Burnout and mental health in medical education

Physician Assistant/Associate (PA) students are facing increased impairment, adverse academic experiences, and impeded performance. Despite well-documented research demonstrating the multi-factorial wellness needs of many PA students nationally, the unnecessary challenges and continuance of harm persists. Such barriers have influenced student performance, stability, outcomes, and undesirable health events. Further, evidence suggests that student learner wellness is influenced by predisposing and mitigatable factors, which can be addressed proactively at the individual and program level. Early identification of well-being needs, risk factors, and modifiable action steps can enhance student success during the intensive educational journey of the PA student pre-clinical workforce. Therefore, examining, optimizing, and integrating longitudinal wellness practices across curricular design and program operations can have a lasting impact on learners, including as the future healthcare workforce (HCW). This scoping review aims to investigate wellness practices, alignment of their terminologies and implementations for PA students in the United States (U.S.) and evaluate health profession programs' implications of the future HCW.

The authors utilized a Joanna Briggs Institute (JBI) scoping review protocol and logic model to investigate the research query. Literature retrieval was led by the research librarian using keywords, Boolean operators, and database-specific terminology. Using a population, intervention, comparison, outcome, and setting (PICOS) framework and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) tools, studies were vetted through a phased eligibility screening process according to inclusion/exclusion criteria (PA students, wellness practices, occurred within the U.S., original research). Data extraction occurred systematically and involved categorization of terminology (constructs, positive/negative tone), wellness practices, and student impact and outcomes. Findings were mapped to best-fit wellness dimensions using the National Wellness Institute (NWI) competency-based model and to the PA Core Competencies. Thematic and directed content analysis was performed in sequence to determine culminative study results.

A total of 447 studies were retrieved from database searching (n = 439) and handsearching (n = 8). After initial screening and full-text review, 25 studies met inclusion criteria for a total of 9,628 PA student participants. Out of the 25 studies examined, 13/25 (52%) explored the didactic year, 3/25 (12%) examined the clinical year, 7/25 (28%) studied both, and 2/25 (8%) did not specify (Table 1). 28% (n = 7/25) of studies were anchored in evidence-based frameworks. Terminology, wellness practices, and implementation varied across the health professions programs. The 'construct tone' across studies used was nearly equivalent when examining positive (50.89%) versus negative (49.11%) terms related to 'well-being,' Three of 7 (42.86%) dimensions of wellness were most prevalent (EP, IM, and OA) (Fig. 2), whereas the remaining 4 of 7 (57.14%) dimensions (Ph, Sp, Soc, and OWB) had less representation (Table 2). Wellness practices were siloed or brief in nature as seen in 15/25 studies (60%), such as an isolated module or class session, and none of the studies (n = 0/25) addressed all the dimensions of wellness. Findings related to PA student positive/negative wellness experiences sourced directly from the included studies showed statistical significance (p < 0.0001 to p = 0.05), a predominance of moderate to strong correlations (r = -0.802, r = 0.762), and a range of effect sizes: odds ratios (1.04 to 2.09), Cohen's d (0.09 to 0.38), and Pearson's r (0.0 to 0.16).

Unified terminology, definitions, and implementation of wellness practices are necessary to optimize PA student success as future clinicians practicing medicine. Establishing and fostering practices that promote wellness habits, work-life balance, and modernization of antiquated health professions programs is an investment in the iterative growth toward long-term well-being, resilience, and success.