This study investigated burnout amongst medical students at RVUCOM. Burnout was measured among students attending a spring break global health trip compared with other spring break activities. Demographic and lifestyle factors such as the quantity of leisure time and spirituality were considered. To our knowledge, this is the first study to utilize a control group in objectively assessing Global Health Outreach Experiences’ impact as a curriculum component. The three-model approach used in this study allows for a comprehensive evaluation of the source of the effect. Model 1 being the simplest displays the typical pattern while the focused models (Model 2 and 3) provide context into each time point and whether confounders provide additional information.
Burnout
A significant reduction in personal burnout, studies related burnout, and colleagues related burnout was demonstrated at 10 weeks after spring break among GHOE participants compared with control participants in the model 2 analysis. No significant change in PB, SRB was found at 1-week after spring break, though reductions in CRB were significant at this time (Table 3). The increasing difference in burnout scores between GHOE and control participants at 10 weeks versus 1 week after spring break suggests that any beneficial effects of GHOEs may strengthen over time. These findings are supported in a prior study by Vu, et al., where feelings of perceived benefit (adaptability, communication, and cultural skills) described by medical students attending a medical mission trip, persisted years after participation in such experiences as medical students [35].
Burnout may fluctuate on a daily or weekly basis [36–37]. Model 1 demonstrates there were not significant fluctuations across the population during the study period (Table 3). However, there was a steady increase in mean burnout estimates over time among the control participants. This finding is consistent with literature describing medical school’s effects of increasing burnout over time [4–5].
In the initial survey, over 75% of individuals scored a mean value greater than or equal to 50 (potential score 0-100) on studies related burnout and personal burnout categories, reflecting high prevalence of burnout within these categories (Table 2). SRB was the highest, while CRB was the lowest scoring category across all surveys. Kristensen describes CBI categories as “the attribution of fatigue and exhaustion to specific domains or spheres in the person’s life” [18]. Considering SRB was the highest scoring category throughout all surveys, we can interpret the sample population attributes existing burnout to attending medical school, supporting medical school’s designation as the primary driver of burnout in students [6]). Reasoning why colleague related burnout was lower scoring, we can consider participants were in the didactic years of school, which primarily consists of self-study with little time coordinating on a team with others.
Model 3 analysis, which accounted for potential confounders, did not show significant association between GHOE attendance and PB at any time. SRB was reduced at 10 weeks post spring break among GHOE participants while CRB was reduced at both 1 week and 10 weeks post spring break among GHOE participants compared to control participants (Table 3). Potential confounders of PB and SRB included gender, religiousness/spirituality, and quantity of leisure time. CRB had different potential confounders, including R/S and campus. Female respondents were overrepresented among control participants as seen in Table 1. Gender discrepancy likely accounts for the differing model 2 and model 3 analysis of personal burnout. However, model 3 findings are agreeable with model 2 in supporting GHOEs benefit on medical student burnout, specifically SRB and CRB.
There are mechanisms, consistent with known protective factors, that GHOE participation may reduce burnout. GHOEs could remind students of the reasons for practicing medicine through service and clinical exposure [38][31]. The experience may help establish friendships with other attendees leading to improved social support [13][4][6]. Exposure to diverse conditions could improve resilience [12][39]). A structured spring break may reduce maladaptive behaviors [40–41]. The significantly reduced CRB in S2 and S3 among GHOE participants may support the mechanism of improved social network. There is likely a combination of factors impacting other aspects of burnout.
Sociodemographic Associations
Female participants had significantly higher levels of PB, SRB than males (Table 4). These findings are consistent with other assessments of burnout and in medical students [8][37]. Female gender was more heavily represented in the control group responses.
Identifying as Religious/Spiritual was associated with decreased burnout, consistent with Wacholtz, 2013 study [42]. R/S may provide a framework to process stress [43]. R/S identity was similar between GHOE and control respondents.
Increased leisure time was significantly predictive of lower PB, and SRB. Leisure time was not associated with CRB. Limited leisure time is a known contributor to stress levels in graduate students [44] and residents [45]. A plurality of students reported 6–10 hrs leisure time weekly from both GHOE and control groups. Leisure time among medical students is a factor curriculum planners may have influence over and should also be considered in burnout prevention.
Utah students were more heavily represented among GHOE respondents compared to control. However, when comparing Utah and Colorado Campuses, there were no significant differences in burnout.
Recommendations
Global health outreach opportunities have become commonplace in medical schools. In 2016, 140 schools offered third-year international electives [46]. The evidence presented in this study suggests GHOEs may be a beneficial offering for students. Medical schools should look at ways to further increase student involvement in GHOEs as one tool to reduce burnout.
The cost of attending GHOEs remains a significant barrier to include everyone interested. Schools can proactively plan fundraisers to reduce costs. Incorporating GHOE expenses into the estimated cost of tuition would allow financial coverage through subsidized loans. Trip availability and timing are other challenges. Spring break or summer break both offer ideal scheduling opportunities and have the benefit of integrating clinical exposure into students’ didactic years.
Some controversy exists regarding the ethics of Global Health Trips. Students may lack the preparation and skills necessary for clinical situations encountered [47]. Local needs are sometimes misread. Hosts may be overburdened [47]. Structural inequalities can be reinforced by taking away jobs and creating dependency [47]. If only volunteers benefit, such trips may become exploitative [47].
Ethically, the focus of GHOEs should be directed towards the beneficence, and non-maleficence of populations served [48]. We recommend these short-term experiences be nested within long-term sustainable programs. Expectations, support, and training should be technically adequate and culturally appropriate [29][48]. The effectiveness of interventions should be regularly evaluated. GHOEs present an opportunity for mutually beneficial experiences.
Limitations
The sample size of respondents who attended a spring break global health trip was small, n = 19–22. Response rate was 46.3%-53.7% with 13.6% attrition from first to last survey for GHOE participants and 19.8%-27.8% with 28.6% attrition from first to last survey for control-participants. Those experiencing high burnout may have been less likely to complete the survey. Self-selection bias may have occurred among trip participants. Inherent burnout related traits may relate to the desire to attend a GHOE. Female population was overrepresented in the control group and is evidenced as a confounder. The CBI-S scale is not as widely used as Maslach Burnout Inventory to measure burnout, limiting comparison to other studies.