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Burnout – a forerunner to depression – starts at medical school

A University of Free State study indicates that symptoms of mental wellness issues, such as burnout – which can be a forerunner to clinical depression – can start as early as a medical professional’s student years.

Burnout, according to the study, describes a process of mental exhaustion. It has been shown to “have a devastating impact on health professionals, such as declining mental and physical health as well as quality of life, which has serious repercussions for health professions as the career becomes less attractive”.

Compared with the general population, the researchers also noted how students and medical practitioners had a higher prevalence of burnout and stress-related mental disorders.

Researchers set out to determine the association between levels of burnout and quality of life among 121 fourth-year medical students at the University of the Free State who were in their first semester of the clinical phase.

“It is well established in research that burnout is the forerunner for clinical depression and that the two conditions share certain similarities. The mental exhaustion experienced in burnout is similar to that experienced in depression,” Edwin du Plessis, the study’s corresponding author, is quoted in the report as saying.

“From the middle of their third year, students are exposed to more practical work as the start of the clinical years. Students are expected to see patients under the supervision of more experienced clinical staff, attend clinical ward rounds and perform after-hours duties like being on call,” he said, adding that this could be extremely gruelling as the students still had to keep up with their theoretical work and also prepare for the following day.

The report says the researchers used the internationally recognised Maslach Burnout Inventory and assessed the risk of burnout by exploring three components: emotional exhaustion, depersonalisation and personal achievement.

“The most surprising of the results was how common the occurrence of high levels of burnout among the fourth-year students was, with 46.1% experiencing it.
“We always expected to find the levels of burnout to be high, given the demands placed on these students, but we were still very surprised as to the extent of the problem,” du Plessis said.

Psychiatrist Jan Chabalala said what was particularly surprising for him about Mayosi’s suicide and the discussions many people were having around depression, was the misconception that “successful and intelligent people don’t become depressed”.

“People think that because you supposedly have ‘everything’ in a material sense, and are intelligent, you won’t suffer from mental illness. But the bottom line is that Mayosi was a human being, and disease is everyone’s risk,” he said.

Chabalala conceded, however, that certain professions were predisposed to their employees suffering from depression. “For instance, dentists, gynaecologists and anaesthesiologists all have high suicide rates because they deal with a lot of complaints and litigation if operations do not go well. That criticism is stressful and can knock one,” he is quoted in the report as saying.

Du Plessis said people often underestimated the impact of stress on mental and physical health. “Unfortunately, issues surrounding mental health still carry a lot of stigma in South Africa. This often prevents people from seeking help when it is clear they are not coping.

“Acknowledging you are not coping is not a sign of weakness, but rather a sign that you are looking after yourself,” he said.

Du Plessis advised medical students to focus on time management, adding that the effective use of time opened up more free time.

Background: Society invests huge financial resources in training medical students. However, the academic and personal demands placed on these students can be taxing and may be detrimental to students’ quality of life leading to high levels of burnout and academic dropout rates.
Aim: To determine the association between the levels of burnout and quality of life among fourth-year medical students at the University of the Free State (UFS).
Setting: School of Medicine, UFS, Bloemfontein.
Methods: All fourth-year medical students in their first semester of the clinical phase were included. Data were collected using anonymous self-report measures. The Maslach Burnout Inventory (MBI) measured the levels of burnout according to three subscales (emotional exhaustion, depersonalisation and personal achievement), and the World Health Organization Quality of Life Assessment (WHOQOL-BREF) measured the quality of life.
Results: Of the 121 enrolled fourth-year medical students, 91 (75.2%) completed the questionnaires. The MBI personal achievement subscale had the highest number of participants (n = 53; 58.2%) with high levels of reported burnout. Significant associations were found between the psychological health subscale of the WHOQOL-BREF and all three subscales of the MBI, in particular emotional exhaustion.
Conclusion: An association exists between the levels of burnout and quality of life among fourth-year medical students. This information could be of value to medical schools as they are in a position to implement interventions that promote students’ well-being.

Lauren Colby, Moliehi Mareka, She'neze Pillay, Fatima Sallie, Christine van Staden, Edwin D du Plessis, Gina Joubert


Doctors and medical students have spoken about their journey through a “black hole”, says a Sunday Times report. Dr Alastair McAlpine said: “We work ridiculously long hours, our goodwill is exploited by our employers, and we are unsupported by our regulatory bodies.”

The report says anaesthetists have the highest suicide rate with at least three suicides a year. South African Society of Anaesthesiologists CEO Natalie Zimmelman said the culture was to be strong, “but the narrative must change”.

“There is unquestionably a problem of wellness and clinician suicide in the industry. In 2013/2014, nine South Africa anaesthesiologists committed suicide in just 18 months, including the vice-president of our association,” said Zimmelman.

The profession created a mental health awareness campaign, offering drug and alcohol abuse therapy and support systems. Academic studies on the issue showed the suicide rate “constitutes a massive human disaster and is reflective of the great seriousness of the problem”, said Zimmelman. Analogies were drawn between the operating theatre and an aircraft cockpit, without the safety measures being adhered to or the physical and psychological fitness of clinicians to perform their work being considered, she said.

One of the reasons for suicide and depression was a high incidence of drug abuse, linked to the high-pressure role in medicine. Another was “horrendous working conditions in public and private care”. Zimmelman added: “Also, they will never fail at suicide because of their access to drugs, and their training means they know very well how to harm themselves.”

There are just more than 1,300 anaesthesiologists in the country, about 2.5 for every 100,000 people. This is against the minimum recommended by the World Federation of Societies of Anaesthesiology is five. “Even this number, though, is badly maldistributed, with almost none in small towns and rural areas and only about 0.9 per100,000 in the public sector,” she said.

A 2015 report found burnout among local anaesthetists was unreasonably high. “When they can’t save lives, or if medicine isn’t available, they feel ineffectual,” Zimmelman said in the report. “Overwork leads to burnout and stress, which leads to depression, which leads to suicide. It is a continuum which is worsening because of the workforce diminishing.”

Zimmelman said the culture in medicine was to be strong, “but the narrative must change. That mental illness is not a weakness.” She added: “What in their training makes anyone think doctors can diagnose their own incapacity? They have to have the answers and when they don’t, it is a problem. It takes strength to ask for help.”

[link url=""]News24 report[/link]
[link url=""]SA Journal of Psychiatry abstract[/link]
[link url=""]Sunday Times report (subscription needed)[/link]

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