Alarm as burnout stalks med schools

Stephen Mutuku felt a strong urge to quit medical school the moment he joined Jomo Kenyatta University of Agriculture and Technology (JKuat).

As the lecturers introduced complex medical terminologies he found difficult to memorise, Mutuku began doubting whether he was cut out for medicine.

He had grown up picturing medicine as nothing more than posting good grades in high school and performing even better in Biology.

However, it did not take him long to realise that medicine had little to do with high school subjects.

 “I came out of high school thinking that I would hack it in med school just because I found Biology easy. I was shocked to realise that the anatomy and physiology taught in first year has nothing to do with the Biology that is taught in high school,” says Mutuku.

And as he struggled to master a completely new medical dictionary, amid early morning classes, hospital sessions and late night research in the university library, it dawned on Mutuku that he had immersed himself in a highly draining academic programme. One that would see him experience high levels of exhaustion, study-related stress and burnout from the heavy workload. But the 24-year-old knew there was a lot at stake every time he thought of quitting.

 “Every time I thought of quitting med school, I thought of how everyone at home was proud of me. Then I would tell myself ‘ukiacha udaktari utaambia nini watu?’ (what will you tell people if you drop out of medical school?),” he says.

Mutuku, a third-year student, grew up admiring his mother, a medical doctor, and eventually developed an interest in the field.

When he received invitation to pursue his dream course at JKuat, everyone was proud of him, including his sister, who decided that she too, wanted to become a doctor.

She would later enroll into medical school at the University of Nairobi (UoN) where she is in her second year of study.

A first born in his family where he believes he has to set an example of resilience, Mutuku keeps persevering in the course that is also characterised with a lot of drop-out cases by students who find it hard to manage course-related burnout.

A report, Burnout among medical students during the first years of undergraduate school: Prevalence and associated factors, published on the National Center for Biotechnology Information (NCBI) showed that 45 per cent of medical students have experienced burn-out.

Additionally, 70 per cent of 330 students interviewed at Barretos School of Health Sciences, Dr Paulo Prata, in Brazil presented high levels of emotional exhaustion.

It also emerged that 52 per cent of the total population had high cynicism that experts link to depression. 48 per cent had low academic efficacy meaning the students perceived their studies as more difficult than they really were.

Low academic efficacy, experts say, creates anxiety, stress and a narrower idea on how best to approach the solving of a problem or activity.

World Health Organization (WHO) has characterised burnout with feelings of energy depletion and exhaustion, increased mental distance from one’s job, feelings of negativism or cynicism related to one’s job and reduced professional efficacy. Burnout was in May added to the WHO International Classification of Diseases, meaning that it will become a globally recognised medical condition as of 2020.

Dr Yubrine Moraa, a vocal health activist and physician at MP Shah Hospital says burnout is real among medical students in Kenya. She says the situation is compounded by poor health systems in Kenyan medical facilities.

“Frustrated health providers in Kenyan hospitals are likely to vent out on students they are supervising in medical schools. In Kenya, 98 per cent of burnout among health providers and medical students results from frustrations at the workplace because of the broken healthcare system,” says Dr Moraa.

Medical students Hashtag spoke to cited heavy workload, poor mentorship and pressure from the society as leading contributors to burnout in the course of their studies.

Heavy workload

Faith Macharia, a sixth-year medical student at UoN experiences the worst form of burnout in the days preceding examinations at the medical school.

“I know I am burnt out whenever I feel there is a lot to be done yet I can’t think anymore. This normally happens just before exams start when I feel that I need to revise lots of things in a limited time,” says Macharia.

She adds: “Whenever I find myself in such a state of mind, I do drastic things like go out with a friend for a coffee or take a walk.”

The life of a senior medical student starts at 7am with lecture sessions that are broken by a tea break. Senior students are those in their fourth, fifth and sixth years of medical school.

The students are then expected to report to wards at 9am where they interact with patients, gather their medical histories and present the reports to their lecturers before they sit in afternoon classes.

Medical students at Maseno University where Mike Odoyo is a fifth-year student report to the wards for a second session that starts at 5pm.

This is followed by group assignments at night and personal studies in the library where students research the clinical cases gathered during the day and go over corrections made by their lecturers.

“My day starts at 4am when I wake up to read and ends at midnight after I complete my own revision. I am used to the daily routine,” says Odoyo.

It hasn’t been easy for Odoyo who had to juggle studies with politics when he was chairman of Students Organisation at Maseno University.

“With all the workload and my responsibilities in student politics, I got to a point that I felt it was too much and thought of quitting. But I talked to my family members who encouraged me to persevere,” he says.

Poor mentorship

Dr Moraa says medical students are mostly stressed by their seniors, especially during their ward sessions.

“Healthcare providers and doctor lecturers who supervise medical students in the wards are people fighting their own frustrations of being overworked without adequate facilities and other frustrations that emanate from a broken healthcare system. They channel their frustrations to these students,” she says.

She says medical students lack mentors to prepare them psychologically for their career.

“There lacks proper mentorship because the would-be mentors are also battling burnout,” says Moraa.

When she worked at Kenyatta National Hospital as a postgraduate student, Moraa admits she experienced several burnout experiences.

“I felt inefficient at work when I saw the suffering that patients were going through that was beyond my capability. Then I started developing a very nasty attitude that not only pushed from my friends away but my patients as well. Someone would tell me their problems and I would roll my eyes from within. Then I knew I was breaking down,” says Dr Moraa.

She adds: “It is time we stopped and asked ourselves who takes care of the caregiver. What is the system doing to ensure that doctors who do everything they can to save lives work in a conducive environment?”

Wycliffe Kimanthi, a sixth-year medical student at UoN has always been empathetic towards sick people.

Growing up in Mombasa, he was a sickly child who frequented the hospital for treatment. It always amazed him how a single jab would make him better.

Despite his passion for a field that made his childhood bearable, no one prepared Kimanthi for the tough experience that lay ahead of him in his first-year of study.

“I wasn’t used to seeing extremely sick patients, some at the brink of death. Moreover, no one told me that in first-year, I would have to work on an actual cadaver for the anatomy lessons. It was very scary in the beginning and I actually thought of dropping out of medicine,” says Kimanthi.

He says many of his classmates could not cope with the shock caused by the dead bodies and too much work and opted to drop out.

Most medical schools involve four years of pre-clinical and clinical content and two years of clerkship. Medical students in first-year study anatomy to understand the human body and physiology to understand how the human body operates.

In their senior years, they specialise in functions of distinct organs in the body and complex medical operations such are surgeries, pathology, pediatrics, and psychiatry.

 “No one prepares you for anything. Medicine isn’t like other courses where you get orientation in first-year,” says Macharia.

Dr Moraa says because of lack of mentorship in the medical career, promising first-year students drop out of the field when they find it hard to cope.

Pressure from family, friends

Odoyo comes from a family of medics. His father is a doctor while his mother is a nurse.

He is the eldest child in a family of two where his younger brother is also a third-year medical student in university. He has thought of quitting medicine, but couldn’t imagine being the only odd one out, and so he pushes himself in the tough filed.

“I don’t want to be the only one who didn’t make it to be a doctor. My parents made it and my brother is also doing just fine. I hate to think what everyone will think of me if I drop out,” says Odoyo.

Pressure in medical school comes from the need to be perfect at one’s job as well as high societal expectations from family and friends, according to the NCBI report.

“In addition to their study-related burdens, many demands and responsibilities are placed on these students because the profession is dedicated to the health care of people and has very little tolerance for mistakes. This creates the perfect conditions for the development of anxiety and stress,” reads the report.

What you need to know to keep burnout at bay

Dr Yubrine Moraa, a Physician at MP Shah Hospital is working with the Kenya Medical Practitioners and Dentists Union to create awareness on symptoms of burnout and how to handle the condition that has been added to the WHO International Classification of Diseases. She talks about burnout in medical schools:

What characterises burnout?

• Emotional exhaustion and inability to co-ordinate thoughts
• Persistent headaches
• Detachment from work and studies - in the case of students
• Inefficiency and strong feelings of inefficiency at what one does
• Loss of personal attachment with friends and patients
• High levels of irritability

Burnout leads to increased medical errors that contribute to increased mortality rates. Studies also indicate that medical students battling burnout are likely to misuse drugs.

What are healthy ways to address burnout?

It is both a system responsibility and the responsibility of individual medical students.

We need a system where heath providers are provided with good working conditions and where they are not overworked to a point of experiencing burnout.

When they are frustrated, they vent out on medical students who need their guidance in the wards. We are also working with universities on the curriculum to address the condition. For students, the following tips can help:

• Self-relaxation techniques like sufficient time-out with family and friends
• Identify a mentor in the medical filed to be talking to
• Mindfulness
• Breathing in and out when anxious and nervous
• Set time aside for hobbies