Burnout in early year medical students: experiences, drivers and the perceived value of a reflection-based intervention
Authors: Prendergast Mabel , Cardoso Pinto Alexandra M. , Harvey Christopher-James , Muir Elizabeth 
Published: January 2024

Abstract
Introduction
According to the 11th Revision of the International Classification of Diseases, burnout is defined as a syndrome resulting from chronic work-related stress that has not been successfully managed. Burnout is increasingly prevalent amongst medical students and has been shown to lead to worsened academic engagement, feelings of inadequacy, poor mental health and increased risk of withdrawal from the course. The aim of this study was to explore the experience of burnout amongst early year medical students and evaluate the perceived impact of a reflection-based intervention on their awareness and experience of burnout.

Methods
The reflection-based intervention comprised two tutorials covering the presentation, drivers, impact and management strategies for burnout syndrome. These were introduced into the second-year medical curriculum at Imperial College London. As part of the reflection-based intervention, students were invited to complete an anonymous Qualtrics form three times during the academic year. This included the Shirom-Melamed Burnout Measure (SMBM) and a free-text question prompting the student to consider their stressors at the time of completing the intervention. The former is composed of 14-questions measuring the extent of feelings or behaviours suggestive of burnout, divided into three categories: physical fatigue, cognitive weariness and emotional exhaustion. At the end of the academic year, students were invited to participate in an online focus group to further explore their experience of burnout and their perceived value of the reflection-based intervention. Results of the SMBM were explored descriptively; free-text questions and the focus group transcript were analysed using inductive thematic analysis.

Results
A total of 59 submissions for the reflection-based intervention were analysed: 26 students participated and consented in the first round, 8 in the second and 25 in the third round. Overall median burnout scores were 4 (IQR 3–5), 2 (IQR 1–4) and 3 (IQR 2–5) in each round of the SMBM, respectively. A total of 8 (30.8%) met the threshold for severe burnout (≥ 4.4) in round 1 of the questionnaire, zero in the second round and 4 (16%) in the third round. Physical and cognitive fatigue showed higher median scores than emotional exhaustion in every round. Four students participated in the focus group, which had two sections. The first was reflecting on burnout in medical school and the intervention, which revealed four themes: (1) indicators of burnout (often insidious, but may involve lack of energy and motivation, or changes in perceived personality); (2) perceived drivers of burnout (perceived expectation that medical school is supposed to be challenging and consistent prioritisation of work over wellbeing); (3) working habits of medical students (unachievable self-expectations and feelings of guilt when not working); (4) value of the intervention (the teaching and reflection-based intervention prompted students to identify signs of burnout in themselves and consider management strategies). The second section included considerations for implementing burnout interventions into the medical school curriculum, which revealed three themes: (1) desire to learn about burnout (students hoped to gain insight into burnout and methods of prevention as part of their curriculum); (2) importance of community (group interventions and the involvement of Faculty helped students feel less isolated in their experiences); (3) feasibility of interventions (sustainable interventions are likely to be those that are efficient, such as using multiple-choice questions, and with allocated periods in their timetable).

Conclusion
Second-year medical students demonstrated symptoms and signs of burnout, including exhaustion, lack of motivation and changes in personality. They also expressed a desire to gain greater awareness of burnout and insight into preventative strategies within the medical curriculum. Whilst certain drivers of burnout can be prevented by students themselves through adequate prevention strategies, many remain systemic issues which require curriculum-level change to be effectively addressed. The students found that the reflection-based intervention was effective at improving their perception of burnout and a convenient tool to use, which could be implemented more widely and continued longer-term throughout medical school.