Levels of Burnout in Entry-Level Doctor of Physical Therapy Students Pre-Post Extended Clinical Education
Purpose:
Burnout in US healthcare providers is reaching epidemic proportions.1–5 Burnout is characterized by a spectrum of symptoms related to three accepted dimensions or domains: Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA).6–9 Of these dimensions the depersonalization domain conceptually seems most related to provider empathy, another current concern in healthcare.3,10,11
Significant research has been conducted looking at the burnout crisis affecting US Healthcare providers and healthcare professional students. Levels of burnout in medical students have been shown to be consistent with, if not higher than in practicing physicians. Burnout has been reported in up to 50% of medical students surveyed, with frequency increasing in more senior students.12 In medical students, dissatisfaction with the learning environment and associated faculty support have the strongest association of burnout with medical students in years 1-2 of the curriculum.12 Clinical rotations were also found to impact burnout in medical students.1 An updated review of the literature on healthcare graduate student burnout reveals that graduate-level healthcare students had higher levels of burnout than their age-matched peers and the general population.13 Increased student distress has also been linked to linked to declining levels of empathy in medical students and may hamper the development of higher learned behaviors. 10,14,15
Recent physical therapy literature questions if valid comparisons between medical students and physical therapy students can be made given differences in the learning environment.16 Recent study of a sample of DPT students described levels and predictors of anxiety. Results described 36% of the sample as reporting moderate-high levels of anxiety with female gender and low GPA as predictors.17 Early burnout literature in physical therapy education investigated patterns of burnout across the bachelor's degree curriculum.18–20
While a recent study has updated descriptions of burnout in practicing physical therapists21 and physical therapist assistant program directors22 little is known about current DPT student cohorts. A 2018 study explored first-year DPT students’ ability to cope with stress and considered how that might change across the program and impact success.23 Alongside increased costs, the evolution of entry-level physical therapy education has included an extension of both didactic curricular hours and professional practice education clinical time with the transition to the Doctor of Physical Therapy (DPT) degree.24 A variety of curricular models have emerged with relatively little study of their effect on the student experience and potential impact on levels of student burnout. The purpose of this study is to describe and characterize levels of DPT student burnout domains before and after extended professional practice clinical experience and explore demographic interaction effects.
Methods/Description:
Study design was a prospective, longitudinal, repeated measures cohort study using a prospective survey measure with a convenience sample of Doctorate of Physical Therapy (DPT) students at the University of the Incarnate Word (UIW). The cohort was comprised of 50 entry- level DPT students. Participants were recruited by convenience sampling during their first year of DPT school by signing voluntary informed consent waivers as a cohort as part of the School of Physical Therapy’s (SoPT) blanket programmatic Institutional Review Board project approval.
The Maslach Burnout Inventory- Human Services Survey (MBI-HSS) is a valid and reliable instrument that is considered the gold standard for measuring the three dimensions of burnout and offers validated versions for human services professionals, students, teachers, medical personnel, and other workers.7,19
Pen and paper versions of the MBI-HSS were first administered to the cohort at the completion of curricular year 3 (Y3) which signals the end the didactic portion of the problem-based curriculum. Repeated measures were collected nine months later just prior to program graduation (Grad) after the completion of two, 4-month, back-to-back professional practice education clinicals.
Data was scored by hand and checked and stored in an excel spreadsheet. Statistical analysis was conducted using SPSS v. 25, and results are reported and interpreted on the MBI individual subscales as consistent with supporting literature.1,7,18,21,22,24,25 Data analysis included descriptive statistics and a factorial, repeated measures analysis of variance (ANOVA) with time and gender factors.
Results/Outcomes:
The cohort demonstrated moderate levels of EE at the Y3 capture (M=18.02 ) and low levels at the graduation capture (M=13.62). Mean cohort DP scores were low at Y3 (M=4.58) and Grad captures (M= 3.76) while PA scores were high at both captures: Y3 (M=39.90) and Grad (M=43.05).
Repeated measures factorial 2-way analysis of variance analysis revealed a significant interaction effect between gender * time on EE scores F(1,48)=9.276, p=.004. There were non-significant interaction effects of gender * time on DP scores, F(1,48)=.817, p=.371, and PA scores, F(1,48)=3.408, p=.07. The main effect of time on PA scores however was significant, F(1,48)=13.322, p=.001, and pairwise comparisons between Y3 and Grad PA data reinforced this finding,Mdiff=3.15 p=.001.
Conclusions/Relevance to the conference theme:
Cohort results indicate that participants were not experiencing high levels of overall burnout. Gender significantly impacts DPT student emotional exhaustion scores. Results indicate that emotional exhaustion is a factor for male students at the end of didactic DPT education with significant improvement over the course of professional practice education clinicals. There were also significant improvements in cohort personal accomplishment scores between the Y3 and Grad captures. The depersonalization dimension of burnout which would theoretically best reflect empathy and engagement did not appear to be a significant issue for students in this cohort at the time frame studied.
Measuring levels of burnout and grit at entry into the program/curriculum will give a more complete picture of potential interaction effects and the impact of time and curricular factors. This cohort was generationally homogenous and only reported admissions data for male/female gender categories. More study is needed to distinguish SPT academic burnout versus emerging practitioner burnout during this formative time in professional practice education. Educators and clinical instructors can leverage screening tools and encourage resilience building activities in academic advising. • Dyrbye LN, Thomas MR, Power DV, Durning S, Mountier C, Massie FS, Harper W, Eacker A, Szydlo DW, Sloan JA, Shanafelt TD. Burnout and Serious Thoughts of Dropping Out of Medical School: A Multi-Institutional Study. Acad Med. 2010;85(1):94-102.
• Dewa CS, Loong D, Bonato S, Thanh NX, Jacobs P. How does burnout affect physician productivity? A systematic literature review. BMC Health Serv Res. 2014;14:325.
• Romani M, Ashkar K. Burnout among physicians. Libyan J Med. 2014;9:23556.
• West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.
• Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-1385.
• Traunmüller C, Stefitz R, Gaisbachgrabner K, Hofmann P, Roessler A, Schwerdtfeger AR. Psychophysiological concomitants of burnout: Evidence for different subtypes. J Psychosom Res. 2019;118:41-48.
• Christina Maslach, Susan E. Jackson, Michael P. Leiter. Maslach Burnout Inventory Manual TM. Mind Garden, Inc.; 1995, 2000, 2004. www.mindgarden.com.
• Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav. 1981;2(2):99-113.
• Maslach C, Leiter MP. Early predictors of job burnout and engagement. J Appl Psychol. 2008;93(3):498-512.
• Hojat M, DeSantis J, Gonnella JS. Patient Perceptions of Clinician’s Empathy: Measurement and Psychometrics. J Patient Exp. 2017;4(2):78-83.
• Mueller K, Prins R, de Heer HD. An Online Intervention Increases Empathy, Resilience, and Work Engagement Among Physical Therapy Students. J Allied Health. 2018;47(3):196-203.
• Dyrbye LN, Thomas MR, Harper W, et al. The learning environment and medical student burnout: a multicentre study. Med Educ. 2009;43(3):274-282.
• Bullock G, Kraft L, Amsden K, et al. The prevalence and effect of burnout on graduate healthcare students. Can Med Educ J. 2017;8(3):e90-e108.
• Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84(9):1182-1191.
• Thomas MR, Dyrbye LN, Huntington JL, et al. How do distress and well-being relate to medical student empathy? A multicenter study. J Gen Intern Med. 2007;22(2):177-183.
• Shields RK, Dudley-Javoroski S, Sass KJ, Becker M. Benchmarking the Physical Therapist Academic Environment to Understand the Student Experience. Phys Ther. 2018;98(8):658-669.
• Macauley K, Plummer L. Prevalence and Predictors of Anxiety in Doctor of Physical Therapy Students. J Allied Health. 2017;46(2):e39-e41.
• Balogun JA, Pellegrini EA, Miller TN, Katz JS. PT Student pattern of burnout 1999.pdf. Journal of Physical Therapy Education. 1999;13(1):12-17.
• Balogun JA, Helgemoe S, Pellegrini E, Hoeberlein T. Test-retest reliability of a psychometric instrument designed to measure physical therapy students’ burnout. Percept Mot Skills. 1995;81(2):667-672.
• Balogun JA. Predictors of academic and clinical performance in a baccalaureate physical therapy program. Phys Ther. 1988;68(2):238-242.
• Berry JW. A Regional Survey & Analysis of Burnout among Physical Therapists in Frontier Counties. PTJ-PAL. 2015;15(3):J3-J11.
• Berry JW, Hosford CC. Burnout among physical therapist assistant program directors: a nationwide survey and analysis. J Allied Health. 2014;43(2):72-78.
• Van Veld R, Slaven EJ, Reynolds B, Shupe P, Woolery C. First-Year Doctor of Physical Therapy Students Demonstrate Change in Coping With Stress. Journal of Physical Therapy Education. 2018;32(2):138.
• CAPTE-The Commission on Accreditation in Physical Therapy Education. Aggregate Program Data 2017 – 2018 Physical Therapist Education Programs Fact Sheet. American Physical Therapy Association; 2018. http://www.capteonline.org/uploadedFiles/CAPTEorg/About_CAPTE/Resources/Aggregate_Program_Data/AggregateProgramData_PTPrograms.pdf.
• Balogun JA, Titoloye V, Balogun A, Oyeyemi A, Katz J. Prevlalence and Determinants of Burnout Among Physical and Occupational Therapists. J Allied Health. 2002;31(3):131-139.
• Maslach. MBI Manual Document.