DOI: https://doi.org/10.21203/rs.3.rs-2470697/v1
Background: Doctors who have been rightly called wounded healers, start experiencing the challenges of this profession right from their student days. Medical students face comparatively higher frequencies of mental morbidities such as depression, anxiety, burnout, and also greater levels of psychological distress. The whole medical curriculum and this field of medicine require immense hard work, sleepless nights, a lot of compassion, and putting in service before self. The students entering medical colleges, who have just taken the first step in this never-ending journey of learning and service begin to experience a lot of challenges and overwhelmed and measurable syllabus, long years of gaining knowledge, and continuous pressure of being up to the mark as it may become a matter of someone’s life or death. Earlier, least discussed as a topic of concern, the mental health of medical professionals is now being talked about, however, enough data is still not available relating to the medical students of Nepal. This study aims to assess burnout among medical students of Nepal.
Methods: A quantitative descriptive study was carried out online among Nepali undergraduate medical students with a cross-sectional design.
Results: Out of 531 students, 72.32% fell in the burnout category. The prevalence of burnout was
76.35% in the first year, and 45.45% in the final year. 67.01% of total males and 78.75% of total females were identified as burnout.
Conclusion: A very high prevalence of burnout was encountered among Nepali undergraduate medical students more commonly in females and first-year students.
Burnout can be defined as a condition where there is psychological and emotional exhaustion accompanied by physical tiredness as a result of chronic stressful lifestyle. It can lead to loss of interest and motivation, decrease in productivity of an individual, and can further invite psychological and physical illnesses.1 Burnout is common in doctors, education sector professionals, armies, private sector workers, students, etc.2,3 Medical students are also highly susceptible to developing burnout as they are laid to a myriad of pressures, obligations, and psychological stressors brought by the overall makeup of the medical education system.4–6 When compared to the general public, mental morbidities such as depression, anxiety, and psychological distress were encountered more in medical students increasing with the years of training.7
Anxiety and depression are more prevalent among medical students in comparison to other students of non-medical disciplines and there were significantly higher rates abuse of alcohol and eating disorders.8 The whole medical curriculum and this field of medicine require immense hard work, sleepless nights, a lot of compassion, and putting in service before self. The students entering medical colleges, who have just taken the first step in this never-ending journey of learning and service begin to experience a lot of challenges and overwhelmed and measurable syllabus, long years of gaining knowledge, and continuous pressure of being up to the mark as it may become a matter of someone’s life or death.9–11 Nepal, being home to around 20 medical colleges, harbors a considerable number of medical students acquiring their medical knowledge at different levels of the course. The trend in the mental health status of students of Nepal is now being made a topic for study. A study has shown a significant 27.8% prevalence of depression in the medical students of Nepal.12
In 2018, Nepal only had 0.749 physicians per thousand population.13 There is the immense amount of pressure being experienced by the medical students of Nepal who have to provide for the upcoming healthcare needs of their country. Apart from the constant exposure to stresses like peer competition, staying away from family, seeing the harsh realities of life, death and sickness greatly affect the overall mental health status of these medical students. Earlier, least discussed as a topic of concern, the mental health of medical professionals is now being talked about, however, enough data is still not available relating to the medical students of Nepal. Our study aims to assess the status of burnout among medical students of Nepal.
This is a descriptive cross-sectional study that was carried out among Nepali undergraduate medical students. This study was conducted as a nationwide online survey.This study includes all the students from the first to final year who wanted to participate and have been enrolled in a medical college in Nepal. The study was started immediately after the ethical approval letter was recieved through Institutional Review Committee-Nepalgunj Medical College. At first, the mailing list of students was obtained from their respective medical colleges, student associations, and clubs. Participants were recruited using the same mailing list. A google form was created which included the details of our study, the consent form, and the burnout scale and it was sent to participants via email. The data was collected from October 1 to November 30, 2021. The Oldenburg burnout inventory Scale was used to assess the burnout status. The oldenburg burnout inventory scale is a tool that was developed to measure burnout, containing exhaustion and disengagement as its two subscales. The participant is provided with a series of 16 items and had to express their agreement or disagreement level. The 16 items are classified into two parts items 1, 3, 6, 7, 9, 11, 13, and 15 are for Disengagement, and items 2, 4, 5, 8, 10, 12, 14, and 16 are for Exhaustion.14 There are four negative items in both parts the score of which need to be reversed like from 1 to 4, 2 to 3, 3 to 2, and 4 to 1 so the greater the score, the higher the burnout is.
The average of both the parts was calculated separately. The obtained scores greater than or equal to 2.25 and greater than equal to 2.1 were taken as the cutoff for exhaustion and disengagement respectively to group the participants as “low exhaustion and low disengagement into the non-burnout group,
low exhaustion and high disengagement into the disengaged group, and high exhaustion and low disengagement into the exhausted group, high exhaustion and high disengagement into the burnout group.”15
This scale has been applied widely in study on German students, employees, psychiatry residents, medical students from Hongkong, Nigeria, etc.16–17−18–19 Analysis was performed using SPSS version 22 and result was presented in the form of figures and tables
The result has been devised based of responses of 531 medical students. Categorization was based on gender and the academic year of the respondents. As shown in Fig. 1, 54.80%(291) participants were male and 45.197%(240) were females. Out of the 531 medical students, 38.23% (203) belonged to the first year, 46.14% (245) were in the second year (25.80% males, 20.34% females), 11.48%(61) were in the third year while remaining were the final year students.
As mentioned in Table 1, the Average of the total score under the disengagement part was 2.39 with a 0.629 standard deviation.
As mentioned in Table 2, The average of the total score under the exhaustion part was 2.47 with a 0.65 standard deviation.
Figure 2 summarizes the burnout categories of the participants. According to the earlier mentioned cutoff scores, 384 (72.32%) participants were in the burnout, 82 (15.44%) were in the disengaged, 25(4.7%) were in the exhausted whereas 40 (10.0%) were in under the non-burnout group
Table-03 Burnout status according to gender and academic year
| OLBI | Burnout | |
|---|---|---|
| Gender | Male | 195 (67.01%) |
| Female | 189 (78.75%) | |
| Total | 384 (72.32%) | |
| Year of Study | First Year | 155(76.35%) |
| Second Year | 180 (73.47%) | |
| Third Year | 39 (63.93%) | |
| Final Year | 10 (45.45%) | |
| Total | 384 (72.31%) | |
As in the table 03, Burnout was prevalent in 76.35%(155) of first year, 73.47%(180) of second year, 63.93%(39) of third year, 45.45%(10) of the final year students. It was 67.01%(195) in males and 78.75%(189) in females.
This survey was designed for the assessment of the status of Burn out among Nepali undergraduate medical students and as well as to compare the levels of burnout with respect to sex and academic year. According to this study, the presence of Burn out is very high in Nepal among undergraduate medical students. It is 72.32% which is more than two-thirds. This is indicative of the poor mental status of the students which can later precipitate mental morbidities like anxiety and depression in absence of psychological intervention as literatures are there showing an association of high burnout status with anxiety and depression.20,21 The present findings seem to be consistent with the result of a similar study conducted in a medical college in Kathmandu, Nepal inJanuary, 2021 where almost two-thirds of the total participant were burnout and around 10% were non- burnout.15 In a research conducted in Monterrey, Mexico, Burnout was identified in only 14.9% (n=23) which is far less in comparision to Nepalese medical students. It also reports males were four times more prone to develop burnout compared to females in contrast to a study where burnout was seen more in females.22 The study conducted at the University of Karbala among medical students in the year 2020 as well as research conducted in the Barretos School of Health Sciences all showed a lower prevalence of burnout when compared to the medical students of Nepal.23,24 Similarly, the medical students from Universiti Sains Malaysia, showed less prevalence of burnout than the students of Nepal.25 The significant difference in the prevalence of burnout between Nepalese and foreign medical students could be because of the difference in the education system, syllabus, academic load, ongoing COVID-19 Pandemic, and other social or personal factors. Further study to find out the causes of this high prevalence of burnout is necessary to be carried out. Our results revealed a higher prevalence of burnout in females than in males. This result confirms the findings of previous research like the one done by Dahlin and Joneberg and the study conducted at the university of Karbala. 23,26
In this study Higher percentage of the first-year students were identified as burnout in comparison to students in second, third and final year. There was a decrease in prevalence of burnout with increasing standards in medical school. The percentage of burnout was more among first-year students (76.35%) compared to second-year students(73.47%) and it was more in second-year students (73.47%) than those who were in their third year (63.93%). This finding remain consistent with findings of the study done in Barretos school of health science where also first year medical students were more burn out.24 This high percentage could be due to the exposure to new conditions and lack of adaptability adding to this was the sudden shift to the online mode of education which gave them less time to adjust to college environment and the medical education curriculum.
The findings of this study should be considered in light of limitations like its cross-sectional design, the application of an online questionnaire, lower response rates from third-year and final-year students, and the variation in response rate among different colleges. The sample is not representative. However, the participants are from different medical colleges all over Nepal making the sample nearly similar to representative sample. Many elements of the current pandemic may have shown effect on the burnout status of the participants. The study has not explored the reasons for the higher prevalence of burnout among medical students in Nepal as well as the effect of elements like sex, age, involvement in extracurricular activities, exercise, etc on the status of burnout.
A very high prevalence of burnout was encountered among Nepali undergraduate medical students, clearly indicating the necessity of effective plans of action for the betterment of the mental health status of future physicians by the authorities concerned. Set-ups such as psychological help desks, the formation of psychological support teams, and some constructive changes in the academic curriculum may be of some positive help. There is a greater prevalence of burnout in females and first-year medical students. Measures can be taken to identify the actual problems in a better manner and effective solutions.
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