The prevalence and effect of burnout on graduate healthcare students.

Burnout is a growing epidemic among professional healthcare students. Unaddressed burnout has been shown to have psychological and performance related detriments. The purpose of this scoping literature review was to investigate the prevalence of burnout and its effects on the psychological, professional, empathetic ability, and academic acuity of graduate healthcare students. Inclusion criteria included English language papers published within the last 10 years and subjects in graduate healthcare professional programs. This search encompassed 8,214 articles. After title and abstract screening, 127 articles remained and were sorted into five domains of interest: etiology, professionalism, mental health, empathy, and academic performance. After duplicates were removed, 27 articles remained for the scoping review. Graduate level healthcare students had higher levels of burnout than age matched peers and the general population. The high prevalence of burnout within graduate healthcare students can have an effect on their mental health, empathy, and professional conduct. Understanding the occurrence and effects of burnout within graduate healthcare programs allows faculty and administration to plan curriculum, and provide information to students to understand, recognize, and create opportunities to decrease burnout in order to create long lasting quality clinicians.


Introduction
Stress is a common problem throughout graduate healthcare professional students' education. [1][2][3][4] It has been reported that the prevalence of higher stress levels in medical students can range from 31% to as high as 73%. [2][3][4] One consequence of high and continuous levels of stress is burnout. 5 Burnout is generally defined as emotional and physical exhaustion resulting from a combination of exposures to environmental and internal stressors as well as inadequate coping and adaptive skills. e91 or those students pursing a doctoral healthcare degree † , progress through their respective programs. [5][6][7] This increased prevalence of burnout, has been shown to affect academic performance, mental health, and quality of life of graduate healthcare students. 9,10 Previous work found an increase in prevalence of burnout in graduate healthcare students 5-7 and subsequent negative effects on mental health, quality of life, and performance. [11][12][13][14] The purpose of this scoping literature review was to rigorously investigate the prevalence of burnout and its effects on the psychological, professional, empathetic ability, and academic acuity of graduate healthcare students. We hypothesized that the literature would demonstrate that burnout decreases students' abilities to cope with psychological stressors, perform professionally and empathetically, and achieve academic excellence.

Methods
To study the hypothesis, a systematic and comprehensive scoping review was performed on the prevalence of burnout and the effects burnout has on graduate healthcare students. 15 This scoping review was performed in order to understand the literature, identify research gaps, categorize study types, and recognize study populations. After an initial search, a total of five burnout domains were created: etiology, professionalism, mental health, empathy, and academic performance. The five domains were generated based upon the prevalence of at least two studies repeating the same theme. Furthermore, each domain was deemed relevant to how burnout could influence practice, policy-making, curriculum, and pedagogy within graduate healthcare students' coursework. 15

Data source and search
A librarian-assisted computerized search was conducted in PubMed, ERIC, and CINAHL in May 2016. An updated search of PubMed, CINAHL, and ERIC were conducted in September 2016. Searches were completed, with an initial screening of PubMed, followed by investigations into the additional † The term "graduate healthcare students" will be used throughout the paper to identify those students who are pursuing a doctoral healthcare degree.
databases. Medical Subject Headings (MeSH) terms and selected free-text terms were utilized for burnout, academic performance, stress, anxiety, depression, mental health, resiliency, altruism, graduate students, health occupations students, and medical school (see Appendix A for detailed search). The bibliographies of included literature were also hand searched for missing publications. Citations were tracked in EndNote (version X7, Thomas Reuters).

Inclusion/exclusion criteria
Articles found in the literary search were examined to meet the guidelines as set by the following inclusion and exclusion criteria: o Studies examining burnout and its effects on professionalism (based on the healthcare code of ethics or standardized tools), mental health, empathy, or academic performance in graduate healthcare students.
o English language papers, regardless of country of origin.
• Exclusion Criteria o Papers that included any students who were not specified to be doctoral degree-seeking students in a healthcare professional program beyond a bachelor's degree.
o Papers that focused on practicing professionals, unless they were only used as a reference measure.
The study population requirements included students at the graduate level in the healthcare profession such as medical, dental, and physical therapy students. Studies were included that discussed factors related to burnout. These factors included the three focus areas of burnout (emotional exhaustion, depersonalization, and low sense of personal accomplishment), 16 suicidal ideation, professional e92 behavior, quality of life, depression, resiliency, and empathy. 6,10,11,17,18 In reviewing title and abstracts, we identified the previously referenced domains: etiology, mental health, professionalism, empathy, and academic acuity. These themes were subsequently divided among individual reviewers. The reviewers then collected articles according to their theme and completed full-text reviews. A second reviewer further examined articles to confirm or deny study viability. In case of disagreement, a third reviewer was incorporated.

Data abstraction
Data were abstracted into a customized Excel spreadsheet by separate investigators for each individual burnout domain. A different investigator verified data for each domain. Disagreements concerning data were resolved by a third investigator's opinion. Data elements included study characteristics (e.g., publication date, population, exposures, outcome measures utilized), results (prevalence within populations, outcomes), conflict of interest, and author's conclusions.

Data synthesis
The abstracted data were aggregated into the five previously referenced domains. The domains entailed the prevalence of burnout on graduate healthcare students, the effect of burnout on altruistic behavior, professional conduct, academic performance, and mental health. These domains were then summarized to describe populations, exposure, definition of burnout, outcome definition, and timing, and key findings.

Results
Citations identified via the search amounted to 8,214. An additional five articles were found from hand searching citations that met the search criteria. After screening for eligibility, 4,255 citations remained for title review. The titles were screened by two reviewers for applicability to burnout and its implications on graduate healthcare students. This left 187 articles for abstract review. Articles with themes not replicated in at least one other article were also removed (n =60). Based on theme, the 127 citations were divided among the five reviewers for full-text review. Following full-text review, 22 articles were hand-searched for additional resources. After duplicates were removed, 27 articles remained for the scoping review. The review process can be seen in Figure 1. Further explanation of groups created from these 27 articles can be seen in tables 1-5 (Appendix B).

Etiology
The demographics and stress-related causes among medical school students were analyzed to determine their correlation with burnout (  18 determined no significant difference between genders for being at risk for burnout. Overall, the majority of studies found that less support, increased stress, and progression to later years in medical school are strongly correlated with burnout.

Professionalism
Detailed study characteristics for professionalism are presented in

Mental health
The search and vetting process for burnout and relationship to mental health yielded 16 papers summarized in Reed et al. 30 noted that burnout correlated highly with depersonalization, stress, and emotional exhaustion in schools that used a grading scale system, which suggests pass/fail-grading systems may be beneficial to students' mental health. Adding to this, Dyrbye et al. 23 found that only 26.9% of medical students would definitely seek professional help for mental health problems, while 44.3% of the general population said that they would seek professional help for the same issues.

Empathy
The effects of burnout on empathy in graduate healthcare students are summarized in  and physician assistants were also examined along with medical doctor students. The MBI was utilized most frequently, while other assessment tools were utilized to evaluate students' empathy. Four of the studies were cross-sectional cohorts. 7,11,14,24,32 and one was a literature review. 33 The cross-sectional studies demonstrated that empathy and compassion satisfaction exhibited an inverse relationship with depersonalization, emotional exhaustion, and burnout (p<0.001-0.02, OR=0.56-0.81). Positive correlations among personal achievement, altruism, and empathy were also documented in the cohorts (p<0.001). While the literature review noted the difficulty of incorporating humanism and empathy into graduate healthcare education, the articles investigating mindfulness, self-reflection, perspective taking, role modeling, and emotional labor are potential methods of increasing empathy, altruism, and prosocial behavior in graduate healthcare students.

Academic performance
Two studies, examining the effect of burnout on academic acuity, met the inclusion criteria (

Discussion
In the scoping literature review on the effects of burnout in graduate healthcare students, 27 studies were identified that met the inclusion criteria. All studies included were published in the last ten years, in order to take into account the characteristics of the modern graduate healthcare student and contemporary medical education. Based on the aggregated surveys, we observed a high correlation between stress and burnout. Additionally, the scoping review indicates that graduate medical students display decreased life satisfaction compared to their age matched peers. We found an inverse relationship between burnout and empathy and professionalism. To further understand the most significant findings from this scoping review, we will discuss the consequences of high levels of stress and its effect on mental health and empathy.
Medical students experience higher levels of mental distress and depression than the general population and age-matched peers. 10 Upon entering graduate programs, students do not differ significantly from their age matched peers. However, as students progress through their curricula, their mental health deteriorates and they experience higher levels of dissatisfaction. 29 A decline in mental health can be mitigated via effective and healthy coping mechanisms. 20 Healthy coping mechanisms often include physical activity, extracurricular activities, familiar and peer support networks, and professional counseling. 20 Although many of these services are available in large academic institutions, they are often underutilized by the graduate student population due to perceived stigma. 23 Because students in health professions are less likely to seek professional help, previous authors 10,30 recommend that university programs stress the importance of healthy social networks, activities, and other coping mechanisms.
10,30 Further research is needed to investigate the benefit and viability of various coping methods including exercise, mentorship, and free professional counseling services.
In addition to services offered to students with deteriorating mental health, strategies to mitigate decreased empathy, 14,17 altruism, 11 and compassion satisfaction 32 have also been explored. 33 Healthcare students experience burnout before they are exposed to treating patients. 17 When students initiate treatment sessions with decreased empathy and compassion, poor patient-provider interactions and low quality of care result. Burks and Kobus 33 proposed mindfulness, self-reflection, perspective taking, role modeling, and emotional labor as potential methods of increasing empathy, altruism, and prosocial behavior in healthcare students. Understanding what methods might be effective to decrease burnout, will not only optimize healthcare professional education, but also create empathetic and compassionate patient providers.
Several gaps in the literature were identified through this investigation. Over 90% of the studies selected e95 were cohort studies. Medical students comprised 85% of the burnout investigations, with only 15% of studies investigated other graduate level healthcare professional students. There was only one randomized control trial that met the inclusion criteria. The limited student variety and study type warrants cautious generalization and begs further research.
Further research examining the efficacy of techniques to improve mental health and empathetic behavior, in addition to broadening the variety of graduate healthcare students will enhance administrators and program directors' ability to create relevant and accessible coping mechanisms into curriculum.

Limitations
This literature review was limited to only English speaking papers and journals. While there may be more publications in other languages, based on our inclusion criteria, there was a low probability of finding pertinent information. It is possible that relevant articles were omitted despite our search strategy. While our search was rigorous, we did not include all gray literature and duplicate papers. Lastly, publications that included practicing healthcare professionals were excluded. Some of these investigations included subjects that were graduate healthcare students. Although certain professional populations within these specific studies would have been relevant, the inclusion of practicing healthcare clinicians was beyond the scope of this investigation. Further investigation into burnout in all forms of healthcare education and training is warranted.

Conclusion
The prevalence of burnout is high within graduate healthcare students, and that burnout can have a negative effect on the mental health, empathy, and professional conduct of students. Understanding the occurrence and effects of burnout within graduate healthcare programs will support faculty and administration to better educate healthcare clinicians via strategic curriculum planning. Administrators armed with this knowledge could then prepare students to not only understand and recognize burnout, but also afford students opportunities to decrease it. Further investigation is warranted into understanding the prevalence and effect burnout has upon other graduate healthcare students. Additionally, intervention strategies at all primary levels are needed to understand how to more effectively create healthy coping strategies for graduate healthcare students.
Conflicts of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Funding: The authors did not receive any funding for this original work.