violence against doctors can lead to emotional detachment. This also can result in the limitation of an enriching teaching–learning environment [Figure 1].[7]
Figure 1: The various academic and nonacademic issues pertaining to medical student's mental health

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Interpersonal issues with colleagues and seniors, patient care responsibilities, moral and ethical dilemmas, secondary victimization of patients' death, tolerating abuse, and violence from patients' relatives and compassion fatigue [Figure 2].
Figure 2: Common issues of stress transforming to distress and psychological disorders among medical students

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Overwhelemed physical and mental health of doctors can provide ground for medical errors refuting the whole idea of a safe and comprehensive service delivery to patients.[8]

Stress transforming to mental health issues

In a systematic review of studies in 43 countries, the prevalence of depression or depressive symptoms among medical students was 27.2% and 11.1% for suicidal ideation. However, only 15.7% out of positively screened for depression sought help.[9] Medical trainees and doctors have substantially higher proportion of psychological issues compared to the general population and other professionals, especially below 30 years of age, thoughts of suicide are significantly higher.[10]

Across India, among the medical students, the pooled prevalence for depression is 39.2% and anxiety being 34.5%, with higher rates of depression and stress reported in females.[11] In a study at a tertiary center of North India, out of 445 respondent doctors, 30% were depressed, and 17% had suicidal thoughts.[12]

Substances are often used as a peer-approved coping measure in young students. In an Indian study, the prevalence of alcohol consumption for UG students and PG students was 16.6% and 31.5%, respectively, and tobacco usage was 8.0% in undergraduates and 14.5% in postgraduates. Tobacco usage for UG students and PG students was found to be 8.0% and 14.5%, respectively.[13]

Preferences to seek help

In a multicentric Indian study, in a descending order student preferred to seek help from peers, followed by faculty members of their own department; however, a fourth of students shared preferences toward a mental health professional such as psychiatrist or psychologist or counselor [Figure 3]. However, help seeking is heavily impeded by perceived stigma and discrimination by such students. Lack of time, fear of profiling, and unwanted intervention were other reasons as well which prevent seeking timely help. A similar scenario is found among Indian resident doctors who also consider a colleague seeking mental health intervention as weak and incompetent [Figure 4].[11],[14],[15]
Figure 3: Graded role of stakeholders for a positive mental wellbeing of medical students

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Figure 4: Different strategies if stress is chronic

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  Medical Student Burnout Top


Burnout during medical training is a crucial concept to understand. The triad of emotional exhaustion, depersonalization, and professional cynicism arising from the occupational front is also seen in medical trainees [Figure 5]. The prevalence varies from 44% to 80% across countries, with 40.8% for emotional exhaustion, 35.1% for depersonalization, and 27.4% for personal accomplishment.[16]
Figure 5: Three-core features of burnout in context of medical students

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  Three-core features of burnout in context of medical students Top


Limited seats, heightened competitiveness

The current trends in Indian medical system are of preference to super specialization degrees in a backdrop of limited seats acquired through tough entrance examinations or huge course fee can limit “cooperative learning.” Unlike the “competitive learning,” the later confers team spirit and multidisciplinary liaison, which bare prerequisites of good clinical practice.[17] This also creates a buffer for prosocial interaction and networking among students. As medical education is not uniform across the country, institute-related practices, work culture, and acculturation can play a significant role in perceived stress. Studies of medical students from various medical colleges in India and other countries worldwide identified a high frequency of stress.[18]

Medical school entry is preceded by a heterogeneous exposure to English language, different teaching–learning methods.[19]


  Family, Gender, and Personal Milestones during Medical Education Top


Parental expectations at times can limit the career avenues pushing students to dichotomous choices. At times, specialty choices can be gender skewed; female trainees being more affected in the work life balance domain.[20],[21]

Apart from academics, the young student embarks on personal milestones such as forming emotional relationship, breakups, marriage, pregnancy, parenting, and financial planning. Despite these if learning environment is stimulating, students can surpass these stressors. Prolonged burnout can trigger contemplation of drop out from training. This can be an emotionally exhaustive process.[22],[23]


  Mental Health Promotion in Indian Medical Training Top


The western education system on one hand is extremely formal and organized, the noncurriculum-related issues can be much individualistic with ample availability of student centric resources. It may be difficult to replicate the same system in Indian medical training.

Indian medical system, although heterogeneous, is slowly moving toward a competency-based curriculum in a changing doctor–patient dynamics. Unsupported psychological health needs and failure to provide an enabling learning environment can be a major roadblock for attaining such goals. The University Grants Commission guidelines discourage discrimination based on gender, sexual orientation, caste, religion, and nationality. It also emphasizes on the provision of active student counseling system in higher education. However, these are difficult to implement unless the available resources are trained, and mental health is proactively promoted and sustained within campus without stigma. Services need to be based on local needs, round the clock available, minimal administrative hassles, need-based involvement of family and peers, and the provision of support for reintegration [Figure 6].[24] Mental health promotion and awareness regarding existing services need to be added during induction sessions of first-year medical trainees every year.
Figure 6: Training and coordination of various stakeholders and services for mental health promotion

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As academic decline can be an earlier manifestation of underlying psychological issues, mentorship role can be extended to early identification, gatekeeping, and mental health promotion. This is important in the Indian context as student–teacher dynamics follows partly the “Guru Chela” relationship of Indian psychotherapy model. This can encompass not only formal core medical teachings but infuses coping skills, self–reflection, and direction to navigate the medical career. Furthermore, a mindful effort for changing the “hidden curriculum” in the context of self-care help seeking and acknowledging psychological needs can provide a “flourishing” mindset for optimal professional output.[25],[26],[27],[28]

Multiple studies have shown the importance of peer support, help seeking from own department faculties, and finally available mental health team. Fear of profiling, stigma, and unwanted interventions are the roadblocks to seek timely help among trainees. Unattended chronic stress in venerable individuals can manifest in psychiatric disorders such as anxiety, major depression, substance dependence, gadget addiction, and suicides.[11],[14]


  Suggested Measure, Experience at All India Institute of Medical Sciences, Bhubaneswar Top


Many institute across India are gearing up for conserving positive mental health during medical training and have come up with multipronged approaches, The All India institute of Medical Scinces Bhubaneswar has been running its campus mental health services for students, all cadres staff, and their families on a proactive basis since year 2018. Apart from previously documented common areas of stress and burnout, some cases need time and resource intensive support.

Informal discussions among hostel authorities, security services, training of faculties, mentors, peer groups, parents' liasoning with medical education unit, and the administrative bodies toward destigmatizing mental health issues have been helpful. Currently, the campus mental health services are equipped with two part-time counselors, a 24/7 telephonic helpline and psychiatrists within institute [Figure 7].
Figure 7: Ensuring continuity of care on voluntary basis

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The suggested plan for upgrading and streamlining the services has been conceptualized as follows:

Supporting vulnerable students who have psychological disorders across the course is equally important to restructure skill set and prevent dropouts.

Considering medical colleges as a homogenous population, care plan approach model can benefit such students for long-term support and care.


  Conclusion Top


Addressing stress, distress, and burnout at young stage of medical training is important to build a long term, resilient, and professionally enriching workforce. Worldwide, there has been wide acknowledgment of these issues; however, organizations struggle to implement a sustainable and integrated support system along with medical training. The Indian medical training along with the refinement of academic curriculum needs to enable mentors and administrators with the cultural and social issues around mental health for designing a robust student support system.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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