This blog is about medical education in the US and around the world. My interest is in education research and the process of medical education.

The lawyers have asked that I add a disclaimer that makes it clear that these are my personal opinions and do not represent any position of any University that I am affiliated with including the University of Kansas, the KU School of Medicine, Florida International University, or the FIU School of Medicine.

Thursday, August 30, 2012

Physician burnout: is there anything that we can do?

A recent post by Pauline Chen, MD on the New York Times Wellblog speaks about the nation-wide epidemic of physician burnout. She quotes a recent study published in the Archives of Internal Medicine by Shanafelt, et al (2) that measured the symptoms of burnout using a validated survey instrument (Maslach Burnout Inventory) (3). There were huge differences based on the specialty of the physicians. The highest rates of burnout were found in doctors at the front line of access to medical care: emergency medicine (OR 3.18), general internal medicine (OR 1.64), and family medicine (OR 1.41). These differences remained even after adjusting for age, sex, call schedule, relationship status, primary practice setting, hours worked per week, and years since graduation from medical school.  When compared to a probability-based sample of working adults in the US, physicians had a higher risk for emotional exhaustion (32.1% v. 23.5%), depersonalization (19.4% v. 15.0%), and overall burnout (37.9% v. 27.8%). Overall, 45.8% of physicians had at least one symptom of burnout.

Wow! That is scary! These are practicing physicians who are working themselves to a state of emotional and physical exhaustion. When physicians feel like this they are more likely to make mistakes and medical errors. So, bringing this back to medical education, is there evidence about burnout in learners? Well, a recent article in AcademicMedicine by Dyrbye, et al (4) addressed this question. The authors found that positive mental health had a protective effect on burnout.
In this study, 4,400 medical students from seven medical schools (Mayo College of Medicine; Uniformed Services University of the HealthSciences; University of Alabama School of Medicine; University of California,San Diego; University of Chicago Pritzker School of Medicine; University ofMinnesota Medical School; University of Washington School of Medicine) were surveyed. The students’ mental health was measured using a validated instrument that measures emotional, psychological, and social well-being. The symptoms of burnout were measured using the same Maslach Burnout Inventory that was used in the practicing physician survey.

What the authors found was not surprising: medical students also had high levels of burnout. 42.1% of the students had high scores in emotional exhaustion, 52.5% had a positive depression screen, and 17.4% reported suicidal ideation. When they asked about mental health, interestingly, most students were doing well. 53.1% were flourishing and 42.5% were moderately healthy, while only 4.3% were languishing. Students that were described as languishing reported a low frequency (“never” or “once or twice” in the past month) on more than one of the emotional well-being items and a low frequency on at least six of the signs of positive functioning.
48.2% of students who were languishing reported suicidal thoughts in the past 12 months compared to 25.1% who were moderately mentally healthy (p< 0.001). The scary part was that those who were flourishing still had a 9% rate of suicidal ideation. Students who were languishing were more likely to cheat, more likely to display other dishonest behaviors, less likely to endorse altruistic beliefs, and less likely to care for medically underserved patients.

This is scary stuff! It suggests that a lower, more negative mental attitude in a medical student is correlated with not only their personal feelings about themselves (ie: suicidal ideation) but also how they act within the professional environment (dishonesty and cheating). It may be that if we could identify those students who are languishing, we could intervene to help them improve their mental health. Interventions could impact their professional behavior and quite possibly their performance in the academic realm of medical school. The question is: what are those interventions? More research will be needed to figure out what can be done and what works best.

(1) Chen PW. The Widespread Problem of Doctor Burnout.  New YorkTimes.  August 23, 2012
(2) Shanafelt TD, Boone S, Tan L, et al.  Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population.  Arch Intern Med. Published online August 20, 2012.
(3) Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, Calif: Consulting Psychologists Press; 1996.
(4) Dyrbye LN, Harper W, Moutier C, et al.  A Multi-institutional Study Exploring the Impact of Positive Mental Health on Medical Students’ Professionalism in an Era of High Burnout. Academic Medicine  2012;87(8):1024-1031.

Thursday, August 23, 2012

Career outcomes of graduates who initially failed Step 1

I know that I have been gone for a while. Sorry about that...
I saw a really interesting article in Advances in Health Sciences Education (1) this month.  The authors decided to study the career outcomes of graduates of six Midwestern medical schools who had initially failed USMLE Step 1. In this retrospective study, the authors sought to determine the academic and professional career outcomes of medical school graduates who failed Step 1 on the first attempt. They took a cohort of students who graduated from the Ohio State University College of Medicine, Michigan State University College of Human Medicine , Washington University School of Medicine, SouthernIllinois University School of Medicine, University ofIowa Roy J. and Lucille A. Carver College of Medicine, and the University of Michigan School of Medicine. In this cohort of 2,003 graduates from 1997-2002 were 50 (2.5%) students who initially failed Step 1 and these students were compared to the 1,953 students who passed Step 1 on the first attempt.

There were several interesting findings in this study. The authors used information from the MSQ (Medical Student Questionnaire), the GQ (Graduate Questionnaire), the AMA Physician Masterfile, ABMS Board certification, and the AAMC Faculty Roster System. Data was gathered from all six schools and merged into a single database. Some of this data has issues, for example the MSQ and the GQ both rely on student self-report. The AMA Masterfile may mis-categorize some doctors and the cohort only includes students who made it to graduation and for whom they had complete data available (about 43% of the total graduates). But with that being said, this is a pretty good study with a large cohort of graduates.
So, what did they find?  As you would guess, passing USMLE Step 1 on the first attempt has major repercussions for medical students. Most students (94%) pass the test, but not all. Students who fail Step 1 are less likely to pass Step 2 and less likely to ultimately graduate from medical school. (2) But this group of students had all graduated so are they still impacted? There is not a lot of evidence that medical school test performance is correlated to residency clinical performance, but Program Directors still put too much emphasis on Step 1. In fact, a national survey of Program Directors (3) found that 84% would seldom or never interview a student who had failed Step 1 even if they eventually passed Step 1.

In this study, those who failed were more likely to be women, minorities, and older. In fact, there were significant differences between these groups. When compared to men who graduated, women were 3.2 times more likely to have failed Step 1 on the first attempt (p < 0.001). African Americans were 13.4 times more likely to fail when compared to whites (p < 0.0001), and Latinos were 7.4 times more likely (p < 0.0001) to fail when compared to whites. They are more likely to end up in primary care residencies, to be older, and to come from families of lower income.
This data obviously has huge implications. Every medical school has a few failures on Step 1 and should be concerned about the implications. Are we willing to tolerate this difference in the relative risk of failing a nationally standardized high stakes examination? There may be pre-matriculate variables that explain some of the differences, but there also may be ways to identify and intervene in high-risk students’ academic career in ways that can decrease their risk of failure.

Take a look at the programs that are in place at the University of Texas Medical Branch in Galveston and Southern Illinois University. They have been successful in helping students that were identified as at-risk students. Unfortunately, but many schools would rather try to decrease the number of at-risk students that they admit.
The method that is often used is to try to admit students with higher MCAT scores and higher undergraduate GPAs. The problem with this strategy is that in doing this the school will also increase the number of rich, white, male students who come from urban backgrounds. This leads to a student body that is less diverse. That is something that our schools should not tolerate.

(1) McDougle L, et al.  Academic and professional career outcomes of medical school graduates who failed USMLE Step 1 on the first attempt. Adv in Health Sci Edu.  7 April 2012 (Online First).
(2) Biskobing DM, et al. Study of selected outcomes of medical students who fail USMLE Step 1. Medical Education Online  2006;11(11):1–7.

(3) National Resident Matching Program, Data Release and Research Committee. Results of the 2008 NRMP Program Director Survey. Washington, DC: National Resident Matching Program. 2008