They Shoot Horses, Don’t They? A warning to medical schools about medical teacher burnout during COVID-19

This article was migrated. The article was marked as recommended. The 1969 film, They Shoot Horses, Don’t They? provides a contextual background for what appears to be happening to medical teachers as they attempt to cope with teaching during the COVID-19 pandemic, staving off the threat of exhaustion. This short piece argues that it is necessary for medical education institutions to recognise the changing demands made on, and by, their teachers, so that they can prevent burnout, and provide the support required to take online teaching to the levels that will now be expected. It traces the medical teachers’ changes across three stages of development, commenting on the overall mood, attitudes towards students, teaching focus, research focus, computer usage, theoretical knowledge and self-growth, assessment and institutional support. The aim is to provide some degree of insight into medical teachers’ needs so that adequate anticipation and responses can occur before it is too late.


Introduction
The 1969 film, They Shoot Horses, Don't They? (Pollack, 1969) (based on Horace McCoy's 1935 novel of the same name (McCoy, 1935)) shows the desperation of people attempting to reach a mostly unreachable goal; not only are they unprepared for the demands of what is to come, but the situation is unpredictably altered by those in charge as the participants proceed.As a result, some lose hope and stop; some move on to better opportunities; most are knocked out by sheer exhaustion.The rest keep on going through the motions of what is expected of them.Yowza!Yowza!Yowza!As a medical educator who has been researching and publishing in the field of online medical education for more than 15 years, I noted the important impact of the COVID-19 pandemic on medical education colleagues: the move to massive online teaching and learning, initially characterised by Emergency Remote Teaching (ERT) (Hodges et al., 2020).In particular, I noted those medical teachers who previously had little or no experience with online teaching, and who are now heavily engaged in it.
Some medical schools may have access to large support departments replete with instructional designers, but, given the fact that so many higher education institutions had to adopt ERT, this is likely to be a minority.Where this support does exist, they, themselves are overwhelmed with the demands (Bessette, 2020).While the change to online learning was unquestionably necessary, it is important for medical schools to reflect upon what has happened over the past year, to think about what is to come, and to ensure that the impact on their teachers does not echo the film's "epic of exhaustion" (Canby, 1969).

What to do?
Perhaps a starting point is for the institution to realise that online teaching is not merely a virtual version of what has always happened in the face-to-face class.Any decision-maker who comments to that effect will not only indicate a lack of awareness of the real situation, but will also cause a loss of confidence in the institution.
The second point is to realise that your teaching staff have also changed.The teachers are no longer the same people they were a year ago, and their needs and expectations have grown.Institution administrators need to recognise and respond to the new situation, or, if they cannot, then step aside and let somebody else do it.

Purpose of the guide
In order to assist in this understanding, this paper presents a simple guide (Table 1) that indicates the progression of the teachers through three stages.It is written somewhat colloquially and in the first person, and the idea is for institutional managers to try to judge the current placing of many of their teachers, respond to current needs, and anticipate future needs.
Not everybody will progress in the same way and at the same speed, so no timeline on this progression exists.Either way, one would imagine that most medical teachers will be able to see themselves somewhere in this table.

Clinical Relevance
It should also be noted that Table 1 has a focus on the teaching activities, and does not address the corresponding developments in clinical health care delivery that face many medical educators.This does not mean that clinical teachers are ignored; on the contrary, given that COVID-19 has, directly or indirectly, substantially complicated the provision of healthcare, most clinical teachers are doubly-burdened, and so require an even greater and targeted response from the education institution.
And it progresses into the future And all the time, the pressure builds and deepens: deliver the same quality of education that you did before this started.Simultaneously, there are anecdotal reports of institutions' wishing to keep the class recordings, using them to replace teachers.(From social media, we learn that recordings are already being used to teach classes after the teachers have died (Ansuini, 2021)).
Medical education literature has many studies of medical students', residents' and physicians' burnout; not so much on medical teachers.(A February 2021 Google Scholar search on "medical student burnout" returned 1,480 results; a search on "medical teacher burnout" returned Zero results).See Figure 1 and Figure 2.
While the few scattered texts that exist are useful, they generally do not deal with a world-wide pandemic; that is not their fault, but it does mean we are working with unknowns.And the unknowns need to be addressed.Because the unknowns will vary widely from institution to institution, the first action required is for institutions to ask (though short surveys, focus groups, or whichever process best suits all), what the specific issues are, and then obtain suggestions for responding.After that, it will be imperative that there is a swift, adequate and appropriate response;  beginning immediately with smaller issues, and then the development of longer-term strategies.In addition, if the facilities exist, formal and informal counselling may be required.
The unknowns will need to be addressed now and in the future, not only because (we hope) higher education has been altered forever, but also because there will be more pandemics, and we do not wish to be caught unprepared for the next one.There is already discussion about medical education technology use after COVID-19 (Goh and Sandars, 2020); we need to ensure that we have a secure base on which to work.

Conclusion
In the film, They Shoot Horses, Don't They? (spoiler alert), the main characters remove themselves from the competition when they realise that the rewards do not match their expectations, and pursuance is futile.Other characters continue; they may or may not know that the rewards are trivial; either way, they keep going because of their desperation and the fact that they have already invested too much into the process, even though very little of their activities match their ideals.
Most were not aware that this would be such a long-term exercise.
Many medical teachers are reaching the points of exhaustion and dejection.Medical Education institutions need to recognise what is happening to their medical teachers, and take immediate action before it is too late.Otherwise, one way or the other, medical education will suffer.Yowza!Yowza!Yowza!Take Home Messages Medical teachers are struggling to cope with the demands brought on by the COVID-19 pandemic, and many are reaching exhaustion.
The typical stages through which the medical teachers progress can be viewed through several characteristics.
Medical schools need to take note, anticipate, and take steps to alleviate the situation in order to prevent medical teacher burnout and the damage to medical education.

Notes On Contributors
Ken Masters (PhD, FDE) is Associate Professor of Medical Informatics in the Department of Medical Education and Informatics, Sultan Qaboos University, Oman.He has been involved in e-learning, education and medical education for some two decades, and serves on AMEE's Technology Enhanced Learning (TEL) Committee.ORCID: https://orcid.org/0000-0003-3425-5020.

Declarations
The author has declared the conflicts of interest below.
The author is an Associate Editor of MedEdPublish.This paper has been submitted through the standard MedEdPublish process.

Ethics Statement
This paper is an editorial and personal viewpoint, and no human or animal subjects were involved, so no ethical clearance is required.

External Funding
This article has not had any External Funding

Acknowledgments
Many thanks to Dr. Julie Hunt and Dr. Barbara Jennings who commented on an earlier draft of the paper.

Figure 1 .
Figure 1.Source: the author's screenshot of Google Scholar, falling under Fair Use.

Figure 2 .
Figure 2. Source: the author's screenshot of Google Scholar, falling under Fair Use.

Table 1 :
Characteristics of stages through which medical teachers have moved, and may move, because of the pandemic