Burnout and mental health in medical education | BMC Medical Education

To the authors’ knowledge, this is the first scoping review of wellness practices in PA education. Additionally, this study contributes to educational and clinical literature regarding evidence-based practice standards and QI needs across programs, institutions, and within the health care system. Based on research and data synthesis across education, health professions, and leading health organizations, this study uniquely proposes operational definitions and key distinctions for understanding and assessing “student success,” “wellness” versus “well-being,” and the application of a validated competency-based model for PA students, which further aligns to CBE and the PA profession competencies at large. Further, the critical synthesis and anchored analyses of recent publications and nationally represented PA student populations support authenticity and transferability.

A PA student’s educational experience propagates the future clinician, positively or negatively, toward a lifelong journey of learning and professional growth. These experiences are extensions of the knowledge, skills, attitudes, and behaviors instilled, shaped, and cultivated in a program. Based on the findings of this scoping review an urgent review is warranted by the PA profession to explore and address program-wide: (1) terminology, (2) wellness practices, and (3) student success implications as the future HCW.

Terminology

Terminology, contextual phrasing, and directional tone were variable across studies. Such variability necessitated more time to be spent analyzing breadth, depth, and meta-accuracy of studies’ methodology and methodological authenticity. Additionally, the ‘keyword’ inclusion was used inconsistently, which could be a hindrance for locating relevant literature and accurately interpreting the salient terms from the researcher’s perspective as well as the reader’s viewpoint. While this heterogeneity is not limited to PA literature, using language variation proves challenging all the same. This challenge demonstrates the need to unify definitions, delineate helpful wellness practice standards whilst mitigating harmful acts, and align the institutions with systems-thinking [90] to communicate efficiently and effectively. Interpersonal communication is among the core competency domains for the PA profession, including PA leaders [4, 5, 8,9,10, 20, 91].

Comparison between the titles and the body of the studies revealed differing (1) directional terminology, and (2) dimensions (Fig.2), which implies that some wellness dimensions receive more exploration (EP, IM) while others were rarely mentioned or directly assessed (Ph, Soc, Sp). Terminology in the titles did not consistently reflect what was examined in the body of the study, which limits recognition of the problems facing students today. Further, inconsistent terminology delays implementation of efficient and effective practices. The pool of terminology used across the literature demonstrates almost equal representation of positive (50.89%) and negative terms (49.11%) when investigating well-being. Positive subconstructs were most prevalent for 3 wellness dimensions (EP, IM, and OA) while negative subconstructs included the same 3 with 1 addition (Ph). Despite relative proportionality between positive/negative terminology, it appears that other crucial dimensions are not receiving equal attention in the literature: Ph, Sp, Soc, and OWB; these research gaps may suggest that approaches to student wellness and success have been too narrow, akin to treating sequalae and mistaking them as underlying causes.

Based on the high degree of mapping alignment and nesting of terminology with the NWI competency-based model of wellness for HCWs, PA education competencies, and accreditation requirements, the authors posit that the model has high utility, feasibility, and cost-effectiveness for its integration into new and existing programs. Longitudinal threading is ideal, such as embedding wellness principles into program philosophy, pedagogical and assessment strategies, and operations (e.g., policies and procedures, faculty/staff development). Adoption and mindful implementation can cultivate tides for change and wellness, empowering students and others to “…function optimally within [their] current environment.” [59, 61].

Wellness practices

While practice-based standards and competencies are often attributed to direct care clinicians, they have perhaps been under-acknowledged in PA programs. Validated frameworks “anchor” expectations and rationale, which inform varying levels of program operations, including curricula, clinical educators, and approaches to student success. However, the inclusion of evidence-based frameworks, learning theory, and pedagogical strategy were minimal in the studies examined. Curricular innovations for wellness practice instruction may have been statistically significant although their implementation was not threaded into the program or did not address all of the dimensions of wellness [27, 29, 70, 83, 89].

Findings across the studies demonstrated positive and negative experiences impacting student perception, well-being, and subsequently outcomes [92]. Studies most often examined wellness practices by “adding” to existing structures and schedules [93], indicating that changes are content driven with likely siloing, rather than threaded into the overall program philosophy. Adding onto existing infrastructure rather than strategically removing or refining practices may predicate endless content cramming and haphazard approaches, requiring even more reason for theoretical grounding [84, 85, 87].

Without establishing and maintaining clear goals with purposeful actions, PA programs risk impeding (or diminishing) the returns on student development and investment. In CBE, utilization of multiple models to adequately develop learners into competent future clinicians is grounded in curriculum design via a multidimensional approach, such as using validated learning theory models (e.g., Miller’s Pyramid) [35, 94, 95]. Taking a cross-sectional approach with continuity from student matriculation through to beyond graduation as lifelong learners and ensures an iterative and goal-directed educational experience toward longevity [52, 57, 95]. After graduation, this PCW will enter clinical practice with capacity to contribute meaningfully toward population health while maintaining equilibrium of well-being, or alternatively, be ill-equipped to contribute to society and patient care optimally and resiliently. Siloing of wellness-focused educational content as seen in the included studies could impede the acquisition or future transfer of wellness practice knowledge, skills, attitudes, or behaviors beyond the classroom and into the clinical setting [95]. For instance, literature frequently summates multi-faceted concepts into one primary term, such as “burnout” – comprised of 3 subconstructs: emotional exhaustion, cynicism/depersonalization, reduced self-efficacy [45, 96]. Respectively, use of a primary term without acknowledgement of its subconstructs, and vice versa, may artificially appear singular and impacts how individuals experience and interpret the world within and around them [97]. Further, terminology used during interpersonal exchanges (verbal and written) can serve to clarify how populations perceive, understand, identify, and label humanistic experiences in the future [97]. Robust and accurate characterization of these experiences mitigates the potential for inadvertent oversimplification; consequently, this risks under-delivering necessary supports to enhance balance and well-being in academia and clinical practice settings [17, 41, 96].

Consistently, studies demonstrated efficacy of wellness-based curricular innovations such as debriefing, decentering, and mindfulness techniques [68, 71, 74,75,76, 82, 83]. Practice strategies that demonstrated mutual respect and consideration for students’ time as a valuable resource were well-received and validated the importance of meeting students’ wellness needs (e.g., time to attend medical appointments) [27,28,29, 70, 79, 85, 89]. Additionally, fostering program and educational cultures that are predictable yet not rigid, was highly regarded when implemented with appropriate scaffolding, reasonable boundaries, and realistic expectations [28, 29, 70, 85, 87]. PA programs and institutions could build on the above noted successes when designing and delivering wellness curricula.

Implications for student success as future providers

Despite varied definitions and approaches to assess and foster student success, the undeniable message permeates—advocating a return to the fundamentals of humanism within PA education. Prioritizing the needs of a person, as a human first, stands to generate inherent value-adds during the time-bound journey with a “student” persona [98, 99]. Addressing these concerns can improve variables critical to student success.

The constructs synthesized from this review (Appendix 1: Table 3) are not simply abstract concepts. Instead, each can contribute to a student’s experience – positive or negative, functioning as “protective” or “risk” factors to mediate outcomes of success and well-being [24]. Accreditation standards and PA competencies necessitate instruction for health promotion – prevention, screening, and maintenance [4, 5, 20], yet educational practices inadequately address the intangible, or “non-somatic” facets of negative student experiences and overarching unmet wellness needs, as individuals and as a collective [13, 18, 19, 51, 115]. The U.S. approach to health and wellness is characteristic of a disease-driven system with emphasis on symptom management rather than preventive services. However, in the authors’ opinion, this traditional practice of clinical medicine has been long overdue for modernization and transformation.

Institutions have experienced unsynchronized systemic changes over years of scientific and technological expansion. Embedding wellness frameworks can inform evidence-based education with practice approaches underpinned by positive psychology [22]. Intentional approaches to frame verbal and written language shapes experiences that may create meaningful, positive change, or fuel negative neurobiological pathways [16, 17, 22]. Collectively, such exchanges are micro-opportunities toward evidence-based healing practices such as cognitive restructuring. Healthier exposures and outlooks minimize the potential for unnecessary negativity that can diminish the quality of an experience and therefore, impede learner optimization of success toward actualization [32, 99]. Based on the research findings, individual’s perception of well-being is catalyzed by: (1) ability to compensate for or cope with dysregulation, (2) the type, frequency, and proportion of wellness dimensions affected by disruptions, and (3) the degree of influences contributing to meaningful increases/decreases in wellness. Therefore, burnout and other negative outcomes beget the antithesis of health, well-being, or wellness. PA education could build on positive psychology principles to move from health promotion to health protection for students as future HCWs.

The health burden of students cannot be addressed solely by adding to existing packed schedules [93, 97, 98]. The perpetuated zeitgeist of the past to “try harder” in the face of crippling HCW and PCW impairment across the U.S. is unacceptable and frankly, dangerous. Core to the physician assistant (PA) ethical duty [100] is the charge to advocate as a systems-citizen [56] and leader [90] within the health care ecosystem, including the workplace, education, and research [9, 91, 101]. As these issues continue to go unaddressed, the U.S.’s population health burdens of morbidity and mortality increase while the supply of competent and resilient new graduates poised to thrive long-term as HCWs dwindles. The nationwide HCW pulse is thready and in dire need of a wellness transfusion [13, 22, 23, 25, 102].

Meanwhile, the hyper-fixation on student performance related to board exam outcomes or attrition is an oversimplification of “success” and inadequately characterizes the underlying problems faced by students [6, 31, 36, 40, 42, 103]. Research supports that the educational launchpad can serve as an environment to role model healthful practices and strengthen trainees’ ability to transfer care skills across settings and above all, use them for self-care [11, 16, 39, 104,105,106]. Otherwise, educators may unintentionally assume a parentified role with students, leading to interpersonal shifts such as maladaptive “unprofessional behavior.” Meanwhile, implicit messaging of “do as I say and not as I do” in the educational environment is not congruent with learner-centered wellness practices [11, 97, 98, 106, 107]. The barren landscape of emotional intelligence and such dynamics fuels unconscious incompetence [37, 39, 95], and the prevalence of negative student experiences across PA education speaks volumes to the illusory learner-centered environment [108]. What is developed, including through educator modeling during this precious time, is critical [15, 109].

Much of PA education focuses on QI practices through self-assessment cycles, benchmark transparency, and practice approaches based on data and trend monitoring [5]. It is possible that conceptualizing such benchmarks could unknowingly create the perception of a false dichotomy; that the threshold is either met or not met, each resulting in various action steps—often disciplinary in nature—and with outcomes negatively impacting students [70]. The outcome does not negate what contributes behind the scenes. The articles reviewed indicate that optimization cannot occur proficiently without a scaffolded, longitudinal design to appropriately map the learner’s experience from matriculation through to HCW success. Increasing a learner’s potentiation must be propagated with supports whilst impediments are dismantled with through trauma-informed approaches [16, 17, 110]. These needs were echoed diffusely across the diverse literature conclusions.

The Institute for Healthcare Improvement’s (IHI) quintuple aim framework [111] is worthy of inclusion in longitudinal program or curricular mapping for the PCW. Just as an injury leads to sequelae, prolonged systemic misalignment impedes efforts toward optimal health [11, 21, 32, 42, 46, 54, 90]. Perhaps, educational systems have unintentionally overlooked core tenets of students success. As humans and future healthcare clinicians, it is empowering to enhance healthful living and care for both patients and themselves [17, 21, 51]. Success is not limited to a board exam and is not a check-box to meet a quota or compliance visit. Reducing the burden of adverse experiences for PA students is possible – program training, empowering learner voice, fostering emotional intelligence growth, and redesigning schedules to reduce content quantity over quality, to name some strategies aligning with Table 1 practice data. Success is worth distinguishing; otherwise, if not living purposefully, finding meaning and value across various areas of life, and having the tools to identify imbalance or restore equilibrium to the best of one’s ability for self and the community, the trajectory is undefined.

Limitations

Given that all included studies were published in the past 7 years and written in the English language, publication bias is a consideration. Additionally, numerous studies had sources of funding, which warrants caution regarding bias. Nearly all studies were peer-reviewed, although the rigor of the reviews varied (e.g., poster presentation of preliminary results, dissertation). The data collection methodologies of the reviewed studies included instances of non-randomized and indirect sampling techniques, such as survey administration electronically sent to a program director for subsequent distribution to students. This multi-step process poses risk for sampling error and bias. Data extraction and analysis was laborious and time-consuming, requiring frequent cross-checks to definitions and protocols to maintain research integrity given the variability across terminology, title brevity, descriptive inconsistencies, implicit methodology, and sparse presence of keywords in the studies [55]. Studies having abbreviated methodologies and undefined use of tools to enhance rigor and transparency was prominent (Table 1) and could confound the results, although reflexivity could be appreciated in the studies’ discussion. Additionally, incongruence between constructs used in the titles (e.g., burnout) and examination in the research body inconsistently addressed relevant overarching concepts (e.g., well-being), painting a narrow depiction of the topic in-situ. Generally, participants sampled across studies were PA students, however, multi-institutional or interdisciplinary programming included other non-PA student participants in the original data sets (Table 1). Thus, the synthesized and excerpted findings must be interpreted with caution for transferability.

The degree of critique may be subject to researcher bias due to the educational background(s) and practice expertise of the researchers. Although, certain findings of this study are consistent with what is represented across the mass literature themes of health professions burnout and the need for institutional wellness practice. Prevalence of wellness practices appeared inadequate and had incomplete implementation for longitudinal scaffolding and may not be a generalizable depiction of the practices used in other health professions programs.

Recommendation for future works

The authors identified a need for unified terminology related to wellness and student success; such work would benefit researchers and students alike. Investigation into the Ph, Sp, Soc, and OWB dimensions is lacking; thus, research focused on these dimensions would provide a more holistic understanding for researchers and education leadership. Finally, implementation and investigation of threaded curricula integrating wellness practices, trauma-informed education, and learning theory is a much-needed next step.