Maximilian Buja, MD, Professor of Pathology and Laboratory Medicine at McGovern Medical School, The University of Texas Health Science Center at Houston, focuses on disruptive change in medical education, including its impact on faculty
Medical education today is in a state of flux around the world. Undergraduate medical education (UME) has moved from the traditional curricular approach to curricula aimed at achieving vertical and horizontal integration of subject matter and a focus on competencies. Graduate medical education (GME) also has undergone a movement toward competency-based education. Medical faculty have been faced with adapting to these changes. At the same time, faculty have to balance commitments to patient care, research and service responsibilities with the education mission. The stressful environment can serve as a substrate for various levels of burnout in the faculty which, in turn, can impact the ability of faculty to embrace participation in the new world of medical education.
The Burnout Syndrome
The Burnout Syndrome is a professional psychological stress-induced syndrome defined as having three dimensions: emotional exhaustion, cynicism or depersonalisation and a lack of sense of personal efficacy and actual low personal accomplishment. Exhaustion is the primary driver affecting burnout in three realms: personal, work-related and client-related burnout. The Burnout Syndrome takes place in three consecutive stages that differ in their manifestations and intensity: flame-out (i.e., the stress of futile effort), leading to burnout (i.e., exhaustion and demoralisation), leading to rust-out (i.e., apathy).
Burnout is characterised as the point at which important, meaningful and challenging work becomes unpleasant, unfulfilling and meaningless. At this point, energy turns into exhaustion, involvement leads to cynicism and efficacy is replaced by ineffectiveness. Burnout Syndrome is typically associated with multiple stresses, and usually is the result of chronic stress, specific to each profession.
Burnout research among staff in medical centres
Burnout prevalence has been found to be high among both clinicians and basic scientists in medical centres. Three types of burnout have been found to be unevenly distributed in academic medical centres in a study conducted by Messias et al. Physicians have a higher risk of personal and patient/client-related burnout, whereas basic scientists are at a higher risk of client-related burnout and nurses have a higher risk of all three types of burnout. Clients for the basic scientists include administrators, colleagues, funding agencies and students.
Could the implementation of new curricular approaches be impeded by such stress/burnout in faculty? As pointed out by Arvandi et al., answering such a question is complex and involves addressing several issues, including: (1) Developing a capacity to understand barriers to implementation of change, as it applies to curricular reform; (2) The measurement of stress and burnout in medical teachers; and (3) The ability to see if measuring such constructs is actually feasible in a medical school setting.
Balancing administrative demands from the medical school while providing patient support and seeking academic advancement can cause personal hardship that ranges from high stress to clinically recognisable conditions such as burnout. Regarding the importance of clinical faculties’ burnout and its effects on different aspects of their professional career, Arvandi et al. conducted a study aimed to evaluate the relationship between willingness to change teaching approaches as characterised by a modified stage-of-change model and measures of stress and burnout.
To determine the link between burnout and curricular reform, Arvandi et al. performed related research on faculties working in Tehran University of Medical Sciences (TUMS). This involved the following components: 1) Adaptation of existing stages of change questionnaire; 2) Application of a standard burnout and distress measurement; and 3) Recruitment of a sample of faculty to answer both questionnaires with subsequent analysis to provide preliminary impressions of the link between faculty burnout and curricular change implementation. This descriptive-analytic study was conducted on 143 clinical faculty members.
A significant relationship was found between faculty members’ readiness to change teaching approaches and the subscales of occupational burnout. Specifically, participants with low occupational burnout were more likely to be in the action stage, while those with high burnout were in the attitude or intention stage, which could be understood as not being ready to implement change. There was no significant correlation between general health scores and stage of change.
Arvandi et al. found it feasible to measure the stages of change as well as stress/burnout in academic doctors. Occupational burnout directly reduces the readiness to change. To have successful academic reform in medical schools, it, therefore, would be beneficial to assess and manage occupational burnout among clinical faculty members. By taking both readiness to change and burnout into account, the launch of a new curriculum could be modified to improve the chances of successful implementation.
The future priorities for burnout research
The study does not address the issues of burnout and readiness to change among the basic science faculty and pathology faculty who teach in the pre-clinical component of the curriculum. Such a study is needed. Similar studies at other universities would be of interest.
Monitoring of the interaction between the psychological functioning of the individuals with the organisational climate in terms of psychological and social well-being should occur between the first two stages of the burnout process – flame-out (i.e. stress of futile effort) and burnout (i.e. exhaustion and demoralisation). This early period in the burnout process is propitious to identify means of intervention for the sake of preservation and recovery of the psychological potential of the workers in such vulnerable groups as medical specialists. At an early stage, the phenomenology of professional “burning” is not difficult to differentiate from the symptoms of psycho-emotional stress, whereas at a later stage (described by the term ‘rust out’), there may be less benefit from psychological interventions as the harm is thought to be firmly established. Therefore, medical school leadership should implement programs to proactively address faculty burnout which can result in more productive faculty and facilitation of curriculum reform.
References
Buja, LM. Medical education today: all that glitters is not gold. BMC Med Educ. 2019;19(1):110. Published 2019 Apr 16. doi:10.1186/s12909-019-1535-9.
Buja, LM. Medical education: past and present. Openacessgovernment.org/category/publications. 6 April 2020, pp. 28-29.
Arvandi Z, Emami A, Zarghi N, Alavinia SM, Shirazi M, Parikh SV. Linking medical faculty stress/burnout to willingness to implement medical school curriculum change: a preliminary investigation. J Eval Clin Pract. 2016;22(1):86-92. doi:10.1111/jep.12439
Bridgeman PJ, Bridgeman MB, Barone J. Burnout syndrome among healthcare professionals. Am J Health Syst Pharm. 2018;75(3):147-152. doi:10.2146/ajhp170460
Messias E, Gathright MM, Freeman ES, et al. Differences in burnout prevalence between clinical professionals and biomedical scientists in an academic medical centre: a cross-sectional survey. BMJ Open. 2019;9(2):e023506. Published 2019 Feb 19. doi:10.1136/bmjopen-2018-023506
Holleman WL, Cofta-Woerpel, LM, Gritz ER. Stress and morale of academic biomedical scientists. Acad Med. 2015;90(5):562-564. doi:10.1097/ACM.0000000000000533
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