Burnout rates among Lebanese pre-final and final year medical students during the COVID-19 pandemic: A multi-centered survey-based study

1Introduction

On the 21st of February 2020, Lebanon reported its first case of the novel coronavirus 2019 (COVID-19) [1]. Since then, it has been sliding into a worsening outbreak that is now threatening to overwhelm the country’s fragile healthcare system [2]. As the number of new cases spike, all healthcare workers (HCWs), from attending physicians to residents and medical students, became directly involved in providing care to infected citizens [2, 3]. Despite growing knowledge about the virus, the Lebanese health care system is still having a hard time to cope with this pandemic, leading to physical/emotional/mental exhaustion, a sense of reduced accomplishment, and a loss of personal identity among healthcare workers [3]. This condition is known as burnout and is increasingly being recognized worldwide as a mental health issue [3] among medical students [4, 5]. It is well established in the literature that similar conditions of heavy human interactions, emotional commitment, overwhelming work, unclear job expectations, and lack of social support [3, 6] can explain the high rates of burnout reported among pre-final and final year medical students (6th and 7th years of medical education respectively): 75% in Lebanon, 52.8% in the United States of America (USA), 37.5% in Spain, and 27% in Sweden [6, 7].

In Lebanon, starting their pre-final year of general medicine, medical students start in-hospital clinical training where they can gradually learn technical, clinical, and interpersonal skills [8]. This is a crucial period where they put in action their theoretical education. Their role is not limited to learning, but it also includes taking the medical history, performing a complete clinical examination, elaborating a tailored plan of investigation, developing a diagnosis hypothesis, and communicating with families [8]. However, during 2020, this experience has been dramatically altered by the pandemic that has weighed heavily on major aspects of national and global society, including education [9]. Medical schools tried their best to keep the students safe by delivering all courses virtually. In addition, considering the serious shortage in personal protective equipment (PPE) and in attempt to avoid unnecessary exposure, some institutions have suspended students’ clerkships and have forbidden any student-patient contact in line with the recommendations of the American Association of Medical Colleges (AAMC) [10, 11]. Conversely, other hospitals have recruited students to serve as front-liners in imitation of what was done in Pennsylvania during the Spanish-flu outbreak in 1918, and in Denmark during the Polio epidemic in 1952 [11], given that students are also clinicians who care for patients.

Whether being directly involved or not, it is hard to stay unaffected. It was widely speculated that the COVID-19 pandemic could affect all aspects of students’ life [3, 12]: psychologically, given the high risk of acquiring the virus while performing their duty [3], professionally, with the belief that the pandemic will affect how they will practice medicine long after it subsides [13], and academically, given the rapid transition to online learning [9]. It is worth noting that previous surveys have been conducted in developed countries where this novel pandemic was a sole problem to be handled. However, no study has evaluated the impact of this pandemic in Lebanon where many heavy challenges are superimposed, including the ongoing financial crisis, the increase in extreme poverty rate, and the decrease in health personnel due to economic constraints [14]. In this paper, our primary objective was to evaluate for the first time in Lebanon, the effect that was imposed by the novel coronavirus on burnout rates only among pre-final and final-year medical students; given that they are at a vulnerable stage in life [12], new to the overwhelming clinical experience, and have the least medical experience, making them the most fragile population at the hospital. Our secondary objective was to evaluate the pandemic’s impact on these students’ academic journey and clerkship.

2Methods

3Results

4Discussion

Taking into consideration the proven impact of the COVID-19 pandemic on undergraduate medical students in developed countries [13, 17], this is the first study to shed light on its influence on burnout rates, academic learning, and clinical training among pre-final and final-year medical students in a developing country such as Lebanon.

The disruptive effect of the current pandemic has prompted the adoption of distance learning at all academical levels [17]. When evaluating the impact on students’ learning, our findings paint a pessimistic picture. With no noted significant difference for all independent variables, 10.00% of surveyed students have regretted choosing medicine and 66.67% believed that their academic learning was disrupted, leading to fear of inadequate preparedness for the next academic level in approximately one third of cases. Regardless of their sociodemographic characteristics, students are facing an increasingly uncertain environment. The pandemic only exacerbated the huge disruption in learning that Lebanon was already experiencing during 2019 following the widespread anti-government protests and the crippling economic situation [14]. Given that academic learning is directly influenced by mental health [18], chronic stress from rapid transition to online teaching along with unclear expectations about residency programs and fears of contracting the virus, can impair students’ cognitive skills such as concentration, attention, and memory [18]. Aucejo et al. reported similar impact on learning, but his findings were contributed to the significant decrease in study hours [17]. However, according to “The Medscape Medical Student & Life Education Report 2020” a negative impact on academic learning was reported in higher percentages (87%), but with almost the same percentage of students feeling underprepared for the next academic level (33%) [13]. Furthermore, 74.7% of students surveyed by Harries et al. have agreed that the pandemic had significantly disrupted their medical education [19]. The long-term impact of the collective shock imposed by the migration to online learning on students’ achievement is difficult to assess. Thus, despite being more experienced in online teaching, educators should closely follow students’ academic progress throughout 2022, to identify hidden long-term ramifications of this pandemic.

Regarding medical students’ clerkships, whether directly involved in treating COVID-19 infected cases or even quarantined at home, many factors have contributed to disrupting students’ clinical training. Our findings showed that 56.67% of students felt that it was hard to work during the current scenario, with significantly pre-final-year students, who still lack adequate experience to handle stressful situations, reporting higher rates. In addition, given the serious shortage in equipment, 78.46% of respondents were afraid of catching the virus or transmitting it to a family member (83.34%). This would lead to avoidance of physical examination, and thus indirectly compromising students’ clinical skills. Another factor was fear of death reported in 28.33% of cases, with women showing significantly more concern, like what was mentioned in previous studies [13]. Our findings were higher than the ones reported in the “COVID-19 Rapid-Cycle Survey 2” where 55.3% of physicians are afraid of getting the disease and 66.9% are afraid of carrying it to a family member [20]. Also, our findings were significantly higher than those reported by Khasne et al. in a similar study conducted among Indian graduated HCWs [3]. Despite all available data, it is still difficult to decide whether one must agree with the abovementioned recommendations. In our opinion, to avoid any shortage in workforce, which would lead to an imminent breaking point, the Lebanese authorities must seek help from the international community to provide sufficient PPEs and train medical students so they can start serving in the COVID-19 units. In addition, other effective alternatives with no risk for disease transmission, should be provided to resume students’ clerkship, such as remotely involving students in patient care (telemedicine), recruiting them in post-COVID units, or even engaging them in online simulation sessions to refresh their memories. These steps will help students learn about new specialties, gain experience, build relationships, and eventually excel their career as future physicians.

As for burnout, it has been always considered a major public health concern among medical students. In comparison to the previously reported rates of burnout among medical students prior to the COVID-19 pandemic, our findings (40.01%) tell a more optimistic story than what was expected. A meta-analysis that evaluated 24 studies conducted between 2010 and 2017, showed an estimated prevalence of approximately 44% [21]. Another meta-analysis conducted during the pandemic and involving 26,842 students showed comparable overall rates [5]. In both reviews, rates varied across countries with the highest ones being reported in the Middle East and Oceania regions [21]. The following percentages were reported among medical students in our region: in Lebanon 75.00% in 2016 [6], 43.00% in 2018 [22], 46.90% in 2019 [23]; in Oman 7.40% in 2017 [24]; in Iran 45.70% in 2016 [25]; and in Saudi Arabia 67.10% in 2017 [26] and 56.50% in 2019 [27]. In the USA, large multi-centered studies reported a prevalence rate of 39.00% to 55.00% in 2006 [28], 49.60% in 2007 [29] and 55.90% in 2012 [30]. European rates of burnout among medical students were 37.50% in 2011 and 2012 [31, 32]. Worldwide, the rapidly evolving COVID-19 pandemic, has presented unprecedented challenges to HCWs [33, 34]. Putting the entire country under national lockdown and enforcing social distancing measures [14, 35] have disrupted all aspects of students’ life with profound impact on their academic, personal, professional, and financial situations. These increasing challenges found common ground with the academic and lifestyle demands as well as the chronic psychosocial stress that medical students are already facing in the Middle East region, from low income to difficult working conditions, heavy workload, ongoing political violence, and social instability [14, 22, 23].

Theoretically, these added stressors would lead to increased burnout levels, similar to what was reported in previous pandemics [3], however, studies conducted during the COVID-19 pandemic revealed burnout rates that are almost similar to the ones reported in the pre-COVID-19 era, with 41.43% in India [3] and 50.00% in Cyprus [36]. In comparison to the Indian [3] study and using the same scale (CBI), we reported lower personal (39.36% vs 52.50%) and pandemic-related burnout rates (39.16% vs 49.70%) but a higher rate on the work-related burnout (41.52% vs 32.90%). Moreover, Portuguese [37] and Lithuanian HCWs [38] scored higher on personal burnouts (53.7% and 44.80% respectively) and work-related burnouts (53.10%; 46.7%) but lower on the pandemic-related one (35.40%; 35.10%). In these studies, as well as in the current one, the prevalence of pandemic-related burnout is surprisingly not higher than the two other evaluated burnouts, possibly because of the high social and emotional supports offered to HCWs by the social media, society, family, and friends. In fact, 74.10% of the surveyed students felt welcomed by the community secondary to their current work, with only 11.00% hesitating to work.

The current study provides many valuable contributions to the literature. Our findings constitute a first step towards encouraging educators to authentically support medical students educationally and emotionally. This would be optimal by creating an educational, protective, respectful, and supportive working environment, maintaining a reasonable number of working hours, developing positive relationships. Another vital step is to mentally prepare the students for crisis management by providing mental health workshops and training programs, as well as encouraging them to routinely fill a self-assessment questionnaire with an opportunity of a free professional psychological evaluation, in case of any alarming result. These major adjustments will not only boost medical students’ confidence and moral but will be beneficial for the society in the long run.

When analyzing our results, it is essential to keep in mind some limitations. First, self-reporting bias influenced by respondent’s level of interest cannot be ruled out in any similar survey-based study. Second, Mount-Lebanon and Beirut governorates were the most represented in our sample, possibly because most of the medical faculties are in these regions and students themselves live next to their educational institutions. As well, we did not ask about the use of psychotropic drugs by our participants. This parameter is important to evaluate, as it could be a cofounding factor. At last, we did not enquire about some cofounders that may influence the burnout scores, such as the financial background, the presence of a past psychiatric disease, or the intake of psychiatric medications. Despite the study limitations, our findings helped in quantifying the toll that this pandemic has taken on medical students’ clinical, academical and psychological wellness, hypothesizing how it may have affected the doctors of tomorrow.

5Conclusions

Medicine is a highly demanding career and a never-ending path that can take a heavy toll on vulnerable non-experienced medical students [12], especially during these times of crisis. As a result of the current situation in Lebanon, pre-final- and final-year medical students’ have reported that their academic life, clerkships, and mental health are being negatively affected. It is the duty of educators, and residency programs to adopt a conscious view of how to guide medical students in finding adequate coping mechanisms to manage stressful situations, improve burnout conditions, manage exhaustion, and subsequently avoid potential professional and personal repercussions.

Ethics statement

This study was conducted in accordance with the fundamental principles of the Declaration of Helsinki. The ethics committee of the Notre Dame des Secours University Hospital approved the study protocol (reference number not available as per the ethics committee).

Informed consent

An online informed consent was obtained from each participant.

Conflict of interest

The authors have nothing to disclose.