“This Isn’t Being a Doctor.”—Qualitative Inquiry into the Existential Dimensions of Medical Student Burnout

Abstract

Recent studies report that up to 50% of medical students feel burned out. Medical student burnout has significant public health consequences—as students detach, the quality of patient care is impacted, and students themselves suffer, as evidenced by the increased risk in substance use and suicide. While some theorize that medical student burnout is due to an inability to confront suffering, death, and their own mortality, this hypothesis fails to explain why pre-clinical students also experience burnout despite having minimal clinical exposure. /r/medicalschool, a news-aggregating website for medical students, was queried for posts from the creation of the subreddit, December 11, 2009, to July 1, 2018, for the term “burnout” and its grammatical variations. Three hundred fifty-two posts and their comment threads were analyzed using a grounded theory approach. When the causes of burnout were interpreted using an existential psychodynamic framework, the predominant themes that arose were difficulties dealing with freedom (groundlessness), existential isolation, and meaninglessness, rather than death anxiety stemming from witnessing the suffering of patients. Students feel as if they are not living up to their own values of what a physician should be like and are troubled by the inconsistent values within the hidden, informal, and formal curriculum. Individualized interventions are temporary fixes that allow people to withstand their environment and complete their training; however, the learning environment needs change to better empower students to live a life full of existential meaning.

Introduction

Burnout affects around 50% of medical students: 35–45% of students surveyed by Shanafelt et al. had high emotional exhaustion, 26–38% had high depersonalization, and 45–56% had scores suggestive of overall burnout. Limited cross-sectional data suggest the prevalence of burnout is higher for students in more advanced years of training [1] and that burnout is a chronic problem, as 73.2% of students surveyed remained burned out in the following year [2].

The degrees to which one experiences any one of the dimensions of burnout are most commonly quantified through the Maslach Burnout Inventory (MBI), a 22-item validated questionnaire which is utilized in over 90% of empirical studies on burnout [3]. As defined by Christina Maslach, one of the MBI’s authors, burnout is comprised of three dimensions—emotional exhaustion, cynicism (depersonalization), and feeling less personal accomplishment. Within her construct, exhaustion stems from work overload and personal conflicts, and feeling less accomplished arises from a lack of resources to do the job properly, as well as inadequate social support and professional development. In response to emotional exhaustion and feeling less accomplished, depersonalization arises as a defense mechanism that results in people doing the bare minimum to fulfill their job requirements [4].

For the majority of medical schools in the USA and Canada, the first two years are pre-clinical and cover basic science topics, such as anatomy, physiology, pathology, neuroscience, immunology, and microbiology, as well as courses in developing clinical skills, professionalism, and ethics. After the first two years, medical students must take the first part of their board licensure exams (United States Medical Licensing Exam Step 1 and/or Comprehensive Osteopathic Medical Licensing Examination of the United States Part 1, both of which have three examinations to be taken over the course of medical training). The USMLE Step 1 is a high-stakes exam; as it is considered the “great equalizer” by residency programs, this single score is the most frequently cited metric when program directors choose and rank applicants [5]. Applicants can also be “screened out” based on this score from being considered for certain specialties or programs.

The entire third year and part of fourth year are spent in a structured series of clinical rotations called “clerkships,” which includes Internal Medicine, Obstetrics and Gynecology, Pediatrics, Surgery, Neurology, Psychiatry, Emergency Medicine, and Family Medicine. The fourth year is largely self-structured, as students try and build their schedules around graduation requirements, as well as unspoken requirements for the residency field they want to apply to. They must also study for and take Step 2, another scored exam which is heavily considered by residency program directors. From October to January, applicants then pay for their own flights and accommodations to interview at residency programs; the majority of applicants attend 10 to 15 [6]. Both the applicants and the programs rank their preferences, and these lists are entered into the National Match Ranking Program by mid-February. An algorithm matches applicants to programs, and the applicants are then contractually obligated to go to the program they are matched to. Programs vary not only by geographic location but also in quality of education as well (patient load and resident autonomy, as well as variety of clinical sites and didactic lectures offered).

As trainees progress in their careers, the stakes are raised significantly as job demands increase and responsibility for the patient becomes more direct. The prevalence of burnout is concerning because depersonalization, which manifests as being callous and cynical towards others, is the most strongly associated with impaired professionalism, such as being disingenuous about whether diagnostic tests had been ordered and reporting physical exam findings as normal when they were not assessed [7, 8]. In addition to various misconducts, M.L. Jennings, who has herself experienced burnout as a medical student, states that “burnout (and especially depersonalization) is likely to impair a student’s ability to reflect and learn from past mistakes, care about her patients, and develop a mature, integrated professional identity.” [9]

/r/medicalschool, a news-aggregating website for medical students, was queried for posts prior to July 1, 2018, for the term “burnout” and its grammatical variations. Three hundred fifty-two posts and their comment threads were coded using a grounded theory approach and interpreted using Irvin D. Yalom’s conceptualization of existential psychotherapy and the four “ultimate concerns” of life (death, freedom, isolation, and meaninglessness) [10]. Key existential dynamics arise from these concerns: “the awareness of the inevitability of death and the wish to continue to be, . . . the clash between our confrontation with groundlessness and our wish for ground and structure, . . . our wish to be part of a larger whole, . . . [and] the dilemma of a meaning-seeking creature who is thrown into a universe that has no meaning” [10].

When the expressed causes of burnout were analyzed within this framework, the predominant themes that arose were (1) meaninglessness, (2) difficulties dealing with freedom (groundlessness), and (3) existential isolation, rather than death anxiety stemming from witnessing the suffering of patients. Individualized interventions are temporary fixes that allow people to withstand their environment and complete their training; however, as my data shows, the current learning environment isolates existential meaning from the medical education process. This divorce of existential meaning from the process of professionalization contributes to burnout.

Materials and Methods

Reddit is a social news aggregator, a web content rating system, and a discussion board rolled into one website. As of February 2017, Reddit was ranked the third most visited website in the USA and the sixth in the world, with the USA representing 58.8% of its user base and the UK following with 7.5% [11]. When posts (texts, links, images, gifs, or videos) are submitted, they appear in a subreddit for users to vote for or against (“upvote” and “downvote” respectively), with the default sorting of each subreddit showing newer posts with higher upvotes.

All subreddits function within this upvote/downvote system as well as a sorting algorithm which determines the order and visibility of posts. /r/medicalschool is one of Reddit’s many subreddits. Users can comment on the posts and respond to each other in a comment tree; these comments can also be up- or downvoted. The intention of the up/downvote is to promote conversations that are relevant to the discussion and downvote those that are not; however, in practice, they are used to create a consensus. “Top” parent posts and child comments have higher visibility and serve as an indication of how widespread or popular an idea is.

I utilized Reddit’s search function to find posts/comments that explicitly mention “burnout” or its grammatical variations on /r/medicalschool. All 352 resulting posts and their comment threads from December 11, 2009, the creation of the subreddit, to July 1, 2018, were included in the analysis. July 1, 2018, was chosen as the end-date because it marks the end of the academic year. The webpages were downloaded using NVivo, a qualitative analysis software, and converted into PDFs which could be easily searched, coded, and analyzed thematically using an inductive approach. The screenshots of the webpages included time stamps as well as the net score of upvotes/downvotes for each post and comment. The data were also managed through NVivo, which helped map relationships between codes and themes, which would otherwise remain hidden in the data, observing both frequency and association of themes.

The posts and comment threads were coded using an inductive method, which allowed for new questions and themes to emerge throughout the interpretive process (Table 1). As this study aimed to understand the lived experiences of students sharing their personal stories of burnout online, no predetermined set of codes based on burnout literature was used. Although participants were anonymous and could not be easily identified by their username alone, I ensured confidentiality by paraphrasing or quoting in a way that obscures the source webpages, so that individual usernames could not be identified. Quotes are presented in the following format: (approximate number of 'upvotes' + type of content). External readers who were also medical students but not involved in the data collection or analysis read the coded posts and comments within their original threads and compared them with the paraphrased quotes. The readers provided feedback that ensures that the paraphrased quotes remained faithful to their source’s context and meaning.

Table 1.

Themes, codes, and sub-codes

Theme	Codes and sub-codes	Descriptions
Meaninglessness
	Inefficient structuring of time	Watching residents write notes instead of being dismissed
	Pressure to maximize productivity	Scores, evaluations, clinical output
	Prioritizing studying or work above all else	Foregoing leisure activities, and the following: Eating healthfully, hygiene, proper sleep schedule (no caffeine), cleaning living space
	Financial pressures	“Why am I paying tuition to sit around/teach myself?”
Groundlessness
	Systemic issues with medicine and medical education	Administrators’ focus on grades and board scores
	Big life change/new stage in life	Learning how to study, learning how to work on team, learning social norms of profession
	Hidden curriculum	Discrepancy in stated mission versus implicit and explicit values
	Cut-throat culture or toxic environment	Abusive behavior from residents and attending physicians
	Demands and work expectations	Subjective grading system, not interested in specialty, cumulative exams, board exams, time required on clinical rotations
	Feelings of inadequacy	Knowledge base, clinical skills, unable to help patients
	Residency applications	Choosing specialty, interviewing, matching
	Ethical issues	Mistakes made by attendings, “I could not do anything”
Existential isolation	Hours	Waiting for dismissal, lack of interest, lack of sleep, time to study
	Picking specialty and matching	Anesthesia, dermatology, emergency, family, internal, neurology, neurosurgery, ob-gyn, pathology, paediatrics, psychiatry, radiology, surgery
	Lack of existential meaning	“What am I doing with my life and why?”
	Working in a team	Role on team, power dynamics within medical hierarchy, interpersonal interactions
	Unfriendliness or unhelpfulness	“If you cannot take the heat, get out of the kitchen.”
	Commiseration on /r/medicalschool	"Does anyone else feel this way?", sharing memes
	Rekindling spark for medicine	Focusing on more on patient care and less on grades
Downvoted comments
	Speaking without clinical experience	e.g., First-year student speaking about how third-years should feel grateful for being able to study medicine

Primeau states that reflexivity, the researcher’s understanding of their degree of influence exerted, intentionally or unintentionally, of their findings is crucial to producing rigorous qualitative research [12, 13]. As I analyzed data using an inductive approach, my characteristics were important in the design of the project. The study was conducted as the basis for my Ph.D. dissertation thesis, and I had completed my third-year rotations in the required specialties prior to beginning my Ph.D. training in the medical humanities. I first became interested in burnout as I experienced burnout myself in my third year of medical school, and witnessed friends and students within the Humanities, Ethics, and Professionalism course wrestle with burnout. I found myself disagreeing with the predominant discourse within the field of health humanities on burnout, which argues that a lack of vulnerability and inability to face death and suffering are contributing factors [14].

This conclusion was reached through literature review on burnout within numerous professions. For example, teachers, C-suite executives, and senior managers also have a high incidence of burnout but do not contend with the existential concern of death and suffering. Furthermore, research on medical students indicates burnout and empathy decline through all four years of medical school [15], even during pre-clinical years which are largely didactic, which does not support similar hypothesis. My personal experience and honest conversations with other medical students indicated that burnout was due to structural factors, such as the learning environment, rather than how individuals themselves process the exigencies of clinical practice. Additionally, I have been an active participant in online communities of medical students since 2012, which includes both Student Doctor Network and Reddit, and browse /r/medicalschool at least three times a week; the long-term involvement on these sites as a participant, upvoting and downvoting content, provides a familiarity with the predominant discourses within /r/medicalschool that other researchers may not have.

As such, in order to mitigate post/comment selection bias, all posts and comments returned by querying “burnout” on /r/medicalschool were coded, and I did not include posts where burnout was not explicitly mentioned within a post or comment. Only including posts and comments that explicitly mentioned burnout reduced the influence of my own definition of burnout—“diagnosing” it in others—during data analysis. Redundancy of overarching themes and subthemes, or metathematic saturation, was reached, and the information power of the data was appropriate to the study’s aim.

Limitations of this method stem from Reddit’s anonymous nature and my own decision to remain anonymous as a researcher. I did not create surveys or polls, or post topics to generate discussion as I wanted to limit my influence on the organic discussions on burnout on /r/medicalschool. Additionally, to date, no users have conducted a demographic study on /r/medicalschool and verifying user data and the veracity of the events recounted in their posts/comments is impossible due to the ability of users to create numerous anonymous accounts. Due to the voting system and the performative aspect of storytelling, it is possible that users embellish or exaggerate their negative experiences. Despite the inclusion of individual stories in my data collection, the inductive coding and creation of themes aggregate these stories into more generalizable sentiments.

Despite these limitations, this methodology provides a different perspective to the phenomenon of medical student burnout by offering a distinctly inductive opportunity that connects the biographical, individual stories to social structures. For burnout and other “negative” emotive states which are highly stigmatized, the usage of an anonymous online social media platform where the conversations are asynchronous and aspatial allows for different types of biographical stories to arise. Additionally, users can express their thoughts and create a community around a shared, stigmatized experience. The qualitative data gathered through this methodology gives voice to students who are within the thick of medical education, and contributes to the body of research on medical student burnout conducted through macro and structurally focused studies that use questionnaires, surveys, and focus groups [16]. As the dataset is circumscribed around a topic rather than following specific users, the results are a bricolage of medical student experiences on burnout, rather than providing detailed accounts and experiences of individuals. As such, the conversations that occur on /r/medicalschool reveal overarching aspects of the medical education experience that contribute to burnout. Finally, the voting system allows for researchers to assess how relatable these overarching aspects are to other users within the community.

Results

Meaninglessness

Posters on /r/medicalschool describe the pre-clinical years as demanding due to the sheer amount of knowledge, and the rapid changes in medicine. The impulse to master this knowledge is an incredible stressor that has caused many pre-clinical students to burnout: “I do the same thing every day: wake up, try and study as much as possible while minimizing down time and distractions, go to sleep, wake up again, and do it all over again. If I take a day off, I feel like shit because I feel like I should be studying for end-of-block exams or for Step 1. It never goes away” (110+ post, 93% upvoted).

Third- and fourth-year students also face academic pressures due to grades and the need to request letters of recommendation. Clinical grades are comprised of a summative exam (the standardized National Board of Medical Examiners Subject Exams) and subjective evaluations, where students are assessed on their ability to perform the following: take patient’s history of present illness, physical examinations, written and verbal communication skills with patients and other providers, ability to build rapport with patients and families, fund of knowledge and ability to apply it to clinical scenarios, and professionalism. These categories are graded from a modified Likert (1–4) scale: Unsatisfactory, Needs Improvement, Competent/Satisfactory, Outstanding, as well as the ability to note that the evaluator “did not observe.”

Because every clinical rotation at every institution weighs the standardized, summative exam and subjective evaluations differently and has different cutoffs for the Honors, High Pass, and Pass grades, the subjective, evaluation-based grading system in third and fourth years was a significant stressor associated with burnout. In a self-declared rant, a poster states, “I am so tired of evaluations. 1/3 of the people will just not like me for whatever reason, even if I diagnose patients accurately, read up conditions, act pleasant. They might not like my voice or think I’m too soft- or loud-spoken. Even if I ask for feedback from the attending, they tell me that I’m doing great, but then shit on my evals at the end” (20+ post, 100% upvoted).

The third- and fourth-year experience, as described by a commenter, can be summarized as, “Welcome to third year, where the rules are made up and the points mean everything” (65+ comment), which illustrates not only how severely the power dynamics affect evaluations but also the level of absurdity present in medical education. Others, in a post asking whether other third-years also feel burnt out (80+ post, 96% upvoted), mention the inconsistency of grading: “No matter what I do, I always get ‘great student, great team-player,’ but a 85% on the final grade” (10+ comment).

The rotation, at times, can feel absurd, due to the lack of clear, defined roles for the student. Students often questioned the value of their educational experience and often felt more burned out if they were not able to fully participate in patient care. For example, one user states:

I don’t have my own patients to follow, no one asks me to write a note - I do so voluntarily and sent them to my superordinates to get feedback, but after the first few days, I stopped because I got the sense that I was being annoying. I do round on a few patients of my own in the morning, but that feels useless because the resident will round without me very quickly and write notes of their own without reviewing mine. Every hour I spend there, I could be studying for the [summative exam], but I’m just shadowing a team for more than ten hours a day. (10+ post, 77% upvoted).

Another poster who wanted to apply to Internal Medicine describes feeling frustrated because he was “essentially shadowing on my rotation. My job was just to get the ‘sign out’ and presenting them to the team. After rounds are over, I just sit in the call room until the attending notices that I’m still there and dismisses me. I’ve even offered to do scutwork and they’ve declined” 40+ post, 94% upvoted).

In some cases, the feelings of meaninglessness refer to the medical student’s inability to care for the patient in a way that creates a lasting impact. For example, a poster asks for advice because he finds himself hating a specialty that he always dreamed of going into:

I hate everything about medicine. I hate doing rushed History & Physicals on patients, only to present the patient on rounds and no one cares. I hate having to document everything. I hate that the goal of this service is to keep patients alive so we can discharge them, just so we can continue admitting people. I hate that no one wants to focus on the underlying problems that these patients have. I hate watching physicians interact with patients because of their atrocious people skills (60+ post, 90% upvoted).

In another example, a 150+ post (92% upvoted) states that he has turned into a “classist, condescending monster” and expresses frustration at his inner-city patients’ behavior: “they’re usually non-compliant and don’t understand their disease or their medications, and I don’t get the point of trying anymore.” A commenter reframes the role of the physician for the poster in an empowering way:

My role is to provide advice and information, as well as access to resources, in order to help people address their problems. I can only explain what their options are and the likely consequences of their actions. My job isn’t to fix people. If they make decisions that you view as a poor choice after understanding the consequences, that’s none of your business - they are free individuals with different priorities than you. (220+ comment)

Imagining the role of the physician as a coach, rather than single-handedly responsible for the patient’s health, helped the commenter deal with feeling burned out. There is also a nod to why patients have difficulties in “fixing themselves”: the original poster states that his cynicism reflects “predominantly class/race/socioeconomic issues over which [he has] no control, and not medical ones. It’s bullshit that people think it’s the task of junior physicians to solve all of the problems with American society - the same ones that people have been fucking up for centuries” (20+ comment).

One commenter suggests continuing to develop and cultivate the self as a way of avoiding burnout: “Medical training will change you, but you have to try not to sway too far into the abyss. You’ll have to develop your personality. Ultimately, it’s up to you to decide what kind of person you want to be” (10+ comment). Another user cites a PBS documentary which followed Harvard medical students longitudinally and the story one physician told: “He was basically waiting for things to get better after going through medical school, residency, and his job as an attending, but he realized that it would never happen. He had to choose to actively seek out happiness by learning to enjoy the path, rather than relying on delayed gratification and for his perfect life to materialize” (10+ comment).

While advice such as “it’ll get better in fourth year” was common, which is reflective of this mentality of delayed gratification towards some sort of end goal, another form of advice was presented when users asked others how they were unaffected by or recovered from burnout:

Halfway during my third year, I decided to stop playing ‘the game’ and putting up with the bullshit and condescension of superordinates that were more burnt out than me. I decided to stop caring so much about my evaluations and grades, and focused on two purposes: 1) learning as much as possible, and 2) providing the best care possible to patients. These goals provided me motivation, gave me a sense of accomplishment at the end of the day, and they were the things most within my control. Unsurprisingly, my grades and mental well-being improved (10+ comment).

Students were also able to continue their education despite the challenges they faced by finding a sense of purpose through focusing on patient care:

“Despite all of the negative thoughts I have poured into this post and the general feelings of uncertainty I have entering my fourth year, I feel privileged to be here. Yes, medical school is hard and residency is even harder, but when I meet all of you amazing people, I am reminded of why I went into this field: to help others recover from illness, to teach them about the disease process, and in return, to be taught aspects of the human condition. When I talk to you about your troubles, I know that I’ve made the right decision” (95+ post).

Furthermore, some users recognized that they could fight their feelings of apathy and find meaning even within their limited role on the healthcare team: “You won’t know as much as your superiors, but you have the luxury of being able to spend a significant amount of time with a single patient. That could really make a difference for that person; for example, I recently picked up on a deep vein thrombosis that would have otherwise missed because of overlying bilateral leg edema” (15+ comment).

Groundlessness

Groundlessness is the existential anxiety that results from the realization that there is no predetermined blueprint for our lives, and that everyone is condemned to be free, to be responsible for living life authentically and with inner consent/relation. In following directives from and observing residents and physicians, students are inculcated with the values and norms of the profession. These are internalized in the creation of producing beings—professionals—that follow certain social norms. These norms and values are articulated both formally and informally: through didactic lectures, modeled behavior, and social interactions. Implicit teaching of what it means to be a physician is called the “hidden curriculum,” which includes values and symbols [17], the hierarchy in medicine, implicit and explicit rules, and medical language [18]. A consistent finding in the sociological research on medical education is the “loss of idealism” as medical students move from idealism to pragmatism, which can sometimes manifest as cynicism [19].

The groundlessness experienced by medical students is a reflection of the professionalization process. When framing medical education through the lens of ritual theory, there are numerous rituals that reinforce the “betwixt and between” liminal state that medical students must experience during the professionalization process [20]. Within this liminal state, students must take up the values and norms of the profession impressed upon them through the formal, informal, and hidden curriculum. “Ritual elders,” those who have experienced different milestones within medical training, guide students through the process—whether it is through providing advice within a “Big Sibling” program [21], or by witnessing the interactions between residents and attendings during their clinical rotations [22].

When the steps and expectations for becoming a physician are ambiguous and sometimes in conflict, students are at risk of burnout. As medical students try to mold themselves into playing the physician role, groundlessness was often expressed as a lack of structure and support from within the learning environment. The most commonly cited problem with the learning environment for pre-clinical students was the discrepancy between the material taught in class and the material they were tested on at the end of each subject. Even if excellent clinicians lectured, this did not necessarily result in good classes: “The first time we talked about anemia, the course directors brought in a renowned hematologist to teach. 60% of the time, he talked about the history of anemia, skipped the main and important concepts because ‘you can read that on your own,’ and then spends the other 35% of the class discussing his research” (45+ comment).

Additionally, users felt as if they had to study for two separate curricula—their medical school’s exams, and the board examinations. Users pointed out that medical school administrators view “teaching towards the boards” as a pejorative, rather than a necessity. Students voiced frustrations with being asked for ideas on how to rearrange the curriculum to better meet their needs, but then being met with the following responses from administrators: “Yeah, that’s great and all, but we’re not going to do that. Instead we’ll add irrelevant things that you didn’t ask for” (130+ comment), or “hiring suicide prevention specialists” (80+ comments) and “bringing in stress relief puppies twice a year to the library twice a year for the students’ mental health” (55+ comments).

The learning environment changes drastically during their clinical training. Medical students rotate through different teams, even during the same clerkship. Students must learn how to work on these new teams, being mindful of the power dynamics to score highly on subjective clinical evaluations, as well as study for the summative exam taken at the end of the rotation. A commenter advises new third-years: “Generally, not being annoying is more important than being smart for good evaluations” (530+ comment). Another commenter expands upon what is considered “annoying”: “being overly casual with attendings and residents and not seeing the boundaries that exist, asking dumb questions at inappropriate times, not being self-directed enough and needing constant instruction on what to do next, or saying awkward things” (85+ comment).

Obtaining good grades and evaluations, given by residents and attendings, is important for being a competitive applicant in residency applications, regardless of specialty. As one commenter points out, “while third- and fourth-years are working 12-13-hour days, they also need to somehow study for a final exam. Zero of the material is covered during the work day” (25+ comment). This was in response to a post where the poster was asked by the intern to collect labs for all of the patients on the service before rounds at 6:00 A.M. and he was seeking advice on whether he could refuse the intern’s request: “I don’t want to be a bad student, but I don’t see the educational value in me waking up at 3:30 A.M. to do something that should already be automated, since we have an electronic medical record. I’m paying tuition for an educational experience, and no one has taught me anything so far” (65+ post, 88% upvoted).

Indeed, many of the stressors that lead to burnout in third- and fourth-year students are correlated to the lack of structure and ambiguity of the learning environment. In the aforementioned post, the original poster is cautioned against directly saying no because of the risk that it will “make your rotation an even worse experience for the next couple of weeks” (60+ comment). Instead, commenters suggest the following solutions: “Say, ‘Of course! When do you want to meet?’” (85+ comment), “Mention that you probably won’t be able to help out since lab results won’t be back that early, which is a ‘soft’ no” (20+ comment), “If I were in your shoes, I’d suck it up and do it, hoping that someone higher up will notice your hard work” (60+ comment).

Additionally, Gordon C. Winston, an economist, frames higher education as operating within a “trust market”—applicants are not fully informed about what the quality of their education will be and cannot do anything about it once they have bought it [23]. Students that choose to pursue higher education take a financial risk on a leap of faith that spending X amount of money to receive a degree will result in a job, or financial stability. Medical students described feeling “locked in” because of this “leap of faith” as a source of existential anxiety:

I actually enjoy medical school for the most part and I’ve had enough experience working in other jobs to appreciate that medicine can be a sweet gig, but I really miss not knowing what I was going to be doing in the immediate future and having your future being wide open. People talk a lot about depression and feeling jaded. but I imagine a lot of that is due to feeling trapped. Even if it’s your dream job, if you feel like you’re locked in, you’ll always have some form of anxiety (65+ post, 94% upvoted).

A commenter commiserates, stating that “I don’t have any answers for you, but I can relate. No matter what you do though, you’ll always run into the same question because you either make decisions or life makes them for you. Medicine is scary because it feels final - you’re training for a solid decade, taking on debt, and building yourself into an identity that can swallow you whole” (15+ comment).

Feeling financially insecure contributed to feeling stuck in the pursuit of medicine as a career and groundlessness. This debt is a driving force behind the goal-based aims of many medical students; it guides whether students quit to pursue more fulfilling careers, what specialties students apply to, and how they end up practicing as attending physicians.

In counseling another poster that stated that s/he was burned out and wanted to drop out of school, a commenter states, “if you don’t want to be a doctor, preclinical coursework is the best possible time to walk away. You won’t be able to in a year or two as you’ll be in the debt trap by that time. If you do want to be a doctor eventually, finish Step 1 then take time off to recover from burnout” (8+ comment). Other commenters debate on the utility of finishing the degree requirements for a M.D. if they are burned out: “Even if you don’t go into medicine, having an M.D. opens many doors, and it’s not a sunk cost fallacy to finish the degree. It’s a good investment” (13+ comment), “It may not open ‘many doors,’ but at least having a degree explains the lack of employment for the last four years and nothing to show for it. It’s a badge of dedication rather than nothing at all” (10+ comment). Furthermore, many of the comments addressing burnout describe working in medicine just long enough to make enough money to retire on and switch to a more fulfilling career. In the aforementioned post, a commenter points out that “medicine doesn’t have to be a permanent thing. Once you pay back your loans, you will be making enough to save aggressively and have money to fall back on. You don’t have to be locked in for the rest of your life if you don’t want to” (45+ comment).

In a post that asked users, “Those of you who have wanted to drop out, what made you hold on?” a commenter quips back, “not having rich parents to pay back what I owe” (35+ comment), and other users comment on how other professions have it worse in terms of levels of physical exertion, mental stimulation, fulfillment, and financial compensation (20+ comment, 10+ comment, 5+ comment). In another post, a commenter states, “after the first week of medical school, I knew I didn’t want to do it. I wrote myself a note saying, ‘Try it for one month before you quit,’ and then realized I was already $20,000 in the hole. So here I am, a couple of weeks away from finishing my third-year” (35+ comment). In an additional example, a post asking “Does anyone else feel as if their life will fall apart all of a sudden?” (30+ post, 90% upvoted), a commenter replies, “Yes; it’s directly correlated with the amount of money in my bank account” (10+ comment).

Students learn over the course of their training that financial security is difficult to achieve due to the seemingly insurmountable amount of educational debt, relationships are hard to form within the artificially fast-paced environment of the clinical encounter, and patients have different motivations driving the trajectory of their health that can be difficult to understand. Furthermore, students describe themselves and their future selves as “cogs in the machine,” powerless to be the agent of change in a healthcare system that treats them as expendable agents of labor. The sunk cost fallacy is deeply ingrained within the psyches of medical students and physicians.

Existential Isolation, and Reddit as a Solution

Educational debt was a reason why students felt “locked in” and groundless; it is also a reason for feeling isolated. Philips et al.’s analysis of medical student essays on debt revealed that students felt isolated because those outside of medical education did not understand how significant their debt is, financially and emotionally [24]. The rising cost of medical education was also seen as a lack of social investment, and in some cases, as exploitation by the university system. Feeling financially exploited resulted in medical students feeling cynical and less altruistic. Interestingly, half of student essays accepted their debt as part of the process and believed that they would be able to pay them back. The other half of student essays report feeling disempowered because of their debt as they considered higher paying specialties because of their debt [24].

Students used Reddit to feel less alone, and to resolve their feelings of existential isolation. As one commenter states, “Reddit is a sounding board. The point is to share experiences, thoughts, and feelings, and getting opinions from other people who also ‘get’ it. Medical school is a unique experience and venting to people outside of it just isn’t the same” (1+ comment). The majority of posts on burnout asked the question, “does anyone else feel this way?” in the title, and the majority of responses to posts seeking help were “You are not alone,” and “I feel this way too.” were common responses to posts seeking help. Users also generally believed that medical students in real life were too outwardly positive and inauthentic in their interactions, which contributed to their feelings of isolation and alienation.

The anonymous nature of /r/medicalschool created a safe space in which medical students from across the country could build a community around their shared experience. Because there were no avatars or real-life identity markers attached to these usernames, users may have interacted with each other in ways that reduced implicit biases about race and class, as some users chose to reveal their positionality and why they expressed certain opinions, while others chose not to. While most community forums do tend to skew towards fostering negative opinions, the users of /r/medicalschool sought validation on their experiences, asking whether anyone else felt burned out, how other students dealt with burnout, and sharing their general experiences through posts and memes. Students were also able to discuss their personal, financial concerns openly, which they felt as if they could not do with peers in the offline, “real” life.

As emotional/mental illness is heavily stigmatized and users feel that revealing them to people may come with unintended consequences, these online spaces are the one of the few places that medical students can reveal what they really do and what they really think. Research on similar optionally anonymous social media platforms reports that posts communicate more negative emotions, such as anger and sadness, than social media platforms that have attached in-real-life identities [25]. However, while the topics on /r/medicalschool may be confessional and convey feelings of guilt, shame, or embarrassment, many of the posts ask for advice and commiseration, and comments provide emotional support. Additionally, the majority of posts are image macros that are created with the intention of bringing levity to the difficulties medical students face.

Most of the posts and comments related to burnout on /r/medicalschool share strategies for avoiding and alleviating symptoms of burnout and provide a safe space for medical students to discuss stigmatized and difficult problems, creating a sense of community and a shared experience. Users on other subreddits also use Reddit as a platform for storytelling [26, 27], which provides a new way of speaking and witnessing, as well as a part of a collective counter-narrative [27]. Within /r/medicalschool, the individual posts and comments form a counter-narrative to the literature on burnout. The narrative within the literature is that medical students need to learn how to take better care of themselves. The counter-narrative presented by /r/medicalschool is that medical students know how to take care of themselves but simply lack the energy and time, and often fail to meet basic physiological needs, such as getting adequate sleep.

Discussion

Maslach and Leiter’s theory of burnout identifies six major domains—workload, control, reward, community, fairness, and values—in which a person can have a mismatch with key aspects of his or her organizational environment; medical students have a potential to have mismatches in all six domains. Students are placed under pressures during all four years of medical school: adjusting to a new environment in which they are compared with other formerly high achieving undergraduates; preparing for a high-stakes standardized exam; adjusting again to a new, high-stakes environment in which grades are highly subjective and students are at the bottom of the medical hierarchy; and finally, applying for residency. The results from the study highlight issues with medical education that were not directly related to the health concerns of patients.

Empirical evidence points to a poor learning environment as a factor associated with burnout, encompassing aspects such as deprioritizing medical student teaching, inadequate support from faculty staff, medical school staff and peers, disorganized clinical rotations, poor supervision, little variety of medical problems encountered, mistreatment, and grading schema [7]. Additionally, as third- and fourth-year students often act in the capacity of junior residents, it is important to note the causes of resident burnout: “stressful relationships with supervisors, attending physician demands, insufficient autonomy, a perception that personal needs are inconsequential, and lack of timely feedback” [7]. Other potential stressors across all years of medical school include dealing with negative personal life events, choosing a specialty, lack of personal time, and financial concerns [7].

Scholars have proposed that students burn out because they either do not want to or do not know how to respond to suffering patients and they cannot recognize their vulnerability as human beings, or confront suffering and death [14]. For example, Piemonte argues that the tension between clinical objectivity and personal subjectivity is the underlying cause for much of the mental ill-health experienced by students [14], and M.L. Jennings argues that the alienation and separation of ideals in medical students (and thus, inability to attain self-transcendance) occur because of the culture of medicine’s adherence to the Cartesian dualism, which separates the “mind” from the “body,” and its positivistic paradigm. This quest for objectivity in the larger culture of medicine not only objectifies patients but also objectifies practitioners and students alike [9].

Egnew et al.’s focus-group study suggests that while witnessing others suffer was a source of suffering for students themselves, additional themes emerged: feeling isolated from family and friends, dealing with role instability and learning how to contribute to new, constantly rotating teams, and also attributing poor professional performance to poor character (“if you’re a bad doctor, you’re a bad person”). Students experienced emotional distress, powerlessness, disillusionment, and dehumanization—characteristics that echo the dimensions of the burnout syndrome [28]. Egnew’s results resonate with my findings from /r/medicalschool, and with the four existential concerns as presented by Yalom: role instability, isolation from loved ones, and forming a personal identity centered on professional performance is respectively groundlessness, existential isolation, and meaninglessness.

Alfried Längle’s logotherapeutic framing of burnout—caused by a lack of existential meaning, a sense of inner fulfillment [29]—is supported by my research on /r/medicalschool. This inner fulfillment comes from the “service of a project or a cause,” not “subjective aims, such as career, influence, income, recognition, social acceptance, obligations or objective constraints,” and those who undertake an activity disingenuously by “not [being] motivated by the substance or value of the work” [29] are prone to burnout. In support of this, /r/medicalschool users who focused on “not playing the game” and caring in the best possible way for the patients in front of them reported feeling less burned out than previously.

The difficulties in finding and holding on to existential meaning and fulfillment do not operate within a vacuum; they are also mediated by the social, political, and economic milieu of the medical school. Schools generally compete with each other through rankings in the U.S. News and World Report, using their ranking as a way to create financial and social leverage. These rankings have been criticized as being unreliable and not particularly useful [30] as well as harmful to the unique mission of each school and its ability to meet the needs of the community in which it is situated [31]. As mentioned previously, students are aware of the pressures of the hidden curriculum which are influenced by the attempt to maximize these rankings, and post on /r/medicalschool to discuss the absurdity of medical education. Within the qualitative data, students express frustration with how quantitative metrics, such as pre-clinical grades, Step 1 scores, and clerkship grades, are heavily utilized in internal rankings by their medical school for honor society inductions, and also in residency applications and the construction of rank lists by program directors. Users feel as if the students as persons do not matter—only their scores matter to themselves, their colleagues, and the administration. This could be argued as part of the “objectification” that Jennings argued: reducing students down to quantifiable measures, rather than their personal characteristics and qualities that make them unique as a person and future physician. Users also reported facing pressures in addition to student debt and feeling “locked in”; generally, this involves pressures that trickle down from administrators at both the medical school and the hospital at which they do their rotations.

The qualities cultivated by the pursuit of academic excellence may not foster the qualities relevant to practicing as a virtuous doctor; for Imogen Thomson, those are patience, empathy, and communication skills. To highlight the discrepancy between the ideal and what is practiced, Thomson paints the picture of the quintessential “good” medical student:

Her dedication borders on obsession and pays dividends in the form of excellent marks, supervisor praise, and the knowledge that she is responsible for raising the bar out of reach of the rest . . . the qualities that facilitate this, and those that are valued throughout medical school by the culture or curriculum, are also those that predispose us to burnout and a poor work-life balance [32].

When the intrinsic meaning of medical education—learning how to be a compassionate and competent doctor—is extracted out of the curriculum in favor of learning how to receive the highest marks, I argue that the entire training process becomes hollow, and thus, unnecessarily difficult.

Paradoxically, the hidden curriculum that prioritizes these quantitative metrics encourages students to feel as if acting in pursuit of social status, financial security, or even markers of scholastic achievement will make their lives feel worthwhile and valuable. As Längle points out, focusing on these external aims results in missing what is valuable and worthwhile (becoming a good, virtuous doctor), and life, as a result, feels hollow because one does not approve internally of how one chooses to act and deal with the exigencies of life [29, 33]. The lack of internal approval was also a common theme in medical students who expressed feeling burned out, especially in posts that discussed the absurdities present in medical education.

Conclusion

Autonetnographic theory can be translated into practice in qualitative education research and provide community-based wellness-related issues and proposed suggestions to the attention of medical school administrators. In the case of burnout, the data show that medical student burnout is not due to unresolved, narrowly conceived existential discomforts—an inability to come to terms with patients’ death and suffering. Rather, medical student burnout is a symptom of the inability to answer the existentialist question: “What am I doing with my life and why?” This question reflects the meaninglessness and groundlessness of their training because of the incongruency between the values and moral norms professed and those that are practiced. The discomfort described by the users of /r/medicalschool does not arise from encountering major ethical dilemmas, but within the students’ every day lives and interactions with others. As Jennings argues, regardless of training year, all medical students suffer from being objectified by an “objective” system of medical school; this is done by measuring student progress through quantified subjective evaluations, cumulative exams, and board exam scores. I argue that this objectification continues as residents and attendings are reduced down to the number of patients they see and how much revenue they bring to their institution, which can obliterate the meaning and purpose of their work. Users report that feelings of burnout are exacerbated when they feel trapped and powerless because they are dissatisfied with medicine but cannot quit due to their educational debt and financial situation.

The high prevalence of burnout in medical students would indicate that a system-wide issue is at play, rather than faulty medical school admissions criteria that fails to screen for personal characteristics that would be protective of burnout. From my personal experience, literature review, and the qualitative data gathered on Reddit, medical students have to independently study for two separate curricula, and also feel inadequately supported by medical school administrators. Qualitative data also suggests that medical students do not feel as if they are appropriately recognized for their contributions for their team, or may not even be seen as part of the team. Additionally, users stated that grading seems subjective and unfair; interrater reliability is perceived by users as low and disproportionately high stakes as students are ranked based on these clinical evaluations.

As the MBI measures how people experience their job and their workplace, the results should be used to change policies on decision-making, establish professional development programs for supervisors, and restructure the workload, and directing other organizational changes that address the root causes of burnout. A more direct approach to addressing burnout is changing the curriculum and content delivery to better suit the needs of learners within the formal and informal setting, as well as de-emphasizing the importance of standardized exams. This restructuring, admittedly, is a more difficult and slower process than deploying individualized wellness initiatives (i.e. meditation retreats, mindfulness training). Additional changes include creating space for students to connect and feel less isolated, whether in process groups on anonymous online forums, or by finding mentors they can model and relate to.

Dovetailing with changes in the learning environment is a change in the organizational structure of academic medicine. As Reinhardt suggests, when everyone is insured under a single-payer system and hospitals only have to worry about reimbursement from one payer, the complex financial web that pushes physicians to produce in pursuit of an unknowable financial end dissolves [34]. When physicians feel less pressured to meet clinical productivity measures, they can turn their attention towards teaching and providing a better educational experience. A single-payer system and increased government funding of higher education may disentangle the complicated financial relationship between the teaching hospital and the medical school, which allows both to pursue their combined missions and goal of providing patient care and to educate students without pitting them against each other. This disentanglement and structural changes that financially incentivize teaching may empower faculty to improve their learning environment within their sphere of influence.

Availability of Data and Material

Upon request

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Conflict of Interest

The author declares that there is no conflict of interest.