Abstract
Purpose
The prevalence of physician burnout has risen and negatively impacts patient care, healthcare costs, and physician health. Medical students are heavily influenced by the medical teams they rotate with on the wards. We postulate that faculty well-being influences student perception of clerkships.
Methods
Medical student evaluations core clerkships at one academic institution were compared with results of faculty well-being scores over 2 years (2018–2020). Linear mixed models were used to model each outcome adjusting for year, mean faculty distress score, and the standard deviation (SD) of WBI mean distress scores. Clerkships and students were treated as random effects.
Results
Two hundred and eighty Well-Being Index evaluations by faculty in 7 departments (5 with reportable means and standard deviations), and clerkship evaluations by 223 students were completed. Higher faculty distress scores were associated with lower student evaluation scores of the clerkship (− 0.18 per unit increase in distress, std. err = 0.05, p < 0.01). Increased SD (variability) of faculty distress was associated with higher student overall ratings (0.49 points per unit increase in variability, std. err = 0.11, p < 0.01), as was year with 2019–2020 having lower overall ratings (− 0.17, std. err = 0.06, p < 0.01). Findings were similar for ratings of faculty teaching: mean faculty distress (− 0.15, std. err = 0.25), SD faculty distress (0.33, std. err = 0.12), 2019–2020 vs. 2018–2019 (− 0.19, std. err = 0.06) (all p < 0.01).
Conclusions
Physician well-being is not only associated with quality of patient care and physician health, but also with medical student perceptions of clinical education. These findings provide yet another indirect benefit to improved physician well-being: enhanced undergraduate medical educational experience.
Keywords: Medical education, Well-being, Burnout, Teaching
Introduction
Over the recent year, the topics of burnout, fatigue and well-being have become significant areas of research. As the research interest surrounding physician wellness continues to expand, new tools are being developed to assess physician well-being [1]. The increasing prevalence of provider burnout negatively impacts patient care, healthcare costs and physician and provider health [2]. In one cross-sectional study, physicians who reported errors were found to have higher levels of burnout, and work-unit safety grades were found to be independently associated with burnout, well-being, and self-reported medical errors [3]. However, academic physicians not only affect the patients they encounter, but also shape the learners with whom they interact. Regarding medical student education, it has been shown that higher burnout rates in medical students may be related to lower professional climate scores [4]. While studies regarding physician well-being and its effects on patient care, healthcare cost, safety, and provider health are numerous, few studies have been conducted evaluating the relationship between physician wellness and learner education. We aim to evaluate if any association exists between faculty wellness scores and student perceptions of their clerkships and the quality of faculty teaching.
Methods
Student evaluations
Students complete evaluations of the core clerkships after each rotation. These evaluations include various questions, on a 5-point Likert scale, regarding organization of the clerkship, usefulness of the clerkship as preparation for residency, professionalism observed on the clerkship, as well as other questions regarding the learning environment. In particular, the questions regarding “Overall Evaluation of the Clerkship” and “Evaluation of Faculty Teaching” were of interest in this study. These survey results were obtained with de-identified student information.
Well-Being Index
The Physician Well-Being Index (WBI) is a screening tool developed to stratify mental quality of life (including depression and recent suicidal ideation), burnout, fatigue, stress, and career satisfaction in medical professionals. It has been validated in residents, medical students, and physicians [1, 5]. The WBI was distributed and voluntarily completed by faculty with the maximum frequency allowed for completion approximately monthly. Data from this 7-item screening tool were made available at the department level with mean distress score, standard deviation of mean distress score, and number of completed WBI’s reported for each department representing core clerkships. A minimum number of 5 unique individuals, set by the developers of the WBI, needed to complete the WBI for the mean distress scores to be generated.
Data analysis
Existing medical student evaluations of each of the 7 core clerkships (Psychiatry, Ob-Gyn, Neurology, Surgery, Family Medicine, Pediatrics, and Internal Medicine) were compared with Physician Well-Being Index scores of faculty over a 2 year period (2018–2020) at a single large academic medical center. The WBI was first implemented at the study institution at the beginning of the 2018–2019 academic year. Student evaluation data was modeled by academic year and both mean and standard deviation (SD) for both overall evaluations of the clerkship and for evaluation of faculty teaching. The primary outcomes were the student ratings of faculty teaching and their overall clerkship rating. Linear mixed models were used to model each outcome adjusting for year, mean distress score (where higher score indicates greater level of distress), and the standard deviation of WBI mean distress scores. The departments and students were treated as random effects to account for the multiple ratings per clerkship (department) and multiple ratings per student throughout the years. Of note, the second year over which this study was conducted (2019–2020) does include the time period where 3rd year medical students began virtual clerkships in place of in-person rotations during the beginning of the COVID-19 pandemic. However, this study was not specifically designed to evaluate the effects of changes in the learning environment due to the pandemic.
The study was submitted to, reviewed, and approved by the Institutional Review Board at the study institution.
Results
In total, 280 individual WBI evaluations were completed by faculty from the departments of the core clerkships over the 2-year period. As the WBI results were available only at the department level, this number indicates the number of unique instances the WBI was completed, and not necessarily the number of 5 unique individuals who completed the WBI. 1240 total student evaluations of the core clerkships were completed over the same time period by a total of 223 students with multiple ratings per student, as each 3rd year medical student rotates through and can evaluate each core clerkship.
Mean distress
Mean distress scores with associated student evaluations of the clerkship overall and evaluations of faculty teaching are shown in Tables 1 and 2, respectively. Of note, mean and SD of distress scores were not reported for Family Medicine and Ob-Gyn departments due to the restrictions placed by the developers of the WBI for a minimum threshold of unique individuals. Higher mean distress scores of faculty were observed to be associated with both lower evaluations by students of the clerkship overall, with a − 0.18 per unit increase in mean distress (std. err = 0.05, p < 0.01) as well as lower evaluations of faculty teaching on the clerkship, with a − 0.15 per unit increase in mean distress (std. err = 0.25, p < 0.01), as shown in Table 3.
Table 1.
Faculty distress vs overall clerkship evaluations
| Department | Mean distress score (n) | Mean student evaluations of clerkship (n) |
|---|---|---|
| Family Medicine | (13)* | 4.19 (157) |
| Internal Medicine | 0.77 (30) | 4.38 (188) |
| Neurology | 1.59 (22) | 3.92 (182) |
| OBGYN | (27)* | 4.15 (172) |
| Pediatrics | 2 (102) | 4.41 (181) |
| Psychiatry | 1 (23) | 3.82 (179) |
| Surgery | 1.34 (53) | 3.71 (181) |
Mean faculty distress scores (higher value indicates greater distress) from the WBI with number of completed WBI’s (n) shown with associated mean student evaluations (5-point scale) and number of evaluations of the clerkship overall(n) for each core clerkship (department)
*Denotes value not reported due to not meeting minimum number of unique individuals set by the Well-Being Index
Table 2.
Faculty distress vs faculty teaching evaluations
| Department | Mean distress score (n) | Mean student evaluations of teaching (n) |
|---|---|---|
| Family Medicine | (13)* | 4.22 (157) |
| Internal Medicine | 0.77 (30) | 4.41 (188) |
| Neurology | 1.59 (22) | 4.15 (182) |
| OBGYN | (27)* | 4.14 (172) |
| Pediatrics | 2 (102) | 4.25 (181) |
| Psychiatry | 1 (23) | 3.92 (179) |
| Surgery | 1.34 (53) | 3.75 (181) |
Mean faculty distress scores (higher value indicates greater distress) from the WBI with number of completed WBI’s (n) shown with associated mean student evaluations of faculty teaching (5-point scale) and number of evaluations (n) for each core clerkship (department)
*Denotes value not reported due to not meeting minimum number of unique individuals set by the Well-Being Index
Table 3.
Summary table depicting coefficients for the associations observed
| Coefficient | Std. Error | p value | |
|---|---|---|---|
| Mean distress vs. evaluations of clerkship | − 0.18 | 0.05 | < 0.01 |
| Mean distress vs. evaluations of teaching | − 0.15 | 0.05 | < 0.01 |
| Variance vs. evaluations of clerkship | 0.49 | 0.11 | < 0.01 |
| Variance vs. evaluations of teaching | 0.33 | 0.12 | < 0.01 |
| Y1 vs Y2 clerkship overall | − 0.17 | 0.06 | < 0.01 |
| Y1 vs Y2 faculty teaching | − 0.19 | 0.06 | < 0.01 |
Variability
Additionally, the association between variability in faculty distress scores, quantified by the standard deviation within each department by year, and student evaluations of the clerkship overall and faculty teaching was assessed. Variance and associated student evaluation scores are shown in Table 4 and Table 5. Increased variability of faculty distress was found to be associated with higher evaluations of both clerkship (0.49 points per unit increase in sd, std. err = 0.11, p < 0.01) and of faculty teaching (0.33 points per unit increase in sd, std. err = 0.12) as shown in Table 3.
Table 4.
Faculty distress variability vs overall clerkship evaluations
| Department | SD distress score (n) | Mean student evaluations of clerkship (n) |
|---|---|---|
| Family Medicine | (13)* | 4.19 (157) |
| Internal Medicine | 1.65 (30) | 4.38 (188) |
| Neurology | 1.50 (22) | 3.92 (182) |
| OBGYN | (27)* | 4.15 (172) |
| Pediatrics | 2.87 (102) | 4.41 (181) |
| Psychiatry | 2.69 (23) | 3.82 (179) |
| Surgery | 2.53 (53) | 3.71 (181) |
Mean SD (variability) of faculty distress scores from the WBI with number of completed WBI’s (n) shown with associated mean student evaluations of the clerkship overall (5-point scale) and number of evaluations (n) for each core clerkship (department)
*Denotes value not reported due to not meeting minimum number of unique individuals (5) set by the Well-Being Index
Table 5.
Faculty distress variability vs faculty teaching evaluations
| Department | SD distress score (n) | Mean student evaluations of teaching (n) |
|---|---|---|
| Family Medicine | (13)* | 4.22 (157) |
| Internal Medicine | 1.65 (30) | 4.41 (188) |
| Neurology | 1.50 (22) | 4.15 (182) |
| OBGYN | (27)* | 4.14 (172) |
| Pediatrics | 2.87 (102) | 4.25 (181) |
| Psychiatry | 2.69 (23) | 3.92 (179) |
| Surgery | 2.53 (53) | 3.75 (181) |
Mean SD (variability) of faculty distress scores from the WBI with number of completed WBI’s (n) shown with associated mean student evaluations of faculty teaching (5-point scale) and number of evaluations (n) for each core clerkship (department)
*Denotes value not reported due to not meeting minimum number of unique individuals (5) set by the Well-Being Index
Year 1 (2018–2019) versus Year 2 (2019–2020)
Finally, associations between mean distress scores by year and evaluations of clerkships and of faculty teaching were evaluated. Mean distress scores and corresponding clerkship and faculty teaching evaluations are shown in Tables 6 and 7, respectively. Again, the minimum threshold of 5 unique individuals completing the WBI for mean distress scores to be reported was not met for year 2 (2019–2020) for Family Medicine and Ob-Gyn. When year 1 and year 2 were compared, year 2 was found to be associated with lower evaluations of both the clerkships and of faculty teaching (− 0.19, std. err = 0.06, p < 0.01), as shown Table 3.
Table 6.
Faculty distress by year vs overall clerkship evaluations by year
| Department | Mean distress score Y1 (n) | Mean student evaluations of clerkship Y1 (n) | Mean distress score Y2 (n) | Mean student evaluations of clerkship Y2 (n) |
|---|---|---|---|---|
| Family Medicine | 2 (12) | 4.25 (93) | (1)* | 4.1 (64) |
| Internal Medicine | 0.41 (22) | 4.41 (99) | 1.75 (8) | 4.33 (89) |
| Neurology | 2.12 (17) | 3.94 (103) | − 0.2 (5) | 3.90 (79) |
| OBGYN | 1.96 (23) | 4.27 (99) | (4)* | 3.97 (73) |
| Pediatrics | 2.06 (80) | 4.42 (99) | 1.77 (22) | 4.41 (82) |
| Psychiatry | 0.47 (15) | 4 (103) | 2 (8) | 3.58 (76) |
| Surgery | 1.64 (42) | 3.92 (100) | 0.18 (11) | 3.45 (81) |
Y1 = 2018–2019, Y2 = 2019–2020
Mean faculty distress scores from the WBI with number of completed WBI’s (n) shown, with associated mean student evaluations of the clerkship overall (5-point scale) and number of evaluations (n) for each core clerkship (department), both by year
*Denotes value not reported due to not meeting minimum number of unique individuals (5) set by the Well-Being Index
Table 7.
Faculty distress by year vs faculty teaching evaluations by year
| Department | Mean distress score Y1 (n) | Mean student evaluations of teaching Y1 (n) | Mean distress score Y2 (n) | Mean student evaluations of teaching Y2 (n) |
|---|---|---|---|---|
| Family Medicine | 2 (12) | 4.33 (93) | * (1) | 4.08 (64) |
| Internal Medicine | 0.41 (22) | 4.47 (99) | 1.75 (8) | 4.35 (89) |
| Neurology | 2.12 (17) | 4.16 (103) | − 0.2 (5) | 4.14 (79) |
| OBGYN | 1.96 (23) | 4.3 (99) | * (4) | 3.92 (73) |
| Pediatrics | 2.06 (80) | 4.28 (99) | 1.77 (22) | 4.21 (82) |
| Psychiatry | 0.47 (15) | 4.09 (103) | 2 (8) | 3.68 (76) |
| Surgery | 1.64 (42) | 3.93 (100) | 0.18 (11) | 3.53 (810) |
Y1 = 2018–2019, Y2 = 2019–2020
Mean faculty distress scores from the WBI with number of completed WBI’s (n) shown, with associated mean student evaluations of faculty teaching (5-point scale) and number of evaluations (n) for each core clerkship (department), both by year
*Denotes value not reported due to not meeting minimum number of unique individuals (5) set by the Well-Being Index
Discussion
This study, performed at a single large academic medical center, shows that lower faculty well-being is associated with lower student perceptions of both the clerkships on which they rotate and of faculty teaching. Faculty in academic medicine are in a unique position with many roles to fulfill which can conflict with teaching and their role as an educator [6]. As workloads increase and faculty wellness declines so may their level of work engagement, which can also include their commitment to undergraduate medical education. A sense of low job control has been observed to be associated with greater emotional exhaustion in one meta-analysis [7]. This may possibly place faculty in a position to become less engaged as educators, which may affect students and learners, as long-term outcomes of learner neglect have been discussed to negatively impact student learning and ultimately lead to learner burnout [8]. Additionally, while this study particularly focused on the association between faculty wellness and student perceptions of their education, burnout in residents has been seen to be related to not only self-reported sub-optimal care but has also been discussed as affecting the medical students whom they encounter via the hidden curriculum [9]. Positive associations have also been observed between medical student burnout rates and medical students reporting having a cynical resident on their team [10], findings the authors of this study would expect be a similar occurrence in the faculty-student relationship.
Additionally, greater variability in the well-being of faculty encountered by students on clerkships is associated with higher student perceptions of clerkships and faculty teaching. As individual wellness fluctuates over time, this finding may be explained in that with greater variability of faculty mean distress students may have had the opportunity to encounter faculty with higher well-being or healthier outlooks and approaches to improving their well-being. However, this study is limited in its ability to evaluate this as it is unable to assess changes and trends in individual faculty wellness over time due to faculty mean distress scores only available to be reported at departmental levels.
In addition, several other important limitations of this study exist. This study was completed at a single academic medical center, which may limit its generalizability to other institutions, as work environments differ between academic medical centers. Faculty distress scores were also only available to be reported by department and year, limiting the ability to incorporate changes in individual faculty well-being through the study period. This also means that we were unable to pair faculty who completed the WBI with students who rotated on the clerkship while these faculty were on service, limiting the ability to evaluate for direct associations between faculty wellness on student education within specific rotations. Further larger and multi-institutional and multivariate studies would be beneficial in the future. Of note, year 2 (academic year 2019–2020) includes the time period when clinical students were withdrawn from the wards during the beginning of the COVID-19 pandemic and began virtual clerkships. While this study attempts to provide some insight into longitudinal association of faculty wellness and student perceptions of education, the associations of lower faculty teaching and clerkships may be largely explained by the transition to virtual clerkships as well as the greater psychosocial effects of the pandemic.
Further studies to evaluate for correlations and causal relationships between wellness of academic medical educators and the education of learners is warranted. Studies investigating the impact of interventions improving educator wellness on education would also be beneficial, as this study did not evaluate if interventions to improve faculty well-being are associated with the perception of education by medical students. Examples of further directions include investigating resident wellness and its relation to student education, as residents also greatly influence medical students’ learning environment. Studies investigating levels of resident autonomy, competence, and social relatedness, which have been found to be associated with greater resident wellness [11], may be insightful, as would improvements in the learning climate, which is associated with higher work engagement and job satisfaction among residents [12].
As more studies regarding well-being in the medical field are carried out over the coming years, attention should be paid to how this area relates to the learning environment. Learner education may benefit from efforts to impact the wellness of educators and learners not only at the individual level, but all levels of education. Buery-Joyner et al. have proposed several questions which clinical educators, educational program directors, and health care systems may reflect on to improve the learning environment [8]. Intentional and systematic action has been proposed to ensure the development of vitality within departments of academic medicine and faculty as this unified drive has been argued to be crucial in combating declining wellness [13]. This process of training not only clinically and academically strong physicians, but those with high levels of work engagement is an important focus, which may be beneficial to begin as early as in undergraduate medical education [14].
Conclusion
Physician well-being is not only associated with quality of patient care and physician health, but also the perceptions medical students hold regarding their clinical education. While further studies identifying correlation are needed, improving physician wellness may enhance the undergraduate medical educational experience.
Funding
No funding was received for conducting this study.
Declarations
Conflict of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
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