Can Physical Activity Help Prevent Burnout in First-Year Physician Assistant Students? A Proposed Research Study

Burnout is a state of physical, mental, and emotional exhaustion secondary to prolonged and excessive stress. In most cases, burnout is primarily due to a work-related cause. Burnout is common in all vocations including amongst medical professionals and those currently in health professions training or residency. PA students, specifically those who are younger, in their clinical year of training, or have children living at home, are known to be at risk of developing a high degree of burnout. Previous studies have also shown that (i) physical activity levels are suboptimal in medical students and that (ii) higher levels of physical activity are associated with higher professional efficacy. The researchers hypothesize that physical activity can help prevent burnout in first-year PA students. 

Methods

All participants will be from the Lincoln Memorial University (LMU) PA class of 2024. Pre-intervention, participants will be administered a 10-item demographics questionnaire as well as the 16-item Maslach Burnout Inventory – General Survey for Students (MBI-GS (S)) which addresses three variables – emotional exhaustion, cynicism, and professional efficacy. Half of the participants will be randomly assigned to the Physical Activity group and the other half to the No Physical Activity group. The Physical Activity group will be verbally instructed to walk approximately ½ mile during each break. The No Physical Activity group will be verbally instructed to not ambulate between breaks in class. The intervention will last approximately one semester or 12 weeks. After completion, the participants will be asked to re-complete the MBI-GS (S) survey. Results will be analyzed using standard statistical methodology including t-test, chi-square, and Spearman correlation coefficient.

Purpose

The aim of this study is two-fold. Firstly, the researchers want to add depth to the literature on the prevalence of burnout in Physician Assistant (PA) students. Secondly, the researchers anticipated that the results of this study can be used to help combat this growing concern within PA academia.

Introduction and Literature Review

Burnout was first described by clinical psychologist Herbert Freudenberger in 1974⁽¹⁾.  Broadly speaking, burnout is a state of physical, mental, and emotional exhaustion secondary to prolonged and excessive stress. When an individual is unable to meet constant demands, they may start to feel overwhelmed, emotionally drained, disinterested, unmotivated, and feel a sense of reduced personal accomplishment amongst other physical, emotional, and behavioral symptoms. This can impact one’s home, work, and social life, as well as leave them vulnerable to illness and disease^(1-5). 

Burnout Affects Care

Personality traits can contribute to burnout, as can one’s lifestyle choices. In most cases, however, burnout is primarily due to a work-related cause^(1-5). Burnout is common in all vocations including amongst medical professionals and those currently in health professions training or residency. Reith⁽¹⁾ reports that in the United States (US) specifically, burnout has reached rampant levels among healthcare professionals, with over one-half of physicians and one-third of nurses experiencing symptoms.

This epidemic is detrimental to patient care as it can give rise to higher patient mortality, lower patient satisfaction, and greater dissemination of hospital-transmitted infections. It can also lead to decreased workforce efficiency and a higher degree of employee turnover^(1,6-8). In 2015, Shanafelt et al.⁽⁹⁾ reported that more than half of US physicians report symptoms of burnout and, if, given the option, only 45% would select their specialty again as a career. These rates are nearly double that of workers in other professions after controlling for hours worked, age, sex, and other factors⁽¹⁰⁾. While burnout in PAs is less studied, initial reports suggest that its prevalence may be similarly elevated⁽¹¹⁾. 

Burnout in Medical Students

Multiple studies have examined the prevalence of burnout in medical students^(12-18). In a 2013 review, at least half of all US medical students were estimated to have experienced one or more symptoms of burnout. In comparison, a 2018 meta-analysis of 16,000 medical students, worldwide, found the prevalence of burnout to be 44%.  Despite these findings, it was not until 2016 before the prevalence of burnout in PA students was first examined. By surveying current members of the student academy of the American Academy of Physician Assistants (AAPA; n=9,557) Orozco et al.⁽¹⁹⁾ were able to demonstrate that PA students, specifically those who are younger in age, in their clinical year of training, or have children living with them at home, are at risk of developing a high degree of burnout.

The literature suggests that any student who is at risk of developing burnout may need additional support during his or her PA training.  Further, these students are more likely to develop substance abuse, depression, and suicidal ideation, among other things. During the clinical year of training, burnout may also give rise to medical errors, especially in a student who has a decreased sense of altruism or if their professional judgment and/or decision-making abilities have become clouded^(12-14). 

Physician Assistant Job Satisfaction

Historically, PAs have reported high levels of professional satisfaction. Emerging research, however, indicates increasing levels of professional burnout in PAs, especially in those who work in certain specialties, namely emergency medicine, critical care, and oncology^(20,21). A small, yet robust study by Benson et al.⁽²²⁾ revealed that organizational factors, such as little control over workload and inadequate administrative support, contributed to burnout in PAs. Strong team culture, on the other hand, may protect against exhaustion, a significant component of burnout.

Bernard and McMoon⁽²³⁾ propose that PAs, as well as PA leadership, must do more to acknowledge and assess the phenomenon of burnout. Specifically, individuals should be mindful of personal boundaries in order to maintain a healthy work-life balance, and commit to creating an organizational culture that sustains overall clinician well-being and fosters PA engagement^(23,24). On a similar note, Coplan and Essary⁽²⁵⁾ argue that the primary cause of burnout in healthcare providers in the healthcare system rather than the individuals per se. The researchers also believe that measures for burnout are imperfect and often used inconsistently. 

Developing Effective Interventions for Burnout

According to Coplan and Essary⁽²⁵⁾, future studies on the topic of burnout in the PA profession should focus on improving understanding and guiding the development of effective interventions for burnout, rather than solely on its prevalence. The researchers also believe that more studies focusing on PAs specifically will increase the likelihood that the PA profession will be included in ongoing burnout research advocated by the National Academy of Medicine and Agency for Healthcare Research and Quality⁽¹⁷⁾.

In line with the increasing amount of scientific work on the topic, one intervention that researchers suggested as an effective alleviator for burnout is physical activity.  According to Ochentrel, Humphrey, and Pfeifer⁽²⁶⁾ who conducted a systematic review and meta-analysis of four randomized controlled trials, there is no evidence to support that physical activity is a successful means by which to help alleviate burnout symptoms. The researchers did mention, however, that the different types of physical activity and treatment modalities used in the included studies impeded clear conclusions from being drawn. They, therefore, suggested that any future studies address the efficacy of a single exercise modality only.

Burnout and Physical Activity

In 2018, Macilwraith and Bennett⁽²⁷⁾ researched the relationship between burnout and physical activity in medical students from University College Cork (UCC), Ireland.  Previous studies had shown that physical activity levels are suboptimal in medical students and that seldom had the relationship between physical activity and burnout been investigated^(28-30). Of the 1004 medical students at UCC, 383 were surveyed and their data were analyzed using standard statistical methodology. Of the respondents, 53.2% were found to engage in Health-Enhancing Physical activity (HEFA-active) as defined by the International Physical Activity Questionnaire (IPAQ). Gender, nationality group and year group all appeared to be associated with the prevalence of burnout and physical activity levels.

In keeping with previous studies, the researchers also found that higher levels of physical activity are associated with higher professional efficacy, a significant component of burnout. The researchers, therefore, concluded that physical activity should be promoted in medical students to help decrease the incidence of burnout. More specifically, relatively simple physical activities such as walking, possibly in addition to other interventions, namely mindfulness, group discussion, and yoga, should be included⁽²⁷⁾.  

ARC-PA Addresses Burnout

Effective September 1, 2020, there is an ARC-PA (Accreditation Review Commission on Education for the Physician Assistant, Inc.) accreditation standard (for Physician Assistant Education) addressing burnout: “B2.20 – The curriculum must include instruction about provider personal wellness including prevention of a) impairment and, b) burnout.” In anticipation of this addition to the ARC-PA accreditation standards, Hoover, Butaney, and Stoehr⁽³¹⁾ recently explored the effectiveness of mindfulness and decentering training in a PA curriculum. Specifically, they designed an innovative first-quarter course for PA students, which included several effective stress management resources, including lectures, in-class demonstrations, and out-of-class activities. Students reported a significant increase in levels of mindfulness post-course, which remained stable at the four-month follow-up. These findings were consistent regardless of previous mindfulness practice, and most importantly, significantly predicted positive changes in life satisfaction and perceived stress. 

Considering the literature, the researchers hypothesize that physical activity (i.e. walking) can help prevent burnout in first-year PA students. The results of this study will likely prompt future works on the subject especially considering its current topicality and the significant need for change.

Methodology

Lincoln Memorial University (LMU) is located in Harrogate TN USA. Its PA program, which has been in existence since 2009, matriculates a class of 96 students each May. All participants will be members of the LMU PA class of 2024 (PA2024). 

Using a written script, researchers will give an oral presentation to PA2024 on May 13, 2022. The rationale for the study will be explained to the participants before they are given the chance to ask questions of the researchers. They will then be asked to complete an informed consent form if they chose to actively participate. 

All participants will be administered, face-to-face, a one-page pre-participation questionnaire once they have consented to participate in the study.  The goals of the 10-item questionnaire are to capture some basic demographic information (name, age, gender, ethnicity, and email contact) as well as assess each participant’s (i) educational history, (ii) current exercise regimen, and (ii) past medical history of burnout. The questionnaires will be completed by hand and returned directly to the researchers for analysis and safe storage.   

The Maslach Burnout Inventory

Participants will also be asked to complete, by hand, the Maslach Burnout Inventory – General Survey for Students (MBI-GS (S)) prior to intervention. The MBI-GS (S) is a 16-item survey instrument that is widely accepted, reliable, and validated by more than 35 years of extensive research. It is used to measure the degree of burnout in adult students in college and university. The MBI-GS (S) addresses three variables – emotional exhaustion (feelings of being overextended and exhausted by one’s studies), cynicism (an indifference or a distant attitude towards one’s studies), and professional efficacy (satisfaction with past and present accomplishments and assessment of an individual’s expectations of continued effectiveness at school). Each scale is considered separately, as burnout is conceptualized as a continuous variable ranging from high to low degrees of the experienced feeling, rather than being either present or absent⁽³²⁾.

Randomization

Following analysis of the student’s MBI-GS (S) surveys, participants will be anonymized prior to randomization. Each participant will be given a unique code, only known to the researchers. Half (n=) of the participants will be placed into the Physical Activity group and the other half (n=) into the No Physical Activity group. The Physical Activity group will be verbally instructed to walk between each and every break in class. No set distance or speed is stipulated, however completing at least five laps of the lecture hall, equaling 1/2 mile, will be suggested during each break. The No Physical Activity group will be verbally instructed to not walk between breaks in class. Instead, they will be asked to remain in their seats unless it was necessary that they ambulate (i.e. to use the restroom).   

Intervention

The intervention will last 12 weeks. At the completion of the 12 weeks, the participants will be asked to complete a post-participation MBI-GS (S) survey, which is identical to the MBI-GS (S) survey that they would have completed pre-participation. This will conclude the participant’s involvement in the study. There will be no formal follow-up. 

Results will be analyzed using standard statistical methodology including t-test, chi-square, and Spearman correlation coefficient. All data, including consent forms, will be retained for three years post-study, at which point it will be safely disposed of.

Results

Upon capture and analysis of all data in summer 2022, the results will be concisely, completely, and accurately documented below. Quantitative and qualitative methods, including free text, tables, and graphical charts will display the results in a logical order and in sufficient detail. All presentation of data will be consistent with AMA guidelines.

Discussion

The aim of this study was two-fold. Firstly, the researchers wanted to add depth to the literature on the prevalence of burnout in Physician Assistant (PA) students. Secondly, they hoped that the results of this study could be used to help combat this growing concern within PA academia. Both of these goals have been achieved, as discussed below. 
Prior to this study, only a handful of researchers have investigated the prevalence of burnout in PA students, most notably Orozco et al. (2016)⁽⁶⁾

Conclusion

Burnout is well-recognized in PA academia. Despite this fact, there was an absence of literature on the topic. There was also little to no evidence on whether or not physical activity could help prevent burnout in first-year PA students.  

By completing this research study, the researchers hope to establish whether or not physical activity (i.e. walking) helps to prevent burnout in first-year PA students. The potential implications of these findings are huge, in PA academia as well as further afield.

The results of this study will prompt future works on the subject, especially considering its current topicality and the significant need for change.