Distress and empathy do not drive changes in specialty preference among US medical students

Does Medical Students' High Expression of Empathy Correlate with Their Choice of Primary Care Residencies?

OBJECTIVES

There are many factors that influence medical students' (MS) decisions when choosing a career. Some prominent factors include life-work balance, indebtedness, and flexibility of work hours. Whereas the expression of empathy has many positive correlates with a trusting and meaningful physician-patient interaction, only a few studies have analyzed the association of MS empathy expression and primary care residency selection. The results of these studies about the relationship of MS expression of empathy and their selection of primary care specialties have been conflicting, depending on the empathy instrument used. In addition, there have been other variables that have affected career decision making in more recent years not previously encountered. The objectives of our study were to analyze the association of The George Washington University School of Medicine and Health Sciences (GWU) MS Interpersonal Reactivity Index (IRI) scores and their residency selection, to compare our results with previous studies to determine whether the IRI provided more definitive relationships between empathy and career choice, and to assess whether our results confirmed the theoretical construct linking empathy with primary care physicians.

METHODS

GWU third-year MS (MS3s), representing the classes of 2008-2011, completed the perspective taking and empathy subscales of the IRI, which measure cognitive and affective empathy, respectively. MS empathy scores for individual specialty were compared to those scores in internal medicine (IM) using a linear regression model. Empathy scores for patient-oriented versus technology-oriented specialties and primary versus surgical specialties were compared using the independent t test.

RESULTS

A total of 593 (77.5%) MS3s had mean IRI scores of 45.1 (standard error 4.8), higher than a recent study involving MS. There were no significant differences between patient- and technology-oriented specialties (-0.65 to 0.88), primary care versus surgical residencies (-0.87 to 1.4), and women versus men (-0.20 to 1.4). Our study did not clarify previous conflicting studies in the literature.

CONCLUSIONS

There are no significant differences in expression of empathy in GWU students who chose patient- versus technology-oriented and primary care versus surgical residencies. The authors can only speculate why students' high expression of empathy was not associated with selecting primary care residencies, namely, women are outnumbering men entering medicine and are selecting technology-related specialties previously identified predominantly with men, and millennials have specific traits inherent in their generation that can affect their specialty choice. The results of our study shed doubt that the theoretical construct linking MS high empathy expression and choice of primary care careers is valid today.

Career decision making in undergraduate medical education

BACKGROUND

It is unclear how medical students prioritize different factors when selecting a specialty. With rising under and unemployment rates a novel approach to career counselling is becoming increasingly important. A better understanding of specialty selection could lead to improved career satisfaction amongst graduates while also meeting the health care needs of Canadians.

METHODS

Medical students from the University of Toronto participated in a two-phase study looking at factors impacting specialty selection. Phase I consisted of focus groups, conducted independently for each year, and Phase II was a 21-question electronic survey sent to all students.

RESULTS

Twenty-one students participated in the focus group phase and 95 in the survey phase. Primary themes related to career selection identified in Phase I in order of frequency included personal life factors (36), professional life factors (36), passion/interest (20), changing interests (19) and hidden curriculum (15). The survey phase had similar results with passion (83), lifestyle (79), flexibility (75), employment opportunities (60) and family (50) being ranked as the factors most important in specialty selection.

CONCLUSION

Personal factors, professional factors and passion/interest may be key themes for medical students when deciding which specialty to pursue. Targeting career counselling around these areas may be important.

Fundamental Curriculum Change with 1-Year Pre-Clerkship Phase and Effect on Stress Associated with Residency Specialty Selection

Vanderbilt University School of Medicine recently changed from 2 pre-clerkship years (Traditional curriculum) to a 1.5-year pre-clerkship phase for one class (Hybrid curriculum) to a 1-year pre-clerkship phase (Curriculum 2.0). This study investigated the relationship between shortened pre-clerkship training and stress associated with selecting a residency field. The surveyed graduating medical student population included one cohort from the Traditional and Hybrid curricula, and the first two cohorts from Curriculum 2.0. The authors modeled recollected stress levels using a Zero-Inflated Linear Mixed Model with additional covariate and random effects adjustments. Specialty decision-related stress levels increased in the Hybrid curriculum by 10.208 points [p = 0.0115, 95% CI 2.293, 18.122] on a 0-100 point scale. Curriculum 2.0 students had an insignificant increase in stress of 4.062 points [p = 0.304, 95% CI - 3.690, 11.814] relative to the Traditional curriculum. Time since starting medical school and time when a specialty was chosen were the largest factors associated with stress. While this study only evaluated a single facet of the potential downstream effects of curricular change, these data should inspire confidence for reform efforts as a significant increase in specialty decision-related stress present in Hybrid curriculum resolved in both cohorts of Curriculum 2.0.

Professional burnout among medical students: Systematic literature review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aim to summarize the available evidence on the prevalence of professional burnout among medical students.

METHODS

The review was performed according to the PRISMA guidelines. Databases were systematically searched for peer-reviewed articles, reporting burnout among medical students published between 2000 and 2017. The meta-analysis was conducted on the available data on burnout rates in medical students measured with the Maslach Burnout Inventory (MBI-HSS).

RESULTS

Fifty-eight out of 3006 studies were found eligible for inclusion. Twelve of these studies met the criteria for meta-analysis. Weighted mean values for the three sub-dimensions of the MBI-HSS were M = 22.93 (SD = 10.25) for Emotional Exhaustion, M = 8.88 (SD = 5.64) for Depersonalization, and M = 35.11 (SD = 8.03) for Personal Accomplishment. Prevalence rates for professional burnout ranged from 7.0% to 75.2%, depending on country-specific factors, applied instruments, cutoff-criteria for burnout symptomatology.

CONCLUSION

This review underlines the burden of burnout among medical students. Future research should explicitly focus on specific context factors and student group under investigation. Such efforts are necessary to control for context-dependent confounders in research on medical students' mental health impairment to enable more meaningful comparisons and adequate prevention strategies.

Differential determination of perceived stress in medical students and high-school graduates due to private and training-related stressors

OBJECTIVE

Numerous studies from diverse contexts have confirmed high stress levels and stress-associated health impairment in medical students. This study aimed to explore the differential association of perceived stress with private and training-related stressors in medical students according to their stage of medical education.

METHODS

Participants were high-school graduates who plan to study medicine and students in their first, third, sixth, or ninth semester of medical school or in practical medical training. The self-administered questionnaire included items addressing demographic information, the Perceived Stress Questionnaire, and items addressing potential private and training-related stressors.

RESULTS

Results confirmed a substantial burden of perceived stress in students at different stages of their medical education. In particular, 10-28% of students in their third or ninth semesters of medical school showed the highest values for perceived stress. Training-related stressors were most strongly associated with perceived stress, although specific stressors that determined perceived stress varied across different stages of students' medical education. High-school graduates highly interested in pursuing medical education showed specific stressors similar to those of medical students in their third, sixth, or ninth semesters of medical school, as well as stress structures with heights of general stress rates similar to those of medical students at the beginning of practical medical training.

CONCLUSIONS

High-school graduates offer new, interesting information about students' fears and needs before they begin medical school. Medical students and high-school graduates need open, comprehensive information about possible stressors at the outset of and during medical education. Programmes geared toward improving resilience behaviour and teaching new, functional coping strategies are recommended.

Empathy in Medical Students Is Moderated by Openness to Spirituality

THEORY

Empathy is one component of medical student education that may be important to nurture, but there are many potential psychological barriers to empathy, such as student depression, burnout, and low quality of life or wellness behaviors. However, few studies have addressed how positive behaviors such as wellness and spirituality, in combination with these barriers, might affect empathy.

HYPOTHESES

We hypothesized a negative relationship between psychological distress and empathy, and a positive relationship between empathy and wellness behaviors. We also hypothesized that openness to others' spirituality would moderate the effects of psychological distress on empathy in medical students.

METHOD

This cross-sectional study included 106 medical students in a public medical school in the U.S. Midwest. Mailed questionnaires collected student information on specialty choice and sociodemographics, empathy, spirituality openness, religiosity, wellness, burnout, depression, anxiety, and stress. Hierarchical multiple regression analysis was conducted, with empathy as the dependent variable, psychological distress and all wellness behaviors as predictors, and spirituality openness as a moderator.

RESULTS

Specialty choice, burnout, wellness behaviors, spirituality openness, and religiosity were significant independent predictors of empathy. In addition, when added singly, one interaction was significant: Spirituality Openness × Depression. Spirituality openness was related to empathy only in nondepressed students. Empathy of students with higher levels of depression was generally lower and not affected by spirituality openness.

CONCLUSIONS

Nondepressed students who reported lower openness to spirituality might benefit most from empathy training, because these students reported the lowest empathy. Highly depressed or disengaged students may require interventions before empathy can be addressed. In addition, burnout was related to lower levels of empathy and wellness was related to higher levels. These provide potential points of intervention for medical schools developing tools to increase medical trainees' empathy levels.

Risky alcohol use in Danish physicians: Associated with alexithymia and burnout?

BACKGROUND

Alcohol abuse may be elicited by psychological problems and can influence physicians' health and patient safety. To act on it, we need knowledge on the prevalence of the disorder and its associations with psychological factors and physicians' well-being. The aim of this study was to explore whether burnout and alexithymia are associated with risky alcohol consumption in physicians and whether burnout mediates the association between alexithymia and risky alcohol consumption.

METHODS

In this cross-sectional study, 4,000 randomly selected physicians received an electronic questionnaire by email containing the Alcohol Use Disorders Identification Test (AUDIT), the Maslach Burnout Inventory Human-Services-Survey (MBI-HSS) and the Toronto Alexithymia Scale (TAS-20). A total of 1,841 physicians completed the questionnaire (46%).

RESULTS

18.8% reached the criteria for risky alcohol consumption. The likelihood of having risky alcohol consumption was associated with high levels of alexithymia (OR=1.93, 95%CI=1.37-2.74, P<0.001). Moreover, risky alcohol consumption was associated with burnout (OR=1.86, 95%CI=1.13-3.05, P<0.014) and each individual burnout dimension: emotional exhaustion (OR=1.89, 95%CI=1.33-2.69, P<0.001), depersonalisation (OR=2.23, 95%CI=1.53-3.25, P<0.001) and low levels of personal accomplishment (OR=1.66, 95%CI=1.14-2.41, P=0.008). Mediation analysis suggested that the association between alexithymia and risky alcohol consumption was partially mediated through depersonalisation.

CONCLUSIONS

The results emphasize a need for enhancing emotional self-awareness in physicians as psychological traits, work-pressure and alcohol dependence might be self-reinforcing aspects for the individual physician. As alcohol dependence and burnout may have consequences for patient safety separately, the aggregated influence of these factors has to be examined.

A Methodological Review of the Assessment of Humanism in Medical Students

BACKGROUND

Humanism is a complex construct that defies simplistic measurement. How educators measure humanism shapes understanding and implications for learners. This systematic review sought to address the following questions: How do medical educators assess humanism in medical students, and how does the measurement impact the understanding of humanism in undergraduate medical education (UME)?

METHOD

Using the IECARES (integrity, excellence, compassion, altruism, respect, empathy, and service) Gold Foundation framework, a search of English literature databases from 2000 to 2013 on assessment of humanism in medical students revealed more than 900 articles, of which 155 met criteria for analysis. Using descriptive statistics, articles and assessments were analyzed for construct measured, study design, assessment method, instrument type, perspective/source of assessment, student level, validity evidence, and national context.

RESULTS

Of 202 assessments reported in 155 articles, 162 (80%) used surveys; 164 (81%) used student self-reports. One hundred nine articles (70%) included only one humanism construct. Empathy was the most prevalent construct present in 96 (62%); 49 (51%) of those used a single instrument. One hundred fifteen (74%) used exclusively quantitative data; only 48 (31%) used a longitudinal design. Construct underrepresentation was identified as a threat to validity in half of the assessments. Articles included 34 countries; 87 (56%) were from North America.

CONCLUSIONS

Assessment of humanism in UME incorporates a limited scope of a complex construct, often relying on single quantitative measures from self-reported survey instruments. This highlights the need for multiple methods, perspectives, and longitudinal designs to strengthen the validity of humanism assessments.

Empathy levels in undergraduate paramedic students: A three-year longitudinal study

Empathetic behaviour is regarded as a positive trait amongst healthcare professionals and has been attributed to increased patient compliance, greater patient satisfaction, and greater diagnostic accuracy and reduced rates of clinical errors. In particular, paramedic students have typically displayed lower rates of empathy when compared to their healthcare counterparts. The objective of this study is to assess both the level of empathy and changes in empathy in undergraduate paramedic students over a 3-year period at a single tertiary institution. A cross sectional study employing a convenience sample of first, second and third year undergraduate paramedic students at Monash University. Student empathy scores where measured with the Jefferson Scale of Empathy-Health Profession Student version (JSE-HPS); a validated, self-reporting questionnaire. 552 students were enrolled in the study. The mean overall JSE-HPS score for the cohort was 108.60 (SD = 12.50). Female students displayed significantly higher empathy scores of 110.27 (SD = 11.62) compared to males at 105.36 (SD = 13.57). There was also a significant difference (p = 0.03) noted between the 2008 JSE-HPS score 106.32 (SD = 14.02), when compared to the 2009 cohort, 110.18 (SD = 12.91). Results from this study suggest that paramedic students display lower empathy than those reported by fellow healthcare students within the literature.

Association of medical student burnout with residency specialty choice

CONTEXT

Given the trend among medical students away from primary care medicine and toward specialties that allow for more controllable lifestyles, the identification of factors associated with specialty choice is important. Burnout is one such factor. The purpose of this study was to examine the associations between burnout and residency specialty choice in terms of provision for a less versus more controllable lifestyle (e.g. internal medicine versus dermatology) and a lower versus higher income (e.g. paediatrics versus anaesthesiology).

METHODS

A survey was sent to 165 Year 4 medical students who had entered the residency matching system. Students answered questions about specialty choice, motivating factors (lifestyle, patient care and prestige) and perceptions of medicine as a profession. They completed the Maslach Burnout Inventory-Human Services (MBI), which defines burnout in relation to emotional exhaustion (EE), depersonalisation (DP) and personal accomplishment (PA). Burnout and other variables were tested for associations with specialty lifestyle controllability and income.

RESULTS

A response rate of 88% (n = 145) was achieved. Experiences of MBI-EE, MBI-DP and MBI-PA burnout were reported by 42 (29%), 26 (18%) and 30 (21%) students, respectively. Specialties with less controllable lifestyles were chosen by 87 (60%) students and lower-income specialties by 81 (56%). Adjusted odds ratios (ORs) indicated that the choice of a specialty with a more controllable lifestyle was associated with higher MBI-EE burnout (OR = 1.77, 95% confidence interval [CI] 1.06-2.96), as well as stronger lifestyle- and prestige-related motivation, and weaker patient care-related motivation. The choice of a higher-income specialty was associated with lower MBI-PA burnout (OR = 0.56, 95% CI 0.32-0.98), weaker lifestyle- and patient care-related motivation, and stronger prestige-related motivation.

CONCLUSIONS

Specialty choices regarding lifestyle controllability and income were associated with the amount and type of medical school burnout, as well as with lifestyle-, prestige- and patient care-related motivation. Given that burnout may influence specialty choice, particularly with regard to the primary care specialties, medical schools may consider the utility of burnout prevention strategies.