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The Savvy Scientist

Experiences of a London PhD student and beyond

PhD Burnout: Managing Energy, Stress, Anxiety & Your Mental Health

PhDs are renowned for being stressful and when you add a global pandemic into the mix it’s no surprise that many students are struggling with their mental health. Unfortunately this can often lead to PhD fatigue which may eventually lead to burnout.

In this post we’ll explore what academic burnout is and how it comes about, then discuss some tips I picked up for managing mental health during my own PhD.

Please note that I am by no means an expert in this area. I’ve worked in seven different labs before, during and after my PhD so I have a fair idea of research stress but even so, I don’t have all the answers.

If you’re feeling burnt out or depressed and finding the pressure too much, please reach out to friends and family or give the Samaritans a call to talk things through.

Note – This post, and its follow on about maintaining PhD motivation were inspired by a reader who asked for recommendations on dealing with PhD fatigue. I love hearing from all of you, so if you have any ideas for topics which you, or others, could find useful please do let me know either in the comments section below or by getting in contact . Or just pop me a message to say hi. 🙂

This post is part of my PhD mindset series, you can check out the full series below:

• PhD Burnout: Managing Energy, Stress, Anxiety & Your Mental Health (this part!)
• PhD Motivation: How to Stay Driven From Cover Letter to Completion
• How to Stop Procrastinating and Start Studying

What is PhD Burnout?

Whenever I’ve gone anywhere near social media relating to PhDs I see overwhelmed PhD students who are some combination of overwhelmed, de-energised or depressed.

Specifically I often see Americans talking about the importance of talking through their PhD difficulties with a therapist, which I find a little alarming. It’s great to seek help but even better to avoid the need in the first place.

Sadly, none of this is unusual. As this survey shows, depression is common for PhD students and of note: at higher levels than for working professionals.

All of these feelings can be connected to academic burnout.

The World Health Organisation classifies burnout as a syndrome with symptoms of:

– Feelings of energy depletion or exhaustion; – Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; – Reduced professional efficacy. Symptoms of burnout as classified by the WHO. Source .

This often leads to students falling completely out of love with the topic they decided to spend years of their life researching!

The pandemic has added extra pressures and constraints which can make it even more difficult to have a well balanced and positive PhD experience. Therefore it is more important than ever to take care of yourself, so that not only can you continue to make progress in your project but also ensure you stay healthy.

What are the Stages of Burnout?

Psychologists Herbert Freudenberger and Gail North developed a 12 stage model of burnout. The following graphic by The Present Psychologist does a great job at conveying each of these.

I don’t know about you, but I can personally identify with several of the stages and it’s scary to see how they can potentially lead down a path to complete mental and physical burnout. I also think it’s interesting that neglecting needs (stage 3) happens so early on. If you check in with yourself regularly you can hopefully halt your burnout journey at that point.

PhDs can be tough but burnout isn’t an inevitability. Here are a few suggestions for how you can look after your mental health and avoid academic burnout.

Overcoming PhD Burnout

Manage your energy levels, maintaining energy levels day to day.

• Eat well and eat regularly. Try to avoid nutritionless high sugar foods which can play havoc with your energy levels. Instead aim for low GI food . Maybe I’m just getting old but I really do recommend eating some fruit and veg. My favourite book of 2021, How Not to Die: Discover the Foods Scientifically Proven to Prevent and Reduce Disease , is well worth a read. Not a fan of veggies? Either disguise them or at least eat some fruit such as apples and bananas. Sliced apple with some peanut butter is a delicious and nutritious low GI snack. Check out my series of posts on cooking nutritious meals on a budget.
• Get enough sleep. It doesn’t take PhD-level research to realise that you need to rest properly if you want to avoid becoming exhausted! How much sleep someone needs to feel well-rested varies person to person, so I won’t prescribe that you get a specific amount, but 6-9 hours is the range typically recommended. Personally, I take getting enough sleep very seriously and try to get a minimum of 8 hours.

A side note on caffeine consumption: Do PhD students need caffeine to survive?

In a word, no!

Although a culture of caffeine consumption goes hand in hand with intense work, PhD students certainly don’t need caffeine to survive. How do I know? I didn’t have any at all during my own PhD. In fact, I wrote a whole post about it .

By all means consume as much caffeine as you want, just know that it doesn’t have to be a prerequisite for successfully completing a PhD.

Maintaining energy throughout your whole PhD

• Pace yourself. As I mention later in the post I strongly recommend treating your PhD like a normal full-time job. This means only working 40 hours per week, Monday to Friday. Doing so could help realign your stress, anxiety and depression levels with comparatively less-depressed professional workers . There will of course be times when this isn’t possible and you’ll need to work longer hours to make a certain deadline. But working long hours should not be the norm. It’s good to try and balance the workload as best you can across the whole of your PhD. For instance, I often encourage people to start writing papers earlier than they think as these can later become chapters in your thesis. It’s things like this that can help you avoid excess stress in your final year.
• Take time off to recharge. All work and no play makes for an exhausted PhD student! Make the most of opportunities to get involved with extracurricular activities (often at a discount!). I wrote a whole post about making the most of opportunities during your PhD . PhD students should have time for a social life, again I’ve written about that . Also give yourself permission to take time-off day to day for self care, whether that’s to go for a walk in nature, meet friends or binge-watch a show on Netflix. Even within a single working day I often find I’m far more efficient when I break up my work into chunks and allow myself to take time off in-between. This is also a good way to avoid procrastination!

Reduce Stress and Anxiety

During your PhD there will inevitably be times of stress. Your experiments may not be going as planned, deadlines may be coming up fast or you may find yourself pushed too far outside of your comfort zone. But if you manage your response well you’ll hopefully be able to avoid PhD burnout. I’ll say it again: stress does not need to lead to burnout!

Everyone is unique in terms of what works for them so I’d recommend writing down a list of what you find helpful when you feel stressed, anxious or sad and then you can refer to it when you next experience that feeling.

I’ve created a mental health reminders print-out to refer to when times get tough. It’s available now in the resources library (subscribe for free to get the password!).

Below are a few general suggestions to avoid PhD burnout which work for me and you may find helpful.

• Exercise. When you’re feeling down it can be tough to motivate yourself to go and exercise but I always feel much better for it afterwards. When we exercise it helps our body to adapt at dealing with stress, so getting into a good habit can work wonders for both your mental and physical health. Why not see if your uni has any unusual sports or activities you could try? I tried scuba diving and surfing while at Imperial! But remember, exercise doesn’t need to be difficult. It could just involve going for a walk around the block at lunch or taking the stairs rather than the lift.
• Cook / Bake. I appreciate that for many people cooking can be anything but relaxing, so if you don’t enjoy the pressure of cooking an actual meal perhaps give baking a go. Personally I really enjoy putting a podcast on and making food. Pinterest and Youtube can be great visual places to find new recipes.
• Let your mind relax. Switching off is a skill and I’ve found meditation a great way to help clear my mind. It’s amazing how noticeably different I can feel afterwards, having not previously been aware of how many thoughts were buzzing around! Yoga can also be another good way to relax and be present in the moment. My partner and I have been working our way through 30 Days of Yoga with Adriene on Youtube and I’d recommend it as a good way to ease yourself in. As well as being great for your mind, yoga also ticks the box for exercise!
• Read a book. I’ve previously written about the benefits of reading fiction * and I still believe it’s one of the best ways to relax. Reading allows you to immerse yourself in a different world and it’s a great way to entertain yourself during a commute.

* Wondering how I got something published in Science ? Read my guide here .

Talk It Through

• Meet with your supervisor. Don’t suffer in silence, if you’re finding yourself struggling or burned out raise this with your supervisor and they should be able to work with you to find ways to reduce the pressure. This may involve you taking some time off, delegating some of your workload, suggesting an alternative course of action or signposting you to services your university offers.

Also remember that facing PhD-related challenges can be common. I wrote a whole post about mine in case you want to cheer yourself up! We can’t control everything we encounter, but we can control our response.

A free self-care checklist is also now available in the resources library , providing ideas to stay healthy and avoid PhD burnout.

Top Tips for Avoiding PhD Burnout

On top of everything we’ve covered in the sections above, here are a few overarching tips which I think could help you to avoid PhD burnout:

• Work sensible hours . You shouldn’t feel under pressure from your supervisor or anyone else to be pulling crazy hours on a regular basis. Even if you adore your project it isn’t healthy to be forfeiting other aspects of your life such as food, sleep and friends. As a starting point I suggest treating your PhD as a 9-5 job. About a year into my PhD I shared how many hours I was working .
• Reduce your use of social media. If you feel like social media could be having a negative impact on your mental health, why not try having a break from it?
• Do things outside of your PhD . Bonus points if this includes spending time outdoors, getting exercise or spending time with friends. Basically, make sure the PhD isn’t the only thing occupying both your mental and physical ife.
• Regularly check in on how you’re feeling. If you wait until you’re truly burnt out before seeking help, it is likely to take you a long time to recover and you may even feel that dropping out is your only option. While that can be a completely valid choice I would strongly suggest to check in with yourself on a regular basis and speak to someone early on (be that your supervisor, or a friend or family member) if you find yourself struggling.

I really hope that this post has been useful for you. Nothing is more important than your mental health and PhD burnout can really disrupt that. If you’ve got any comments or suggestions which you think other PhD scholars could find useful please feel free to share them in the comments section below.

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Tips for Beating Burnout in Graduate School

Claire Dunphy, MA; Doctoral Student in Clinical Psychology, Fordham University

Jennifer mandelbaum, mph; doctoral student in public health, university of south carolina, mary martinelli, ma; doctoral student in clinical psychology, drexel university.

Graduate students in the health field are typically expected to balance many roles and responsibilities involving mentally and often physically taxing work. Therefore, it’s no surprise that so many grad students experience burnout, which usually takes the form of emotional and physical exhaustion in response to chronic work-related stress. While burnout isn’t a new concept, its prevalence in higher education settings is a relatively new area of focus. Therefore, it is very important to stay healthy during graduate school. Here are some quick tips for preventing, recognizing, and addressing burnout in graduate school health programs and beyond:

Tips for preventing burnout:

When it comes to life balance in graduate programs, look for long-term strategies that will have a deep impact on the way you allocate your time.

Say “no” to the culture of overwork

In academia especially, we often view overwork in a positive light and wear it as a badge of honor. At any career stage, though, it’s important to set firm boundaries. If you feel that you are overworking, have an open conversation with your advisor around expectations and priorities. Do you always make yourself available, no matter how full your schedule is? Do you work through the weekend? These habits can fuel burnout. Be wary of overextending yourself, and learn how to say “no” or delegate tasks. Remember, saying “no” to one thing might allow you to say “yes” to something more meaningful.

Consistently prioritize your mental and physical health.

Prioritizing wellbeing allows us to approach our daily tasks with energy, focus, and enthusiasm. Establish healthy habits while you are obtaining your graduate degree so you can carry these habits into your post-grad life. Regular exercise will provide you with increased energy and productivity, as well as help you get a good night’s sleep. Eating a healthy diet low in sugar, refined carbs, and caffeine can also improve your energy levels. Meditation, deep breathing, yoga, and other relaxation techniques can reduce the impact of stress on your body. Above all, don’t wait until you feel overwhelmed to make time for self-care.

Find activities that feed your soul...

...rather than drain your energy. You might embrace your creative side or get back into a favorite hobby. Having outlets that allow you to explore or rediscover interests during your graduate studies can be a powerful motivator and stress-reducer. Slow down and give yourself time to reflect on what’s important to you.

Tips for recognizing burnout:

Check in with yourself mindfully and nonjudgmentally: how are you feeling.

Take frequent inventory of how you’re feeling physically and emotionally. Burnout can take the form of persistent negative feelings which reduce your ability to work efficiently. Look out for feelings of physical or mental exhaustion, loss of motivation, decreased satisfaction, apathy, frustration, resentment, detachment, or cynicism, especially in relation to your work.

Check in with yourself mindfully and nonjudgmentally: what are you doing?

Notice behavioral signs of burnout, which can include reduced productivity, procrastination, withdrawal from others, or frequent mistakes.

Tips for addressing burnout:

Take time off.

When faced with the high demands of being a grad student, you may feel pressure to work long hours without taking time off. However, overworking increases the risk of burnout and may even harm productivity. If you’re struggling with burnout, ask for time off to take a trip somewhere. Even to just take a few days off to “unplug” from work and focus on activities you enjoy is great for your mental health. Another tip is to make changes to your day-to-day work schedule, by setting a time each day when you will stop working and disconnect from email.

Seek social support

While in grad school health programs, one of the best ways to relieve stress and beat burnout is to connect with others. Reach out to a trusted loved one or join a graduate student support group to talk about your experience with burnout. Carve out time in your calendar for social activities (e.g., schedule a weekly phone date with a friend or family member, sign up for group exercise classes).

Talk to a professional

If you are struggling to beat burnout on your own, it may be beneficial to seek treatment with a licensed therapist. They will work with you to make gradual changes and develop strategies for addressing burnout. Check out your university’s counseling center or health services (most schools offer free services to students). Additionally, you could search online for nearby providers in your insurance network or if you are unable to attend face-to-face therapy, consider online therapy options like BetterHelp or Talkspace .

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Tips to help improve your mental and physical health in Graduate School. Staying healthy is hard as a Graduate Student, get the tips you need to say healthy during school.

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• Ways to prepare for grad school

How to Combat Grad Student Burnout

• March 26, 2021

Home Educators Blog

Ready to expand your instructional abilities , become the go-to literacy expert , or take that first step into leadership ? Diving into a graduate education program is a worthwhile undertaking, but it doesn’t come without its fair share of hurdles. One hurdle best avoided: grad school burnout.

What is Student Burnout?

Assignments, readings, essays, group projects, deadlines. In a blink of an eye, a semester can become completely overwhelming for graduate students. Student burnout is a real thing and should be taken seriously. Students who are experiencing burnout and choose not to do anything about it will most likely fail their courses, lose scholarships and assistantships, and even be asked to leave the university.

Signs of Burnout in College Students

Balancing life, work, and school can be incredibly challenging. Once a student begins to feel overwhelmed and misses assignments, the burnout cycle begins. There can be many causes of burnout for students. This can happen right when the semester begins because the student has taken on too many classes. Having an excruciating course load can cause a student to not even know where to begin when starting assignments.

Once the student feels like he/she is drowning in assignments, the balance of school and life will be gone. This takes another toll on the student. He/she will feel depressed because they feel they do not have time to spend with friends and family. He/she will feel as though he/she never has enough time for enjoyment nor his/her schoolwork. Lack of sleep may also cause burnout. The constant weight of assignments will be on the student’s mind and prevent him/her from sleeping at night. This can then lead to extreme fatigue and loss of energy during the day. The burnout cycle continues.

Fatigue and lack of energy can make the student not be able to concentrate. Assignments will be even harder and focusing in class may seem impossible. These can lead to another common sign of burnout – missed deadlines and poor grades. A student dealing with burnout will find it exceedingly difficult to get assignments done on time. They will not be able to organize their thoughts and get the work in on time. They will have poor time management and may have many overdue assignments at the same time. Professors who see a student’s grade going down and missed deadlines should reach out and find out what is happening.

The feeling of loneliness is another sign of student burnout. Students might feel that they are missing out on fun activities and are the only ones feeling this way. Insomnia can increase this feeling of loneliness. When someone is wide awake at night and he/she thinks everyone else is sleeping, that can provoke feelings of sadness, depression, and loneliness. Burnout is so cyclical and can be extremely hard to break. The student may even lose interest in social activities. This loss of interest would make the student feel isolated from the rest of the world.

The exhaustion that follows sleepless nights can then cause a student to be very irritable. A sign of a student experiencing burnout is that he/she might snap more quickly than usual. He/she becomes annoyed by things that never bothered them in the past. Friends and family should be aware of this change in behavior and personality, as it is a sign of burnout.

Ways to Combat Grad School Burnout

• Analyze course syllabi . At the beginning of each semester, be sure that your workload is not going to be completing overwhelming. Look ahead and see what assignments you are going to have throughout the semester in all of your courses and make a decision as to whether or not you will be able to handle it. If it seems like it is going to be too much, it probably is. Speak with your advisor and see which course you can drop and not have it affect your course plan. You will be happier in the long run for doing this.
• Find activities that you love and make time for them . If you feel as though all you do is work and study, then take a moment and find something outside of classwork that makes you happy, that gets you excited to write it on your calendar. Fit it into your schedule no matter what. Having a distraction like this will actually give you more energy and will help you focus on your assignments.
• Eat nutritiously and get enough sleep . We all know how we feel after days of eating and drinking unhealthily. Once you get into this habit, it is hard to stop it. Make a conscious effort to choose healthy foods throughout the week. Of course, do not limit yourself from your favorite desserts or junk food. Just be aware of what you put into your body and balance the bad with healthy food. Additionally, try to get 7-8 hours of sleep a night. Do not pull all-nighters. Use time management and break large assignments down into smaller pieces throughout the week. Do not forgo sleep to get an assignment done.
• Take time off . There is absolutely nothing wrong with realizing that you may need to take a semester or year off. If you have no motivation, have become pessimistic about school, and just can’t seem to get assignments done, it is time to take a break. Meet with your advisor and find out any rules or regulations for taking time off. Be sure that any scholarships or financial aid will not be negatively impacted. You will be more focused and ready to jump into a new semester while giving yourself the much-needed break from school.
• Surround yourself with a great support network . Supportive family, friends, and classmates could be all that you need to get through a stressful semester and prevent student burnout. Share your feelings with them and let them know that you are feeling overwhelmed. They may have great solutions you may have never thought of. They can also be great listeners for when all you need to do is vent. They will also be able to see when you are suffering from burnout and help you through those difficult times.
• Exercise and get outside . Take breaks from challenging assignments. Do not spend a ridiculous amount of time sitting at your desk or in the library. Get up and walk around. Go to the gym. Go to a park and take a walk. Fresh air can do wonders for a mind block. You will be able to attack an assignment with fresh eyes and most likely will get it done faster.

No matter what, students need to recognize that burnout is real. Take the time to self-reflect on how and why you are feeling negatively about school and assignments. Do not wait too long, otherwise, you may end up failing courses and dropping out.

• #Graduateschool , #StudentBurnout

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Why Do So Many Graduate Students Quit?

Universities themselves may be contributing to burnout.

With half of all doctoral students leaving graduate school without finishing , something significant and overwhelming must be happening for at least some of them during the process of obtaining that degree. Mental illness is often offered as the standard rationale to explain why some graduate students burn out . Some research has suggested a link between intelligence and conditions such as bipolar disorder, leading some observers to believe many graduate students struggle with mental-health problems that predispose them to burning out.

But such research is debatable , and surely not every student who drops out has a history of mental illness. So, what compels students to abandon their path to a Ph.D.? Could there be other underlying factors, perhaps environmental, that can cause an otherwise-mentally-healthy graduate student to become anxious, depressed, suicidal, or, in rare cases, violent?

Research suggests that the majority of students who enter doctoral programs possess the academic ability to complete their studies, but systemic issues at schools may lead to high attrition and mental distress among graduate students. In exploring what exacerbates mental-health issues among graduate students, it may be wise to shift the focus away from labeling graduate students “deficient” to investigate how institutions themselves may be causing attrition.

The culture of Ph.D. programs can make some students snap, according to Karen Kelsky, a former tenured professor and academic career coach. In fact, she said in an email, “it isn't usually a snap so much as a gradual disintegration.” Ph.D. programs are extremely lonely and based on a culture of critique rather than support in which professors and peers constantly look for weaknesses in the doctoral student’s arguments, she said.

During Kelsky’s 15 years as a tenured professor and advisor, she witnessed many students toil in solitude on their dissertations while sacrificing their outside interests. “You become overly fixated on what your professors think of you,” she said. “Paranoia is quite rampant in Ph.D. programs because Ph.D. students can get so isolated and so fixated on whether or not the people in authority [committee members] approve of what they're doing since they have total authority to grant the degree.”

Marcella Wilson , a computer-science professor at the University of Maryland, Baltimore County (UMBC), completed her undergraduate work at Washington Bible College, a small, historically black institution. The close-knit campus with doting professors, she said, did not prepare her for certain aspects of life as a computer-science doctoral student at UMBC. “[The graduate faculty] don’t have time to help you,” she said. “You get [the coursework] or you get out.”

After encountering a number of obstacles to on-time completion—including disagreements with faculty over shifting course-completion requirements, watching as a graduate faculty member warned other faculty not to advise her, and feeling that she was being ostracized—Wilson said she started to have panic attacks and feelings of paranoia. “I felt trapped when I was inside my car … I was becoming agoraphobic,” she recalled. “When I would get into the car, I had visions of myself opening up the door and rolling out into traffic and hurting myself.”

Janet Rutledge, the vice provost and graduate-school dean at UMBC, said Wilson’s recollections are reflective of a widespread problem at her university and graduate programs across the country: a lack of communication between faculty and students. “Very rarely is the faculty motive … malicious,” she said. Faculty members are often “very busy and they don’t communicate the full reason for some of the things that they do, so it is only natural that a student makes certain assumptions based on what they have been able to observe.”

In a brief titled “ Re-Envisioning the Ph.D ,” Jody Nyquist, the former dean of graduate studies at the University of Washington, asked doctoral students across eight disciplines about the flaws they perceived in the graduate-school process. An overwhelming number complained about a lack of quality mentoring and support from faculty. The study also noted that doctoral students believed mentoring needs to begin earlier, be more systematic, and be based on a multiple-mentor model.

Graduate programs that encourage a multiple-mentor model of advising are rare, but this type of support is precisely what helped Wilson complete her doctoral program, she said. After being informed of Wilson’s troublesome graduate experiences, Rutledge introduced her to PROMISE , a program that supports the academic development of graduate students at UMBC. “Once I began to believe I could graduate, I realized that it was not about [the professors],” Wilson said. “I have good relationships with them all now.”

Scott Kerlin, a former doctoral-committee member at the University of Washington and the author of Pursuit of the Ph.D.: “Survival of the Fittest,” suggested that students describe the doctoral process as more “political” than intellectual in nature. There are “lots of issues of power and powerlessness that pervade the graduate experience,” Kerlin said, which may induce extreme distress for students who feels powerless. Indeed, a common reaction to highly stressful situations is difficulty engaging in mutual problem-solving, which, according to Rutledge, makes it especially important for graduate-school administrators to mediate discord between faculty.

But that can be hard to achieve: Many students are convinced the doctoral experience sets them up to fail. “Dysfunctional graduate departments, toxic faculty, and the Navy Seal-like brutality of the Ph.D. process all contribute to the burnout experienced by the estimated 50-plus percent of Ph.D. students who fail to earn their doctorates,” wrote Jill Yesko, then a doctoral student in geography, in a 2014 op-ed for Inside Higher Ed .

And many students enter their doctoral programs assuming that they’re always expected to maintain the illusion of mental stability and confidence while interacting with faculty members, peers, or future employers—regardless of any issues that may arise. While colleges and universities are expanding mental-health services for students, many doctoral candidates feel they need to mask their weaknesses because asking for help would be detrimental to their professional reputations.

In 2011, the University of Texas at Austin’s sociology department conducted a study of graduate students at 26 major universities across the United States. The study, “Stress and Relief for American Graduate Students ,” found that 43 percent of all study participants reported experiencing more stress than they could handle, with Ph.D. students expressing the greatest amounts of stress. Of the students polled, more than half listed stress or burnout as a major concern, about a quarter cited feeling like an outsider, and nearly a third listed their relationships with professors. Only 6 percent of graduate students said they felt they could frequently turn to their mentors and advisors for assistance during stressful times .

“I live and work in a context in which I am encouraged to conceal my [depression], lest it somehow devalue or denigrate my intellectual efforts or the currency of my reputation … This is a toll that academia exacts from so many of us,” Jacqui Shine, a doctoral student at UC Berkeley wrote in a column on Chronicle Vitae .

Chester Goad, a graduate instructor at Tennessee Technological University and the director of its disability-services offices, said he’d never experienced an anxiety attack until he entered his doctoral program in educational leadership.

Goad thought he had been doing well managing his hectic schedule, which included being a father and husband, and maintaining a full-time job, often working on literature reviews or research that forced him to leave the university well after midnight. One day, he had a panic attack while en route to an examination with his peers. Feeling lightheaded and claustrophobic, he had to run away to catch his breath. When he regained composure, his first reaction was a feeling of shame. “As professionals you don’t want people to see you in that situation,” he said. “You want people to think you have got it all collected and together.”

Dion Metzger, an Atlanta-based psychiatrist who specializes in mental illness, argued that the graduate-student experience “produces unique stressors that may not necessarily be found in other career paths.” In pursuing an especially high level of education, she noted, many people may feel an especially high pressure to receive a return on their investment. Alienation from friends and family, an average of eight years spent developing and presenting research, and the cost, are just a few of the ways students feel they have invested.

But sometimes the emotional, social, and financial sacrifices doctoral students make during their studies are, at least initially, difficult to recuperate. In 2014, well over a third of doctorate recipients reported no firm employment upon graduation .

“The students place these expectations on themselves, but sometimes feel the pressure from loved ones who have supported them through their education,” said Metzger, the psychiatrist. “A simple question of ‘Have you found a job yet?’ can [create] instant panic-like symptoms for graduate students. There is a greater pressure to get a job that measures up to the hard work that was put in. Depending on the graduate school path chosen, that is easier said than done … This can be devastating.”

Voices of Academia

Improving mental health in academia by giving you a voice., at breaking point: burnout and its consequences post-phd by marissa edwards.

As I leaned against the wall of my apartment, tears running down my face, one thought kept circling around and around in my head: “This shouldn’t be happening.”

Indeed, from all outside appearances, my life was pretty good.  I had completed my PhD with no major difficulties, I had a supportive family and a wonderful circle of friends, I had no major health problems, I had a job that I loved and knew I was a strong candidate for a tenure-track position in the near future, and had no significant financial difficulties. I was incredibly privileged and still recognize how lucky I was. So why was I crying so hard, and why couldn’t I leave my apartment?

A Precarious Situation

Looking back, a series of events had brought me to this moment. I am, without question, someone who feels the need to perform to a high standard at work all the time. I am a life-long perfectionist. At this point in my career, the self-imposed pressure and culture of academia meant I was perfectly willing to sacrifice many things that I loved in order to land that elusive tenure-track position. I worked extremely long hours and had been rewarded for it with excellent teaching evaluations, international conference presentations, awards, and had even edited a book while completing my PhD.

It was an additive feedback loop; the more I worked, the more I pushed myself to do more and be more. But the more I ‘succeeded’, the work I worked, and so on. Yet as I found out, pushing yourself to the limit only works for a discrete period of time.

In addition to my excessive work hours, I had faced a series of stressful events in a short period of time that sent me spiralling into uncertainty and fear. I had lost my beloved dog of fourteen years, and the grief was utterly overwhelming. (Anyone who has known and loved a pet will know what this feels like) . Less than a month later, a close friend died by suicide. Again, the grief was all-consuming . It was also the beginning of the teaching semester, and prior to this I had agreed to take on a much higher teaching load than ever before, meaning that collectively I was teaching just under 1000 students in several different courses. (At my institution in Australia, we can have up to 600 or more students enrolled in a single course!). And as a casual (adjunct) employee, I was not eligible for paid bereavement leave, though I doubt I would have taken it. In fact, taking any leave didn’t even cross my mind; instead, I decided to work even harder.

The Slow Slide Down

Unsurprisingly, things started to unravel over the next few months and I began to experience symptoms of burnout . The World Health Organization recently defined burnout as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.” It has been studied extensively in the work stress literature, and is characterized by symptoms such as emotional exhaustion, cynicism about one’s job, irritability, and a range of physical ailments. In my case, I believe that my job contributed to my burnout, but the intense losses I experienced compounded the situation. 

Almost immediately I stopped sleeping through the night. For me, this was the single worst part of the experience, because it was only when I was sleeping that I felt any respite from the overwhelming fear. Often I would fall asleep and wake up many times during the night; some nights I couldn’t sleep at all. There is compelling evidence that key areas of the brain that help to regulate emotions are sensitive to sleep deprivation , and that missing even one night of sleep can increase anxiety the next day.  This went on for months, and soon I was becoming terrified of everything.

Although I was somehow still performing well at work, I was struggling enormously. My menstrual cycle became erratic and after Googling (which is never a good idea) I managed to convince myself I was dying. A series of examinations and blood tests revealed that I wasn’t dying but in fact was experiencing a “flare” of Graves’ Disease , an autoimmune illness associated with insomnia, weight loss and – interestingly – increased anxiety.  I had been diagnosed several months earlier and had assumed that it been treated successfully. Clearly not, and there is evidence that stress may play a role in the development and exacerbation of such conditions.

But I knew that my condition wasn’t only due to the Graves’ Disease. Somehow I was still managing to function effectively at work, but I was sick to my stomach, gradually losing weight, in tears almost daily, and not coping. 

Receiving Support and Seeking Help

At this point, a few friends took me aside and did the most important thing they could do: listen . One friend took me for regular day trips to the beach, even when I didn’t want to leave my apartment. This taught me the importance of “opposite actions”; sometimes, the thing that is best for us is the very thing we don’t want to do. Another friend often invited me for coffee and simply listened to me talk about the constant insomnia, grief, and fear; just expressing how I felt made me feel so much better (momentarily). Yet another friend came to my apartment unannounced and chatted with me while making me dinner and made sure I was eating properly.  These and other friends encouraged me to speak to my GP (primary care doctor), which was the first step in accessing help.

I think it’s important to say here that it took me a long time to admit that I wasn’t coping. It took months of gentle encouragement from others that forced me to (reluctantly) take action. In retrospect, I wish I had sought assistance earlier. I wish that the shame and stigma around mental illness hadn’t prevented me from reaching out for professional help. And I wish that I hadn’t succumbed to the pervasive belief in academia that we are defined by our professional success, and that if we aren’t working constantly, we simply aren’t good enough.

When we support others with mental illness, it is often the case that they have to come to the realisation themselves that they needed help – this was no different for me. And to do that, I had to acknowledge first that I was deserving of help.

From here, the story gets much better. My GP referred me to a number of different health professionals to help with the insomnia and anxiety, and things started to improve slowly. Again, I recognise that I was very privileged to have the access and financial means to get help relatively quickly.  If I hadn’t been in that position, I could have been waiting months for assistance, and I am still grateful. With the help of melatonin and other medication, I began sleeping through the night again. It took around five months for the insomnia to resolve completely, but it was a huge relief and had an immediate impact on my well-being.

The academic year finished, classes ended, and finally I took weeks of recreation leave. For once, I didn’t think about work. I read books. I took naps. Over time, I started to relax and enjoy myself. I went travelling to beautiful places, including the south island of New Zealand. I spent time with friends. Eventually, my family and I rescued a beautiful older dog, Ziggy, who still brings constant joy every day.

Lessons Learnt

In closing, this experience taught me many lessons that I would like to share here:

• If you are struggling, please reach out for help.   It doesn’t necessarily have to be to a psychologist or psychiatrist, but please try to talk to someone. Talking and getting the emotions off your chest alone can help. And vice versa, if you have a friend or colleague who is struggling, offer to listen to them (if they are willing). Listening and validating their experience is so important.
• Just because you are coping successfully at work does not mean that you are okay. I still remind myself of this constantly. It’s important that we check in on our colleagues and their mental health, even those who look like they have it together.
• Find a good primary care doctor . They are in the best position to refer you for additional help if needed, which may include medication, therapy, or both. If you don’t like the first doctor you try, keeping looking until you find one you “click” with.  A good doctor will also do bloods to rule out any physical issues, such as low iron, low Vitamin D, etc.
• Don’t underestimate the importance of sleep, nutrition, and exercise.  These are some of the “building blocks” of wellness and can have a significant impact on your mental health. And exercise doesn’t mean that you have to go the gym!  I am not a gym person, but I love taking long walks. If you are out of the house and moving, that’s a good start.
• Social support is absolutely crucial to recovery . I will be forever grateful to my friends who were there for me when I was grieving and unwell. Research suggests that having supportive friends can help people deal with life stressors more effectively , and I think that there is some truth to the argument that depression is a disease of loneliness.

Finally, it’s important to remember that your list of publications and other work achievements won’t be there to hold your hand when you are struggling, but chances are some of your family and friends will.

I have to admit that disengaging from work and taking the time to rest is still a constant struggle for me, even now that I am tenured. In academia, there is always another paper to write, a project to start, a grant to apply for, etc. I agree strongly with those who have argued that cultural change is needed in academia. This will take time and will likely be a process of small, incremental changes. In the meantime, there are still steps we can take to look after our mental health.

When we face extremely distressing life events, turning to work as a coping mechanism is unlikely to be effective. Talking to others and reaching out for support are among the best things you can ever do for yourself.

We also have to recognise we are not machines, and physiologically and psychologically we are not designed to work 24 hours a day, seven days a week.  We are human beings, deserving of rest, support and compassion. Ultimately, please be kind to yourself: you are worth it.  

Marissa Edwards is an Education-Focused lecturer at the UQ Business School at the University of Queensland. Her major research interests are mental health and mental illness in academia, PhD student well-being, and voice and organisational justice. She is currently lead guest editor of a forthcoming Special Issue of the Journal of Management Education focused on mental health and well-being among management students and educators. In her spare time, Marissa loves travelling, seeing live music and spending time with her rescue dog Ziggy.

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• Published: 23 March 2023

Academic burnout among master and doctoral students during the COVID-19 pandemic

• Diego Andrade   ORCID: orcid.org/0000-0002-5323-1211 1 ,
• Icaro J. S. Ribeiro   ORCID: orcid.org/0000-0002-4389-7810 2 &
• Orsolya Máté   ORCID: orcid.org/0000-0003-4778-3519 1  

Scientific Reports volume  13 , Article number:  4745 ( 2023 ) Cite this article

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• Public health

The COVID-19 outbreak has had an immense impact on academic life and public health. Graduate students had experienced obligatory curfews and quarantines due to the COVID-19 outbreak directly impacting their mental health and triggering academic burnout. In this cross-sectional study, we address the issue of mental health in graduate students by relating it to the factors associated with burnout syndrome during the COVID-19 pandemic. A total of 519 graduate students from master's and Ph.D./DLA degrees across universities in Hungary and other European countries participated in this study. The Copenhagen burnout inventory student version was used to evaluate burnout syndrome as an outcome. Our findings displayed burnout significantly lower among graduate students who had good sleep quality, receive high levels of support from their university, and were satisfied with how their university dealt with the pandemic. The excessive consumption of alcohol, the use of antidepressants, being single, and thinking about dropping out showed as predictive factors of burnout. The results add to emergent evidence on the impact of the COVID-19 pandemic on mental health and the predicted factors of academic burnout among master and doctoral students.

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Introduction.

The COVID-19 pandemic has forced universities worldwide to adopt strong measures through compulsory confinement and social isolation. As a result, a negative impact on many students’ mental health was observed, such as the development of academic burnout 1 , 2 , 3 .

Studies has shown that graduate students are more affected by mental health issues and more likely to present higher levels of stress than undergraduate students and the general population during COVID-19 4 , 5 . With the COVID-19 pandemic, new demands have arisen that directly interfere on students' mental health, such as interruption of learning, uncertainty about prolongation of research duration, laboratory closures, losing part-time teaching job, expiring visas for foreign students, uncertain of funding/grant discontinuation, inadequate mentoring, lack of concentration at home and performing more household chores 1 , 6 , 7 . These academic disruptions combined with significant apprehension about the completion and quality of the work, career concerns, usual high workload even at home, colleagues’ competition, inadequate university support, insufficient supervision, financial issues, low autonomy, emotional suffering, academic dissatisfaction, are examples of factors that predispose to a chronic stress and result in academic burnout 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 .

Burnout is described as a psychological disorder emerged as a response to chronic emotional and interpersonal stressors in the working environment, composed of emotional exhaustion, depersonalization and reduced personal accomplishment 17 . Emotional exhaustion refers to depletion of emotional resources by feeling emotionally overextended, exhausted and drained. Depersonalization is often referring to cynicism, and includes negative attitudes toward other people, like colleagues, patients, or clients. A reduction in personal accomplishment refers to decreased satisfaction and declined feeling of competence and successful achievement 18 . The development of burnout in students is directly related to excessive and prolonged stress caused by piling school work and academic demands combined with drained energy, reduced enthusiasm toward academic tasks, lack of positive attitudes and low academic achievements 19 , 20 .

In addition to all of the academic pressure, graduate students also have had to deal with the COVID-19 outbreak, experiencing curfews, social isolation, and quarantines. In these stressful circumstances, studying and conducting research can have a wide range of effects on mental health, which can lead to academic burnout 16 , 21 , 22 , 23 .

The study of this issue may be of special international interest, considering the recent COVID-19 pandemic, that by itself addresses a critical and unique gap in research concerning the mental status in regard to academic burnout among graduate students in Hungary and some European countries. We aim to address the issue of mental health in graduate students by relating it to the factors associated with burnout syndrome during the COVID-19 pandemic.

A total of 519 students (365 women [70.30%]) with a mean age of 31 years (± 7.76) were included in the evaluation. Single individuals (55.3%), from non-European countries (43.4%), from the University of Pécs (49.1%) and with PhD/DLA educational level (56.3%) prevailed (Table 1 ).

Higher averages of burnout were observed in all the dimensions of the CBI for females, with a significant difference for the dimensions CRB (CRB, p  ≤ 0.01). With regard to marital status, all dimensions of the CBI were higher among singles and the difference was significant for all dimensions (PB, p  = 0.04; SRB, p  ≤ 0.01; CRB, p  = 0.02; TRB, p  ≤ 0.01) (Table 2 ). Evaluating aspects related to academic life, those who thought often about dropping out of the course had higher levels of burnout for all dimensions. With regard to how the university dealt with the pandemic, burnout was more frequent among those dissatisfied with the strategies used. Finally, among those who did not feel supported by the university, burnout was also higher (Table 3 ).

Excessive alcohol consumption (CRB, p  ≤ 0.01) and use of antidepressants (CRB, p  ≤ 0.01; TRB, p  = 0.04) were also associated with higher levels of burnout, but only for the CRB and TRB dimensions. With regard to sleep quality, among those who rated it as poor, they had higher levels of burnout for the PB and SRB dimensions (PB, SRB, p  ≤ 0.01) (Table 4 ).

The current study discloses the influence that the COVID-19 pandemic has had on the mental health of graduate students by analysing the factors associated with burnout syndrome. We analysed sociodemographic, academic, health and life habits factors. We found that being single had an effect in all burnout domains and the sex female as well with the colleagues related burnout domain along the sociodemographic characteristics. Among the academic characteristics, we found high levels of academic burnout for all dimensions among those who had university drop-out intentions, were dissatisfied with how the university dealt with the pandemic and also those who did not feel supported by the university during the outbreak. We found high levels of academic burnout among colleagues-related burnout and teacher-related burnout dimensions in the health and life habits characteristics with those who had excessive alcohol consumption and took antidepressants. The personal burnout and studies-related burnout presented a high level among those who had a bad sleep quality.

Sex differences associated with burnout is still without a literature consensus. Some authors suggest that females are more likely suffer from exhaustion and have higher levels of stress than males, while others report no difference between the two sexes regarding exhaustion and stress 9 , 24 . Nonetheless, our study found association between sex and the colleagues-related burnout dimension, corroborating that females are more likely to develop burnout. Studies has been reporting 25 , 26 , 27 that the higher chronic stress level among females is influenced not only by the university environment that includes role conflict, excessive workload, competitive colleagues and considerable mental pressure to publish, but also by inappropriate behaviours, such as harassment, bullying and gender discrimination.

Woolston 28 published a study by the Nature’s survey with 6.296 PhD respondents, one-quarter of who identified as female reported personally experiencing harassment or discrimination compared with 16% of those identifying as men. Moreover, 57% of students who experienced bullying reported fear of personal repercussions if they discuss their situation. This discloses that sex differences associated with burnout exist and being a woman researcher is still a challenge.

We also found that being single was associated with higher burnout scores in all dimensions compared to those with married or other marital status. This result was well reported by Maslach et al. 17 that found higher burnout among those who identified as single rather than married. Among postgraduates, other study also found higher burnout scores in single individuals compared to the married ones 14 . Marriage as a social support may act as a protecting factor from chronic stress and can play a role in reducing academic burnout.

Evaluating aspects related to academic life, we found that many graduate students at some point had considered abandoning their studies. Several studies have reported high rates of university withdrawal intentions, for example, 30–70% of doctorate students will may not complete their PhD degree 8 , 29 , 30 , 31 . Experiences of high stress, anxiety and exhaustion, demonstrated a lack of interest in their studies which appears to influence drop-out intentions 8 , 32 , 33 . In contrast, satisfaction and engagement in research, supervision from several supervisors, integration and networks in the research community has a reverse effect in reducing burnout rates and enhancing success to degree completion 34 , 35 . This reveals that the decision to drop out of studies has a direct influence on burnout experiences, as shown by an association in all four burnout’s dimensions.

Furthermore, relating to the academic life, we found that the feeling of not being supported by the university during the COVID-19 outbreak had an association with all burnout dimensions. The academic support that graduate students receive from their department, faculty or university is essential to develop the sense of belonging and fitting in the educational environment. The lack of this perceived organizational support can increase the risk of experiencing exhaustion and the dissatisfaction with the doctoral studies, leading to academic burnout and consequences such as the intention to leave the degree 8 , 36 , 37 . The dissatisfaction with how the university dealt with the pandemic was another result found associated with the dimensions studies-related burnout, colleague-related burnout and teacher-related burnout, showing the direct influence of the institution, work environment and supervision on student satisfaction and well-being 37 , 38 , 39 . Particularly, the perceived organizational support and satisfaction with the institution can be decreased when the graduate students need to deal with the lack of transparency, undefined career prospects, unclear expectations during an outbreak such the COVID-19, thus the aforementioned factors can raise the risk for developing burnout.

Analysing the health and life habits characteristics we found that a bad sleep quality is associated with two burnout dimensions, personal burnout and studies-related burnout. Allen et al. also found in their study with graduate students that sleep quality has more consistent relationship with burnout and might be more important than sleep duration in order to reduce burnout levels 40 . It is already known that a poor sleep quality is associated with higher levels of fatigue and exhaustion, and when it comes to graduate students, this can impact directly and negatively the student’s personal life and academic productivity 41 , 42 . Given that together with prolonged and chronic stress, the lack of energy and motivation can make students less interested in their studies and more prone to develop academic burnout.

Moreover, with regards to the health and life habits factors related to academic burnout, we found that self-reported excessive alcohol consumption and use of antidepressants are both associated with colleague-related burnout and teacher-related burnout. The association between burnout syndrome and the consumption of alcohol has been widely reported, although a limited number of studies have examined this relationship among graduate students. The vulnerable situations of the students, emotional conflicts in the academia environment, excess of activities and competitiveness are pointed as the most contributing factors in the development of high levels of stress and alcohol misuse. This excessive alcohol consumption may be viewed as a dysfunctional coping mechanism, since the students may abuse alcohol as a strategy for regulating tension and stressful situations in the academia 43 , 44 , 45 , 46 .

The use of antidepressants can be also observed as a way of coping with adversity in the academia. It is already known that the academic stressors are related to stress, anxiety, depression, and when combined with extra load on studying as well as the need to enhance performance and concentration, students may resort to the use of antidepressants to avoid episodes of social anxiety and depressive behaviour. This finding is consistent with other studies, that reported students who use antidepressants, present high levels of burnout 47 , 48 , 49 . The misuse of alcohol and/or other substances are linked with burnout, and by neglecting that, it can lead to serious consequences.

1 Limitations

Our study has some important limitations. The cross-sectional study design limited our ability to establish causality between the associations. The online assessment to collect data during the COVID-19 outbreak may carry response bias and are less reliable. Therefore, we have used screening tools in this study and our findings should be interpreted carefully, since it is not a clinical psychiatric diagnostic instrument.

Conclusion and implications

This study analysed a number of factors thought to influence graduate students to develop academic burnout during the COVID-19 pandemic. Burnout showed significantly lower among graduate students who receive high levels of support from their university, were satisfied with how their university dealt with the pandemic and had a good sleep quality. The excessive consumption of alcohol, the use of antidepressants, being single and thinking about abandoning the university had a negative impact academic success and were predictory to burnout. We believe that these findings can offer patterns and predictors for future graduate students and university administrators to identify, promote and implement changes to help those who are facing the academic burnout and prevent other graduate students from develop it.

Study design and data collection

This current study is a cross-sectional analytical research. Data were collected through an online survey between September 2021 and March 2022. We tested a pilot of our preliminary instrument to ensure question clarity, and confirm completion of the survey in approximately 15 min. Data collection was done by virtual distribution over the Google Forms platform, along a close co-operation with international associations of graduate students and university departments. The form was disseminated through emails and included an invitation to participate, social media channels from communities for graduate students, and by asking participants to pass along the survey link to other eligible participants. The survey was designed and carried out in accordance with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) 50 (Supplementary Table S1).

Participation was anonymous and voluntary throughout the entire study period, and they were informed about the research and goal before giving their consent. We were unable to assess how many people viewed the online invitation, and therefore we could not determine the response rate of the study. Altogether, 542 students participated in the study. After eliminating incomplete answers, the final sample consisted of 519 graduate students which yielded a 95.75% completion rate.

Inclusion criteria were graduate students at master or Ph.D./DLA level by voluntary participation. Exclusion criteria were incomplete questionnaires and those who did not wish to participate in the research. The pilot test data and incomplete questionnaires with missing responses were excluded from the study.

The dependent variable was academic burnout syndrome, which was evaluated through the Copenhagen burnout inventory—student version 51 . The CBI was developed by Kristensen et al. 51 , and adapted for students by Campos et al. 52 . This scale consists of 25 items that represent 4 subscales: Personal Burnout (PB), Studies-related Burnout (SRB), Colleague-related Burnout (CRB), and Teacher-related Burnout (TRB). The answers are quantifying as 100, 75, 50, 25, and 0% respectively, with a reverse scoring for item 10. We used the Kristensen’s criteria of burnout score, 50–74 is consider moderate, 75–99 is high, and a score of 100 consider as severe burnout 53 . In the current study, the Cronbach’s alpha for the CBI-S scale was 0.93, indicating good internal reliability.

All the other selected variables were classified according to sociodemographic, academic and health status by self-reported answers.

Sociodemographic variables: age, sex (male, female, prefer not to mention), marital status (single, married, other), education level (PhD/DLA, master’s), and origin country (Hungary, European, non-European).

Academic variables: university of origin, study year, university’s drop-out intention (3-point scale ranging from: frequently; sometimes; never), university’s satisfaction during COVID-19 pandemic (5-point scale ranging from: strongly disagreed; disagree; neutral; agreed; strongly agreed), university’s support during COVID-19 pandemic (5-point scale ranging from: strongly disagreed; disagree; neutral; agreed; strongly agreed).

Health status and life habits variables: alcohol consumption (excessively; moderately; no consumption), antidepressant medications in use (yes; no), and quality of sleep (4-point scale ranging from: poor; regular; good; very good).

Statistical analysis

Statistical analysis was performed using initially the Microsoft Excel for Microsoft 365 (Microsoft Corp., Redmond, WA, USA). A p value of 0.05 (two-tailed) was considered to be statistically significant. Descriptive statistics were performed with the calculation of the mean (M) and standard deviation (SD) for quantitative variables, and percentages were calculated for qualitative variables.

In order to verify the difference between the means of the CBI dimensions and the independent variables, the t test (two groups) and the ANOVA (more than two groups) were applied, given the normality of the data attested by the Kolmogorov Smirnov test. All analyses were performed using the Stata statistical package version 12 (Stata Corp., College Station, TX, USA), with a significance level of 5%.

Ethical considerations

The study was approved Ethical Committee from the University of Pécs approved the study, under protocol number 8471, and also respected the Helsinki guidelines at all times. All participants statement an informed consent before becoming part of this study.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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Acknowledgements

The authors acknowledge the study participants who took their valuable time to participate in this research. The Stipendium Hungaricum scholarship program held by Tempus Foundation. And Dr Viktor Farkas for all great contributions.

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Andrade, D., Ribeiro, I.J.S. & Máté, O. Academic burnout among master and doctoral students during the COVID-19 pandemic. Sci Rep 13 , 4745 (2023). https://doi.org/10.1038/s41598-023-31852-w

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Math and Mental Health: Tackling Anxiety and Burnout

Math anxiety and burnout are bearing down on high school students in a post-pandemic academic landscape. And math classes’ lack of relevance to the contemporary world appears to have something to do with it.

A downturn in math scores has been driven by COVID-19 challenges—not just school closures but also the social and emotional tolls of those closures. But math learning could start to recover with more innovative course options, math lessons that reflect the students’ experiences in the world, and a better understanding of what colleges are looking for. At least that’s the thinking of some experts on the topic—students themselves.

More than 30 percent of 16- to 18-year-olds surveyed this year by the Society for Industrial and Applied Mathematics (SIAM) said their anxiety over math has increased in the past two years, while a whopping 83 percent said they experienced overall academic burnout. 

The students surveyed were from the United States and the United Kingdom, and were participants in SIAM’s annual MathWorks Math Modeling Challenge . When asked to weigh in on the causes behind falling math scores, 66 percent cited lack of motivation and focus. About half pointed to the disconnect between math instruction and its relevance to “real life.” And 43 percent blamed the burnout that they are experiencing. 

 It’s well known that student mental health crises have spiked in the last several years. Early this month, in a mental health survey, nearly 60 percent of 18- to 22-year-old college students said they had accessed mental health care during their K–12 years, many of them during high school.

‍ Understanding math pressure to alleviate anxiety ‍

The math students from SIAM’s survey had suggestions about how to raise those falling math scores. Their ideas are not only insightful, they’re achievable. 

Addressing the underlying issues of math anxiety and burnout were atop their list with 45 percent. But how? The students (44 percent of them) emphasized making math classes more applicable to everyday life, and uncovering learning gaps and addressing them with extra help (42 percent).

 What they are suggesting is what experts have been working toward: making math more engaging for all students, not just for those seeking out STEM degrees or careers. 

High school counselors surveyed for our 2022 report Calculating the Odds: Counselor Views on Math Coursetaking and College Admissions noted that students often face undue pressure to accelerate in math, leading many to rush through the curriculum to take courses such as calculus, even when they are not planning to pursue STEM majors. 

“This often leads to unnecessary stress and struggle. In some cases it undermines math confidence for these students,” shared one counselor.

Indeed, the SIAM survey revealed that, for a majority of students, it was the desire to get into a good college or university that kept them going in math over the last few years. This tracks with a prior study , which found that many students cited getting into college as their reason for accelerating to a calculus course—even though many lacked an intrinsic interest in math or STEM, and even though only about 5 percent of students who do so benefit by taking the next-level course in college. 

‍ Looking beyond the calculus standard of success

While calculus is considered an important stepping stone to STEM degrees and careers, there are other ways for high school and college students—STEM and non-STEM majors alike—to show rigor and understanding of advanced math concepts.

In fact, negative math experience and lack of confidence can create “cognitive interference” that shuts down a student’s ability to focus on schoolwork, according to Colleen Ganley, associate professor of psychology at Florida State University and a panelist for our March conference, The Mathematics of Opportunity: Advancing by Degrees . This pattern is especially prevalent, Ganley noted, during math testing, which may lead to inaccurate measures of a student’s actual capacity for math learning. 

“If you’re anxious about something, whether it’s math or anything else, you’re more likely to avoid that,” Ganley said in the TMO session From Math Anxiety to Math Belonging . “We’ve studied it more at older ages and see people less likely to go into careers that involve math.” 

Alleviating the pressure to race through the math curriculum may be a helpful strategy for managing stress, reducing math anxiety, and getting more students—including underrepresented students—to master higher-order math skills and prepare for STEM majors and careers. Traditional courses on the calculus path are one route, but another comprises new, innovative quantitative reasoning courses that keep students engaged in mathematics, students who might otherwise be turned off. 

New approaches to assessment may also help alleviate the pressure and anxiety, Ganley noted: “There are small changes, especially, the way we talk about assessment and the way we talk about standardized testing. This is not to show what you don’t know. This is to show what you know and what you’ve learned.”

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5 Tips to Disrupt the Burnout Cycle

Written by Erin Michel, Graduate Assistant for the Graduate College

Several weeks ago, we asked our GradCurrents readers to describe their emotions at this point in the semester. A staggering 48.4% answered “tired,” and another 24.2% responded “burned out.”  Unfortunately, this figure is not all that surprising when considering the nature of graduate school; research shows that PhD and master’s students worldwide experience anxiety and depression at rates more than six times higher than that of the general public . Graduate students experience stress at a higher rate than undergraduates , and studies have found that as many as 75% of graduate students report being “stressed” or “very stressed.” Scholars suggest that this may be due to the multitude of competing demands that define graduate education; in addition to the typical pressures of higher education, graduate students face additional stressors including pressure to publish and teach as well as family responsibilities, financial pressures, and lack of campus social community. 

Burnout is real, and yet the demands of school and that final push towards the end of the semester loom. How do we manage burnout? Read on to learn about what burnout actually is, and how we can fight back against it to rediscover the joy in our studies. 

What is Burnout?

By understanding exactly what burnout is, we can figure out how best to combat it. Conceptual models of burnout tend to classify it into three key dimensions: exhaustion, cynicism, and feelings of personal ineffectiveness/lack of achievement. Essentially, when we are feeling burned out, we feel a deep, all-encompassing sense of tiredness, both emotionally and physically; we lose enthusiasm in our work and begin expecting the worst out of the people around us; and our negative feelings turn inward, making us doubt our abilities and contribution to a bigger mission. Because these feelings pervade both our perceptions of our environment and our own capabilities, burnout can make it very difficult to function and fulfill our responsibilities, which can perpetuate feelings of ineffectiveness. Sounds pretty bleak, but the good news is there is plenty of research to inform us how we can deal with our burnout and return to our optimistic, motivated selves. 

Burnout Tips 

Sleep . It sounds like a no-brainer, and many of us are probably tired of hearing it, but making sure we are well-rested is absolutely critical in disrupting the burnout cycle. One study of almost 3000 master’s, doctoral, and professional students found that the relationship between stress and exhaustion lessened significantly with length of sleep as well as increased quality of sleep. Essentially, being well-rested makes you more resilient and able to take the stressors of graduate life in stride. Check out these sleep hygiene tips for some expert advice on improving your sleep schedule and getting better quality rest. 

Connect with your peers. As discussed above, the graduate student experience comes with its own unique stressors, one of which is the siloed nature of program and dearth of opportunities to connect with other graduate students across the university. It’s unfortunate that the very people who are best suited to understand our graduate student struggles are difficult to connect with. Taking the leap to ask someone in your class out to coffee can make all the difference in the world. Additionally, consider the Graduate Student Support Peer Group, meeting every Monday with both virtual and in-person options (visit their website for more info) . 

Connect with your advisor. Research shows that students who are satisfied with their advisor display lower levels both the cynicism and inefficacy aspects of burnout. Try connecting with your advisor and being honest with them about your concerns. If you and your advisor just don’t mesh, consider a little bit of self-advocacy in switching advisors or connecting with a different faculty member in an informal mentorship capacity. 

Treat yourself with kindness and compassion. Because burnout makes us feel useless and incapable, it can be difficult to be a cheerleader for ourselves, but at the end of the day we are the only ones who can disrupt our own burnout cycle by reconnecting with our strengths. A helpful place to start is to give yourself the same kind of encouragement and support that you would give a friend who was struggling with a similar situation. Even when feeling poorly about ourselves, we can usually muster up some kindness and support for a loved one. Learn to recognize your negative self-talk for what it is—a symptom of burnout—and what it is not (rooted in truth). If you are struggling, try to first reframe your negative thoughts to be neutral, since that is less challenging than jumping directly from negative to positive. When you think something like, “I’m behind on my dissertation writing—why am I such a bad student and terrible procrastinator? I’ll never finish it;” think, “I’ve fallen a little bit behind, but this isn’t the first time I’ve had to play catch up. Finishing on time will be stressful and challenging, but it is definitely possible.” This kind of thought is easier to adjust to than “I’m doing amazing on my dissertation and will finish it early.” Counseling can help you learn healthier thinking patterns; consider making an appointment with CAPS today; their 15-20 minute “Let’s Talk” sessions can be a good first step and can be accessed virtually for any UC student.

Consider your options. It can be scary to think about making changes or taking time off when graduate school is such an investment, but if your burnout feels so deep seated and intense that your efforts to deal with it haven’t helped, perhaps a change is needed. At the very least, thinking about your reasons for starting graduate school in the first place can help you reconnect with your motivation and make what you’re doing seem more meaningful. As higher educational expert Andrew Crain writes, “A serious contemplation of the value of staying versus leaving is an opportunity to remind yourself of your core reasons for pursuing a graduate degree in the first place. Often, the pain and frustration you are experiencing are merely temporary, and you can manage them by refocusing on the long-term vision you hold for yourself. Conversely, I know many graduate students who have engaged in this serious reflection only after beginning their programs, ultimately concluding that completing the degree is not the best path forward for them. Persisting and leaving are both completely reasonable choices depending upon your own personal circumstances.” Also, remember that changes exist between the two extremes of “staying” and “leaving” graduate school – options include switching to part time status or a leave of absence; talk to your advisor or program direction about these options. Other adjustments can also likely be made – consider the full breadth of your commitments and tap into the emotions behind each one. Does a particular extracurricular give you an inexplicable sense of dread? Think about quitting! Take stock of your life, figure out what sparks joy, and trim the things that don’t.

Guide to Graduate Studies

The PhD Program The Ph.D. program of the Harvard Department of Mathematics is designed to help motivated students develop their understanding and enjoyment of mathematics. Enjoyment and understanding of the subject, as well as enthusiasm in teaching it, are greater when one is actively thinking about mathematics in one’s own way. For this reason, a Ph.D. dissertation involving some original research is a fundamental part of the program. The stages in this program may be described as follows:

• Acquiring a broad basic knowledge of mathematics on which to build a future mathematical culture and more detailed knowledge of a field of specialization.
• Choosing a field of specialization within mathematics and obtaining enough knowledge of this specialized field to arrive at the point of current thinking.
• Making a first original contribution to mathematics within this chosen special area.

Students are expected to take the initiative in pacing themselves through the Ph.D. program. In theory, a future research mathematician should be able to go through all three stages with the help of only a good library. In practice, many of the more subtle aspects of mathematics, such as a sense of taste or relative importance and feeling for a particular subject, are primarily communicated by personal contact. In addition, it is not at all trivial to find one’s way through the ever-burgeoning literature of mathematics, and one can go through the stages outlined above with much less lost motion if one has some access to a group of older and more experienced mathematicians who can guide one’s reading, supplement it with seminars and courses, and evaluate one’s first attempts at research. The presence of other graduate students of comparable ability and level of enthusiasm is also very helpful.

University Requirements

The University requires a minimum of two years of academic residence (16 half-courses) for the Ph.D. degree. On the other hand, five years in residence is the maximum usually allowed by the department. Most students complete the Ph.D. in four or five years. Please review the program requirements timeline .

There is no prescribed set of course requirements, but students are required to register and enroll in four courses each term to maintain full-time status with the Harvard Kenneth C. Griffin Graduate School of Arts and Sciences.

Qualifying Exam

The department gives the qualifying examination at the beginning of the fall and spring terms. The qualifying examination covers algebra, algebraic geometry, algebraic topology, complex analysis, differential geometry, and real analysis. Students are required to take the exam at the beginning of the first term. More details about the qualifying exams can be found here .

Students are expected to pass the qualifying exam before the end of their second year. After passing the qualifying exam students are expected to find a Ph.D. dissertation advisor.

Minor Thesis

The minor thesis is complementary to the qualifying exam. In the course of mathematical research, students will inevitably encounter areas in which they have gaps in knowledge. The minor thesis is an exercise in confronting those gaps to learn what is necessary to understand a specific area of math. Students choose a topic outside their area of expertise and, working independently, learns it well and produces a written exposition of the subject.

The topic is selected in consultation with a faculty member, other than the student’s Ph.D. dissertation advisor, chosen by the student. The topic should not be in the area of the student’s Ph.D. dissertation. For example, students working in number theory might do a minor thesis in analysis or geometry. At the end of three weeks time (four if teaching), students submit to the faculty member a written account of the subject and are prepared to answer questions on the topic.

The minor thesis must be completed before the start of the third year in residence.

Language Exam

Mathematics is an international subject in which the principal languages are English, French, German, and Russian. Almost all important work is published in one of these four languages. Accordingly, students are required to demonstrate the ability to read mathematics in French, German, or Russian by passing a two-hour, written language examination. Students are asked to translate one page of mathematics into English with the help of a dictionary. Students may request to substitute the Italian language exam if it is relevant to their area of mathematics. The language requirement should be fulfilled by the end of the second year. For more information on the graduate program requirements, a timeline can be viewed at here .

Non-native English speakers who have received a Bachelor’s degree in mathematics from an institution where classes are taught in a language other than English may request to waive the language requirement.

Upon completion of the language exam and eight upper-level math courses, students can apply for a continuing Master’s Degree.

Teaching Requirement

Most research mathematicians are also university teachers. In preparation for this role, all students are required to participate in the department’s teaching apprenticeship program and to complete two semesters of classroom teaching experience, usually as a teaching fellow. During the teaching apprenticeship, students are paired with a member of the department’s teaching staff. Students attend some of the advisor’s classes and then prepare (with help) and present their own class, which will be videotaped. Apprentices will receive feedback both from the advisor and from members of the class.

Teaching fellows are responsible for teaching calculus to a class of about 25 undergraduates. They meet with their class three hours a week. They have a course assistant (an advanced undergraduate) to grade homework and to take a weekly problem session. Usually, there are several classes following the same syllabus and with common exams. A course head (a member of the department teaching staff) coordinates the various classes following the same syllabus and is available to advise teaching fellows. Other teaching options are available: graduate course assistantships for advanced math courses and tutorials for advanced undergraduate math concentrators.

Final Stages

How students proceed through the second and third stages of the program varies considerably among individuals. While preparing for the qualifying examination or immediately after, students should begin taking more advanced courses to help with choosing a field of specialization. Unless prepared to work independently, students should choose a field that falls within the interests of a member of the faculty who is willing to serve as dissertation advisor. Members of the faculty vary in the way that they go about dissertation supervision; some faculty members expect more initiative and independence than others and some variation in how busy they are with current advisees. Students should consider their own advising needs as well as the faculty member’s field when choosing an advisor. Students must take the initiative to ask a professor if she or he will act as a dissertation advisor. Students having difficulty deciding under whom to work, may want to spend a term reading under the direction of two or more faculty members simultaneously. The sooner students choose an advisor, the sooner they can begin research. Students should have a provisional advisor by the second year.

It is important to keep in mind that there is no technique for teaching students to have ideas. All that faculty can do is to provide an ambiance in which one’s nascent abilities and insights can blossom. Ph.D. dissertations vary enormously in quality, from hard exercises to highly original advances. Many good research mathematicians begin very slowly, and their dissertations and first few papers could be of minor interest. The ideal attitude is: (1) a love of the subject for its own sake, accompanied by inquisitiveness about things which aren’t known; and (2) a somewhat fatalistic attitude concerning “creative ability” and recognition that hard work is, in the end, much more important.

PhD Student Burnout

Fmhs-pgsa blog.

Doctoral study is associated with high levels of anxiety and depressive symptomatology, and poor wellbeing overall (1) . Unsurprisingly, the prevalence of burnout is also high among this population (2) . Along with PhD students, nursing and medical students also suffer from disproportionate rates of burnout (3) . This is not a great omen for PhD students in the Faculty of Medical and Health Sciences.

What is burnout?

Burnout is defined as ‘‘ a prolonged response to chronic emotional and interpersonal stressors on the job, and is defined by the three dimensions of exhaustion, cynicism, and inefficacy ’’ (4) .

Exhaustion may include fatigue and low energy due to the draining of emotional resources (5) . Cynicism may refer to an attitude of distancing from work or feelings of indifference towards work. Inefficacy refers to lower rates of success at work or reduced accomplishments.

It’s important to note that burnout is not a failure of the individual. While precise definitions of burnout may vary, the core issue is chronic workplace stress due to poor management. Most of all, burnout reflects a failure of the system.

Universities should take note that the experience of burnout is linked to attrition intentions among PhD students (6.7) .

HOW DOES BURNOUT FEEL FOR PHD STUDENTS?

For PhD students, burnout may feel like high levels of chronic stress . PhD students often serve in a variety of roles as teachers, students, and researchers, and this unclear delineation of roles may in itself be a source of burnout stress.

Students experiencing burnout may feel under constant strain, unhappy, and experience depressive symptoms . Students may experience sleeping difficulties due to worries and an inability to overcome difficulties.

Additionally, burnout feels like emotional exhaustion. Students experiencing burnout may feel increasingly irritable and strained. Students might feel resentful, taken for granted, and with nothing left to give. Depersonalization, or a feeling of detachment, may be experienced such that students appear emotionally cold. 

Feelings of worthlessness and lack of accomplishment are typical during episodes of burnout. Students may feel an absence of motivation to complete their work.

Finally, physical symptoms may accompany the psychological symptoms of burnout. Fatigue, exhaustion, headaches, gastrointestinal disturbances, hypertension, colds, and flu are among the physical symptoms associated with burnout (8.9). 

I think I’m getting better at recognising burnout because it’s happened so much and it’s getting quite normal. For me, I just tend to feel tired a lot and start to experience apathy and anhedonia. For me, recovery requires taking long breaks (at least a few days) from work, and finding time to reconnect with the people and things that I love.

What contributes to burnout?

Key predictors of burnout among doctoral students include:

• Chronic stress (9, 10) 
• Low frequency of supervision (7) 
• Lack of satisfaction with supervision (2, 7, 10) 
• Lack of equality among researchers (7) 
• Poor sleep quality (11)
• Bullying by faculty members (12) 
• Feeling a lack of belongingness to a team (13) 
• Conflict in work responsibilities (2, 13) 
• Low autonomy (13) 

Perfectionism, subjective appraisal of employment opportunities, and an existing psychiatric disorder may also increase risk of burnout (6, 14). 

What reduces risk of burnout?

The risk of burnout may be decreased by:

• Doing PhD in hometown (2) 
• Quality supervision- emotional, social, and informational support (7, 10, 15, 16) 
• Equal treatment as part of research community (7) 
• Regular supervisory meetings (7) 
• Sense of belonging (17) 
• Social support (18) 

Of the predictors and risk factors, supervision appears to have a consistent and powerful impact on burnout for doctoral students. Quality supervision has a buffering effect on stress which social support from family/friends cannot match (16) .

I think the key to avoiding burnout during PhD is 1) setting realistic milestones, and 2) making sure you meet them along the way. Often PhD students set unrealistic milestones and feel like a failure if these are not met. The best way around this is to check in with your supervisor and your peers who may have more experience in how long tasks may take. And secondly, three to four years seems like a really long time but it will really be over quite quickly. Therefore students should work consistently throughout the PhD to ensure that these realistic milestones are met. Making progress in small but consistent increments should help avoid overload and risk of burnout. Remember it is a marathon not a sprint!

HOW CAN YOU PROTECT AGAINST BURNOUT?

The prevention of burnout is not an individual responsibility, but a collective one. Universities should identify risk factors for burnout and attempt to mitigate these. These efforts might include specialised training to aid doctoral supervisors in developing constructive and supportive leadership styles; clear and comprehensive information on the roles and responsibilities of doctoral students; and fostering of a cohesive community for doctoral students, faculty, and staff (1, 10, 15, 16, 19).

In the absence of power to drastically change university systems and culture, an individual doctoral student might be able to slightly reduce burnout risk by:

Engaging with peers.

Peer support has been shown to help with motivation, identification of stressful tasks and workloads, and confidence to talk with supervisors about changes that are needed to prevent burnout (20). 

Active involvement in the academic community.

Students are more likely to feel empowered when they actively engage in the research community (17) . Students may attend conferences or participate in academic events or seminars to increase their involvement.

Avoid overload.

It can be difficult for students to say no to extra work due to several factors including the power imbalance between supervisors and students. But if students can cut down on tasks that don’t serve them, this would be beneficial (19). 

Prioritise sleep.

Sleep was frequently mentioned in studies of doctoral student burnout. Better sleep quality and duration is a modifiable factor that may reduce the risk of transitioning from ‘stressed’ to ‘exhausted’ (11). 

• Levecque K, Anseel F, de Beuckelaer A, van der Heyden J, Gisle L. Work organization and mental health problems in PhD students. Research Policy . 2017;46(4):868-879. doi:10.1016/J.RESPOL.2017.02.008
• Sorrel MA, Ángel Martínez-Huertas J, Arconada M. It Must have been Burnout: Prevalence and Related Factors among Spanish PhD Students. The Spanish Journal of Psychology . 2020;23:1-13. doi:10.1017/SJP.2020.31
• Bullock G, Kraft L, Amsden K, … WGC medical, 2017 undefined. The prevalence and effect of burnout on graduate healthcare students. ncbi.nlm.nih.gov . Accessed August 1, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5661741/
• Maslach C, … WSA review of, 2001 undefined. Job burnout. dspace.library.uu.nl . Accessed August 1, 2022. https://dspace.library.uu.nl/bitstream/handle/1874/13606/maslach_01_jobburnout.pdf?sequen
• Schaufeli WB, Martínez IM, Pinto AM, Salanova M, Barker AB. Burnout and engagement in university students a cross-national study. Journal of Cross-Cultural Psychology . 2002;33(5):464-481. doi:10.1177/0022022102033005003
• Nagy G, Fang C, Hish A, … LKCS, 2019 undefined. Burnout and mental health problems in biomedical doctoral students. Am Soc Cell Biol . 2019;18(2):1-14. doi:10.1187/cbe.18-09-0198
• Cornér S, Löfström E, Doctoral KPIJ of, 2017 undefined. The relationship between doctoral students’ perceptions of supervision and burnout. helda.helsinki.fi . doi:10.28945/3754
• Symptoms of professional burnout: A review of the empirical evidence.: EBSCOhost. Accessed August 1, 2022. https://web.s.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=0&sid=b9d14b7e-56fe-4370-8d56-049a6bad9a99%40redis
• Meis L de, Velloso A, Lannes D, … MCBJ of, 2003 undefined. The growing competition in Brazilian science: rites of passage, stress and burnout. SciELO Brasil . 36(9):2003. Accessed August 1, 2022. https://www.scielo.br/j/bjmbr/a/X9Fby6spKPD7B9mt4PcSHsF/abstract/?lang=en
• Allen HK, Lilly F, Green KM, Zanjani F, Vincent KB, Arria AM. Graduate Student Burnout: Substance Use, Mental Health, and the Moderating Role of Advisor Satisfaction. International Journal of Mental Health and Addiction . 2022;20(2):1130-1146. doi:10.1007/S11469-020-00431-9/TABLES/3
• Allen HK, Barrall AL, Vincent KB, Arria AM. Stress and Burnout Among Graduate Students: Moderation by Sleep Duration and Quality. International Journal of Behavioral Medicine . 2021;28(1):21-28. doi:10.1007/S12529-020-09867-8/FIGURES/2
• Goodboy A, Martin M, Johnson Z. Communication Research Reports The Relationships Between Workplace Bullying by Graduate Faculty with Graduate Students’ Burnout and Organizational Citizenship Behaviors. doi:10.1080/08824096.2015.1052904
• Kusurkar RA, van der Burgt SME, Isik U, et al. Burnout and engagement among PhD students in medicine: the BEeP study. Perspectives on Medical Education . 2021;10(2):110-117. doi:10.1007/S40037-020-00637-6/FIGURES/2
• Chun KH. 의과대학ㆍ의학전문대학원생의 학업소진 양상과 관련 변인들과의 관계 Relationship between Academic Burnout of Medical and Graduate Students and Related Variables. Korean Medical Education Review . 2014;16(2):77-87. Accessed August 1, 2022. http://www.ysmed.net/kmer
• Devine K, Hunter KH. Innovations in Education and Teaching International PhD student emotional exhaustion: the role of supportive supervision and self-presentation behaviours PhD student emotional exhaustion: the role of supportive supervision and self-presentation behaviours. InnovatIons In EducatIon and tEachIng IntErnatIonal . 2017;54(4):335-344. doi:10.1080/14703297.2016.1174143
• Kovach H, Nancy C, Murdock L, Koetting K. Predicting Burnout and Career Choice Satisfaction in Counseling Psychology Graduate Students. The Counseling Psychologist . 2009;37:580-606. doi:10.1177/0011000008319985
• Stubb J, Pyhältö K, Lonka K. Studies in Continuing Education Balancing between inspiration and exhaustion: PhD students’ experienced socio-psychological well-being. Published online 2011. doi:10.1080/0158037X.2010.515572
• Galdino MJQ, Martins JT, do Carmo Fernandez Lourenço Haddad M, do Carmo Cruz Robazzi ML, Birolim MM. Burnout Syndrome among master’s and doctoral students in nursing. Acta Paulista de Enfermagem . 2016;29(1):100-106. doi:10.1590/1982-0194201600014
• Rigg 1 J, Day 2 J, Adler 2 H, Rigg J. Emotional Exhaustion in Graduate Students: The Role of Engagement, Self-Efficacy and Social Support. Journal of Educational and Developmental Psychology . 2013;3(2). doi:10.5539/jedp.v3n2p138
• Peterson U, Bergströ G, Samuelsson M, et al. Reflecting peer-support groups in the prevention of stress and burnout: randomized controlled trial. Journal of Advanced Nursing . 2008;63(5):506-516. doi:10.1111/J.1365-2648.2008.04743.X

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For everyone whose relationship with mathematics is distant or broken, Jo Boaler , a professor at Stanford Graduate School of Education (GSE), has ideas for repairing it. She particularly wants young people to feel comfortable with numbers from the start – to approach the subject with playfulness and curiosity, not anxiety or dread.

“Most people have only ever experienced what I call narrow mathematics – a set of procedures they need to follow, at speed,” Boaler says. “Mathematics should be flexible, conceptual, a place where we play with ideas and make connections. If we open it up and invite more creativity, more diverse thinking, we can completely transform the experience.”

Boaler, the Nomellini and Olivier Professor of Education at the GSE, is the co-founder and faculty director of Youcubed , a Stanford research center that provides resources for math learning that has reached more than 230 million students in over 140 countries. In 2013 Boaler, a former high school math teacher, produced How to Learn Math , the first massive open online course (MOOC) on mathematics education. She leads workshops and leadership summits for teachers and administrators, and her online courses have been taken by over a million users.

In her new book, Math-ish: Finding Creativity, Diversity, and Meaning in Mathematics , Boaler argues for a broad, inclusive approach to math education, offering strategies and activities for learners at any age. We spoke with her about why creativity is an important part of mathematics, the impact of representing numbers visually and physically, and how what she calls “ishing” a math problem can help students make better sense of the answer.

What do you mean by “math-ish” thinking?

It’s a way of thinking about numbers in the real world, which are usually imprecise estimates. If someone asks how old you are, how warm it is outside, how long it takes to drive to the airport – these are generally answered with what I call “ish” numbers, and that’s very different from the way we use and learn numbers in school.

In the book I share an example of a multiple-choice question from a nationwide exam where students are asked to estimate the sum of two fractions: 12/13 + 7/8. They’re given four choices for the closest answer: 1, 2, 19, or 21. Each of the fractions in the question is very close to 1, so the answer would be 2 – but the most common answer 13-year-olds gave was 19. The second most common was 21.

I’m not surprised, because when students learn fractions, they often don’t learn to think conceptually or to consider the relationship between the numerator or denominator. They learn rules about creating common denominators and adding or subtracting the numerators, without making sense of the fraction as a whole. But stepping back and judging whether a calculation is reasonable might be the most valuable mathematical skill a person can develop.

But don’t you also risk sending the message that mathematical precision isn’t important?

I’m not saying precision isn’t important. What I’m suggesting is that we ask students to estimate before they calculate, so when they come up with a precise answer, they’ll have a real sense for whether it makes sense. This also helps students learn how to move between big-picture and focused thinking, which are two different but equally important modes of reasoning.

Some people ask me, “Isn’t ‘ishing’ just estimating?” It is, but when we ask students to estimate, they often groan, thinking it’s yet another mathematical method. But when we ask them to “ish” a number, they're more willing to offer their thinking.

Ishing helps students develop a sense for numbers and shapes. It can help soften the sharp edges in mathematics, making it easier for kids to jump in and engage. It can buffer students against the dangers of perfectionism, which we know can be a damaging mindset. I think we all need a little more ish in our lives.

You also argue that mathematics should be taught in more visual ways. What do you mean by that?

For most people, mathematics is an almost entirely symbolic, numerical experience. Any visuals are usually sterile images in a textbook, showing bisecting angles, or circles divided into slices. But the way we function in life is by developing models of things in our minds. Take a stapler: Knowing what it looks like, what it feels and sounds like, how to interact with it, how it changes things – all of that contributes to our understanding of how it works.

There’s an activity we do with middle-school students where we show them an image of a 4 x 4 x 4 cm cube made up of smaller 1 cm cubes, like a Rubik’s Cube. The larger cube is dipped into a can of blue paint, and we ask the students, if they could take apart the little cubes, how many sides would be painted blue? Sometimes we give the students sugar cubes and have them physically build a larger 4 x 4 x 4 cube. This is an activity that leads into algebraic thinking.

Some years back we were interviewing students a year after they’d done that activity in our summer camp and asked what had stayed with them. One student said, “I’m in geometry class now, and I still remember that sugar cube, what it looked like and felt like.” His class had been asked to estimate the volume of their shoes, and he said he’d imagined his shoes filled with 1 cm sugar cubes in order to solve that question. He had built a mental model of a cube.

When we learn about cubes, most of us don’t get to see and manipulate them. When we learn about square roots, we don’t take squares and look at their diagonals. We just manipulate numbers.

I wonder if people consider the physical representations more appropriate for younger kids.

That’s the thing – elementary school teachers are amazing at giving kids those experiences, but it dies out in middle school, and by high school it’s all symbolic. There’s a myth that there’s a hierarchy of sophistication where you start out with visual and physical representations and then build up to the symbolic. But so much of high-level mathematical work now is visual. Here in Silicon Valley, if you look at Tesla engineers, they're drawing, they're sketching, they're building models, and nobody says that's elementary mathematics.

There’s an example in the book where you’ve asked students how they would calculate 38 x 5 in their heads, and they come up with several different ways of arriving at the same answer. The creativity is fascinating, but wouldn’t it be easier to teach students one standard method?

A depiction of various ways to calculate 38 x 5, numerically and visually. | Courtesy Jo Boaler

That narrow, rigid version of mathematics where there’s only one right approach is what most students experience, and it’s a big part of why people have such math trauma. It keeps them from realizing the full range and power of mathematics. When you only have students blindly memorizing math facts, they’re not developing number sense. They don’t learn how to use numbers flexibly in different situations. It also makes students who think differently believe there’s something wrong with them.

When we open mathematics to acknowledge the different ways a concept or problem can be viewed, we also open the subject to many more students. Mathematical diversity, to me, is a concept that includes both the value of diversity in people and the diverse ways we can see and learn mathematics. When we bring those forms of diversity together, it’s powerful. If we want to value different ways of thinking and problem-solving in the world, we need to embrace mathematical diversity.

• Open access
• Published: 27 May 2024

The effects of mindfulness-based interventions on alleviating academic burnout in medical students: a systematic review and meta-analysis

• Zhizhuo Wang 1 ,
• Peiyun Wu 1 ,
• Yutong Hou 1 ,
• Jing Guo 2 &
• Cheng Lin 1  

BMC Public Health volume  24 , Article number:  1414 ( 2024 ) Cite this article

47 Accesses

Metrics details

Mindfulness-based interventions have been tested to be the effective approach for preventing/reducing burnout in medical students. Therefore, this systematic review and meta-analysis aimed to synthesize the scientific evidence and quantify the pooled effect of MBIs on the burnout syndrome in medical students.

A comprehensive literature search was conducted in the databases, including PubMed, Embase, ERIC, PsycINFO, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), China National knowledge Information Database (CNKI) and WanFang Database from database inception to February 2023 using the terms of “mindfulness”, “burnout” and “medical students”. Two reviewers independently reviewed the studies, and extracted the data of the eligible studies, as well as assessed the risk of bias. A random-effects model was employed to calculate the standardized mean differences (SMD) with 95% confidence intervals (CI) of overall burnout and its sub-domains of burnout (i.e., emotional exhaustion, cynicism, and academic efficacy).

Of 316 records in total, nine studies (with 810 medical students) were ultimately included. The four RCT studies demonstrated an overall judgment of some concerns risk of bias, and the overall risk of biases of the five qRCT studies were judged as serious. In term of the SORT, the RCT and qRCT studies were evaluated as level 2 evidence, and the overall strength of recommendation was classified as B (limited-quality patient-oriented evidence). The pooled analysis showed that MBIs were associated with significant small to moderate improvements for medical students’ overall burnout (SMD=-0.64; 95% CI [-1.12, -0.16]; P  = 0.009) in the included four RCTs, emotional exhaustion (SMD=-0.27; 95% CI [-0.50, -0.03]; P  = 0.03) and academic efficacy (SMD = 0.43; 95% CI [0.20, 0.66]; P <0.001) in the four qRCTs.

Conclusions

MBIs can serve as an effective approach for reducing burnout symptoms in medical students. Future high-quality studies with a larger sample size and robust randomized controlled trial methodologies should be obtained to reinforce the effectiveness of MBIs for reducing academic burnout in medical students.

Peer Review reports

A fast-growing body of studies is providing that burnout can be seen in medical students prevalently and then progressively develops over the course of medical education [ 1 , 2 , 3 ]. Burnout is a common term that was initially introduced among human service employees and subsequently investigated among other professionals and students [ 4 ]. Recently, researchers have not only sought to investigate burnout in a wide range of occupations, but also paid great attention on student population. As is known, medical students receive much longer and more arduous educational training compared with general college students. Medicine is a profession related to human life, which does not tolerate errors. According to a report in a systematic review, the prevalence of burnout among medical students ranged from 33.4 to 55.0% [ 5 ]. During the preclinical training, medical students are exposed to numerous academic and psychosocial stressors, e.g., heavy workload, high-demand academic achievements, and peer competition, leading to higher likelihood to suffer from burnout [ 6 , 7 ]. Burnout may result in many adverse consequences if not appropriately addressed, which includes but not limited to depression, suicidal ideation, insomnia, thoughts of dropping out of medical school, increased drug or alcohol dependence/abuse [ 8 , 9 , 10 ]. What is worse, burnout may predispose medical students to an unprofessional situation, which can potentially place patients in peril [ 11 ].

Burnout is defined as a syndrome of emotional exhaustion, depersonalization and low personal accomplishment [ 12 ]. Maslach Burnout Instrument (MBI) was developed and employed to examine burnout in the three subscales including exhaustion, depersonalization and professional efficacy [ 5 ]. When the targeted population changed to students, another term “academic burnout” was adopted to highlight the core ingredients of burnout including emotional exhaustion, cynicism, and academic inefficacy [ 13 ]. Therefore, the MBI-Student Survey (MBI-SS) was developed to better precisely measure burnout among students, which is compatible to the specific circumstances encountered by students in an academic context [ 13 ]. In the MBI-SS, the subscale for emotional exhaustion examines fatigue caused by studies, the subscale for cynicism evaluates the indifference in student attitudes toward their studies, and the subscale for academic efficacy focuses on the academic accomplishment. The MBI-SS has proven to have good reliability and validity to measure student burnout across a number of countries [ 14 , 15 , 16 ].

Mindfulness is described as a process of paying attention to the present moment purposefully and nonjudgmentally [ 17 ], which can be trained through mindfulness-based interventions (MBIs). The parameter of MBIs varies in different studies they refer to, such as length, frequency, and delivery format. In recent years, the popularity of MBIs has grown rapidly due to the increasing evidence showing their effectiveness for diverse psychological and physical disorders, including burnout, depression, anxiety, stress, and chronic pain across a wide range of populations [ 18 , 19 , 20 ]. Although there was a large quantity of systematic review and meta-analysis reporting the effectiveness of MBIs, the population they focused on was primarily the healthcare professionals (e.g., physicians and nurses) and the outcomes broadly reflected the psychological syndromes (e.g., depression, anxiety and stress) rather than the specific aspects of burnout. Nevertheless, to the best of our knowledge, there is no prior systematic review and meta-analysis examining the pooled effect of MBIs on the overall burnout and their three compartments (i.e., emotional exhaustion, cynicism, and academic efficacy) in medical students. So, synthesizing and analyzing the current studies to secure a more precise estimate of the effects of MBIs on burnout is crucial for providing the evidence of implementing MBIs in medical students. Therefore, the systematic review and meta-analysis aimed to synthesize the scientific evidence and quantify the pooled effect of MBIs on the burnout syndrome in medical students.

Search strategy

This systematic review was strictly performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 21 ]. The protocol for this systematic review can be found on PROSPERO (ref: CRD42023388097, available from https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023388097 ). A comprehensive literature search was conducted in the databases, including PubMed, Embase, ERIC, PsycINFO, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), China National knowledge Information Database (CNKI) and WanFang Database from database inception to February 2023 without any language restrictions. The main search terms were “mindfulness”, “burnout”, “medical students” in various combinations. For example, the search strategy in PubMed database was as follows: (((“Burnout, Psychological“[Mesh] OR “Burnout, Professional“[Mesh]) OR (((Burnout[Title/Abstract]) OR (Burnout Syndrome[Title/Abstract])) OR (Academic Burnout[Title/Abstract]))) AND ((“Mindfulness“[Mesh]) OR (Mindfulness*[Title/Abstract]))) AND ((“Students, Medical“[Mesh]) OR (((Medical Students[Title/Abstract]) OR (Student, Medical[Title/Abstract])) OR (Medical Student[Title/Abstract]))). The references from the already-retrieved literature were also searched to find additional articles of interest.

Eligibility criteria

The PICO tool, endorsed by the Cochrane Collaboration, is the acronym of the Population, Intervention, Comparison and Outcomes of an article, which is universally employed to identify compartments of clinical evidence for systematic reviews and meta-analysis. However, the PICO tool has been modified to “PICOS” where the “S” implies the Study design due to the fact that qualitative research or qualitative designs were not specifically identified [ 22 ]. The inclusion criteria were set according to the PICOS guidelines: (1) Participants (P): participants were medical students regardless of their specialty, such as psychology, nursing, surgery, etc.; (2) Intervention (I): any type of mindfulness-focused interventions was included, such as breathing, body scanning, contemplation meditation exercises, yoga, etc.; (3) Comparison (C): any type of comparison conditions was considered, such as active intervention, nonactive intervention, waitlist; (4) Outcome: three sub-indicators of burnout syndrome involved emotional exhaustion, depersonalization and personal accomplishment measured by the Maslach Burnout Inventory and the Oldenburg Burnout Inventory; (5) Study design (S): quantitative research design including randomized controlled trials (RCTs) and non-RCTs.

Study selection and data extraction

The research results were exported to Endnote 20.0 and the duplicates were identified and removed automatically. Two reviewers (Y.T.H. and J.G.) independently screened all titles and abstracts. The full-text review was subsequently conducted by the same two independent reviewers. Disagreements were resolved through in-depth review and discussion, and a third reviewer (Z.Z.W) was invited to reach a consensus if necessary. The extracted information of each study included: (1) characteristics of the study (i.e., authors, country, year of publication, study design); (2) characteristics of the population (i.e., sample size, sex, age, race/ethnicity, studying university); (3) characteristics of the intervention (i.e., treatment setting, treatment length, treatment frequency and type of delivery); (4) characteristics of the outcomes (i.e., means and standard deviations of three sub-indicators of burnout syndrome). If the extracted data were not reported in the article, we emailed the first/corresponding author/authors of that article to secure the missing data.

Quality assessment and strength of recommendation

The quality of the eligible studies was assessed by two reviewers (Z.Z.W. and P.Y.W) independently, and the disagreements were resolved by thorough review and discussion until the consensus was reached. For RCTs, we used the revised Cochrane risk-of-bias tool for randomized trials (RoB 2.0) [ 23 ], which comprises five domains: (1) the randomization process, (2) deviations form intended interventions, (3) missing outcome data, (4) measurement of the outcome, and (5) selection of the reported results. The risk of bias of each included study is categorized as “low risk”, “some concerns” or “high risk”. Furthermore, the risk of bias of non-RCTs was evaluated by the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) across seven domains [ 24 ]: (1) confounding, (2) selection of participants, (3) classification of interventions, (4) deviations from intended interventions, (5) missing data, (6) measurement of outcomes, and (7) selection of the reported results. The risk of bias in each domain is rated as “low risk”, “moderate risk”, “serious risk”, “critical risk”, and “no information”. In term of the level of evidence and strength of recommendation, we used the Strength of Recommendation Taxonomy (SORT) [ 25 ], which classifies each study into three levels from 1 to 3 (level 1: good-quality patient-oriented evidence; level 2: limited-quality patient-oriented evidence; level 3: other evidence) and three strengths of recommendation from A to C (A: recommendation based on consistent and good-quality patient-oriented evidence; B: recommendation based on inconsistent or limited-quality patient-oriented evidence; C: recommendation based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening).

Statistical analysis

The Review Manager software (RevMan v5.4, Cochrane Collaboration, Oxford, UK) was employed to conduct the data analysis. A random-effects model (DerSimonian–Laird approach) was used to determine the effects of mindfulness-based interventions on alleviating academic burnout of medical students by computing the standardized mean differences (SMD) with 95% confidence intervals (CI) [ 26 ]. We used the inverse variance method to weigh the studies. The value of the SMD was rated as small (from 0.2 to 0.49), moderate (from 0.50 to 0.79), or large (equal to or greater than 0.80) [ 27 ]. Besides, we used inconsistency test (I²) to examine the heterogeneity between included studies [ 28 ]. It is commonly accepted that I² values above 25%, 50%, and 75% were interpreted as low, moderate, and high heterogeneity, respectively. P  < 0.05 was considered as statistical significance.

Study search results

Our searches yielded 316 records in total (seen in Fig.  1 ). After removing duplicates, we screened the titles and abstracts of the remaining 203 records, of which 121 were determined to be eligible for full-text screening. A total of nine articles met the inclusion criteria for the qualitative analysis [ 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 ]. For the meta-analysis, one study was excluded due to the inaccessibility of extracting the data [ 37 ].

PRISMA flowchart for study selection

Characteristics of the included studies

The characteristics of the included studies were demonstrated in Table  1 . The year of publication of included studies ranged from 2013 to 2021. Three studies were conducted in China [ 29 , 30 , 31 ], two in Ireland [ 33 , 34 ], one in Norway [ 32 ], one in Spain [ 35 ], one in the United Kingdom [ 36 ], one in the United State [ 37 ]. All studies were reported in English, except for 3 studies in Chinese [ 29 , 30 , 31 ]. A total of 810 participants were included in the qualitative review. Four RCTs and five qRCTs analyzed the effect of MBIs on burnout in medical students. The included studies employed a variety of intervention categories. Two studies used the Mindfulness-Based Stress Reduction (MBSR) course [ 32 , 37 ], five studies used the modified MBSR course [ 29 , 30 , 31 , 34 , 35 ], one study used online version of MBSR programme [ 33 ], and one study used “Five-week Living Mindfully MBSR” [ 36 ]. The length of the MBIs ranged from 2 to 16 weeks. The MBIs involved diverse mindfulness-based practices, such as breathing, body scanning, contemplation meditation exercises, didactic exercises, yoga, and dialogue groups. In term of the outcome measures, three studies used the 20-item Learning Burnout of Undergraduate Students (LBUS) [ 29 , 30 , 31 ], three studies used the 15-item Maslach Burnout Inventory-Student Survey (MBI-SS) [ 32 , 35 , 36 ], three studies used the 16-item Maslach Burnout Inventory (MBI) [ 33 , 34 , 37 ]. Four studies reported the statistically significant difference of burnout after receiving MBIs [ 29 , 30 , 31 , 33 ].

Risk of bias, level of evidence, and strength of recommendation

As shown in Table  2 , Four RCT studies [ 29 , 30 , 31 , 32 ] demonstrated an overall judgment of some concerns risk of bias. Specifically, the overall some concerns risk of bias was found to be from the bias in the deviations from intended intervention and the measurement of outcome. In term of the SORT, the RCT studies were evaluated as level 2 evidence, and the overall strength of recommendation was classified as B (limited-quality patient-oriented evidence). Regarding the qRCTs [ 33 , 34 , 35 , 36 ], the overall risk of bias was judged as serious, which mainly derived from the bias in the measurement of the outcome according to ROBINS-I (presented in Table  3 ). In term of the SORT, the qRCT studies were rated as level 2 evidence, and the overall strength of recommendation was classified as B (limited-quality patient-oriented evidence).

Meta-analysis results

As shown in Fig.  2 , four RCTs [ 29 , 30 , 31 , 32 ] analyzed the total score of burnout, including a total of 461 participants (230 in the MBIs group and 231 in the control group). The pooled analysis revealed a statistically significant moderate effect of MBIs on the overall burnout (SMD=-0.64; 95% CI [-1.12, -0.16]; P  = 0.009). However, due to the relatively high heterogeneity (I 2  = 78%), a sensitivity analysis was conducted where the included studies were removed separately. The heterogeneity was significantly reduced when the study of de Vibe et al. (2013) was excluded (SMD=-0.85; 95% CI [-1.16, -0.54]; P <0.001; I 2  = 0%). On the subgroup meta-analysis, there was a significant difference between Asian sub-group and Western sub-group ( P <0.001) (Fig.  3 ).

As presented in Fig.  4 , four qRCTs [ 33 , 34 , 35 , 36 ] analyzed the emotional exhaustion, cynicism and academic efficacy of burnout, including a total of 308 participant (146 in the MBIs group and 162 in the control group). The pooled result revealed a significant small effect of MBIs on emotional exhaustion (SMD=-0.27; 95% CI [-0.50, -0.03]; P  = 0.03; I 2  = 5%) and academic efficacy (SMD = 0.43; 95% CI [0.20, 0.66]; P <0.001; I 2  = 0%) (Fig.  4 a & c). However, the pooled analysis revealed that the improvement of cynicism in the MBIs group was not significantly different from the control group (SMD=-0.16; 95% CI [-0.38, 0.07]; P  = 0.18; I 2  = 0%) (Fig.  4 b).

Forest plot for the overall burnout

Forest plot for the sub-group analysis of the overall burnout

Forest plot for the sub-domains of burnout. a the emotional exhaustion of burnout. b the cynicism of burnout. c the academic efficacy of burnout

The research of MBIs in medical students has skyrocketed in recent years. To be best of our knowledge, this is the first systematic review and meta-analysis of current studies evaluating the effectiveness of MBIs to alleviate burnout in medical students. A total of 8 studies included in the meta-analysis, suggesting that MBIs had significant small to moderate effects on reducing overall burnout and its two sub-domains (i.e., the emotional exhaustion and academic efficacy). However, the effects of MBIs on the cynicism of burnout were not statistically significant. Although previous reviews and meta-analysis also reported the beneficial effects of MBIs in reducing burnout [ 38 , 39 , 40 ], the population they targeted was healthcare professionals rather than medical students. The study of Daya and Hearn (2018) synthesized the impact of MBIs on medical students for psychological symptoms [ 41 ]. For the burnout aspect, only three studies were included in this review, which concluded that no significant reductions were observed due to lack of sufficient high-quality studies included. Nevertheless, despite a total of 8 studies included in the meta-analysis, we need to be cautious of the results due to the overall high risk of bias and limited-quality evidence observed in the included studies. In the meanwhile, it is noted that the contents and durations of MBIs were not consistent across studies, and the effects also varied. For example, Zhao et al., found that there was a significant difference between medical students receiving or not receiving the modified MBSR course of 8 weeks with 8 sessions of 1.5-hour duration each, including breathing, mindfulness practice, yoga, dialogue groups [ 30 ]. While de Vibe et al. failed finding the significant results for medical students who received the MBSR programme of 8 weekly sessions with 2.5 h each, including physical and mental exercises, didactic teaching and group process [ 32 ].

The results showed that MBIs can reduce the emotional exhaustion of medical students in the included four qRCT studies. A large amount of literature supported that emotional exhaustion can be considered as one of the core elements of burnout [ 4 , 42 , 43 ]. According to a national survey, medical students were more likely to experience high emotional exhaustion and low academic efficacy than early career physicians (44.6% versus 39.6%) [ 44 ]. Likewise, a meta-analysis reported a prevalence of 40.8% (95%CI: 32.8% ∼ 48.9%) of high emotional exhaustion in the included 7588 medical students [ 5 ]. Given that high emotional exhaustion is correlated with high psychiatric morbidity [ 45 ], medical students should be informed about the importance of preventing/alleviating emotional exhaustion through evidence-based interventions, such as MBIs. Previous meta-analysis only reported the effectiveness of MBIs on the overall burnout score and found no substantial difference post-intervention for burnout (SMD=-0.42; 95% CI [-0.84, 0.00]; p  = 0.05; I 2  = 0%) [ 46 ]. Our results provided the evidence that MBIs can significantly reduce the overall burnout and emotional exhaustion in medical students. Therefore, it is MBIs that served as an effective approach to prevent or reduce overall burnout and emotional exhaustion in medical students.

The meta-analysis revealed a non-significant small reduction in the cynicism domain of burnout for medical students receiving MBIs in the included qRCT studies. Cynicism is regarded as a medical student’s detached feelings and impersonal treatment or negative attitudes towards others [ 47 ]. It was reported that the prevalence of cynicism reached 35.1% (95%CI: 27.2% ∼ 43.0%) among 7588 medical students [ 5 ]. Considering the positive association between cynicism and psychiatric morbidity [ 45 ], medical organizations or institutes should alert medical students of the importance of preventing/alleviating cynicism through evidence-based approaches, such as MBIs. The estimate of effect supported the MBIs in reducing cynicism in the included four qRCTs, albeit the non-significant difference between the MBIs group and the control group. Thus, future more studies are needed to strengthen the evidence of MBIs for improving the cynicism domain of burnout in medical students.

For the academic efficacy domain of burnout, it is suggested that MBIs can significantly enhance academic efficacy of medical students in the included four qRCT studies. Academic efficacy refers to the feeling of being effective in the study and being promoted for the position [ 11 ]. As reported in a meta-analysis, the prevalence of academic efficacy got to 27.4% (95%CI: 20.5% ∼ 34.3%) in a number of 7588 medical students [ 5 ]. Compared with the other domains of burnout, the prevalence of academic inefficacy is relatively low. But in practice, burnout is seen as an intertwined unity rather than three separate compartments. So, addressing the academic inefficacy domain of burnout is also of importance. Our findings supported the effectiveness of MBIs in alleviating the academic inefficacy domain of burnout.

The strength of this study is that, to our best knowledge, it is the first systematic review and meta-analysis to determine the pooled effect of MBIs for alleviating overall burnout and its sub-domains in medical students. The findings of this study can provide evidence of MBIs for burnout prevention/reduction among medical students in academic milieu. However, there are some limitations we need to address in this study. First of all, a small number of 8 studies included in the meta-analysis, of which only 4 studies were RCT design. Hence, the results should be interpreted cautiously. Secondly, the publication bias was not evaluated due to fewer than ten studies included in the meta-analysis. Thirdly, for the subgroup meta-analysis of the overall burnout, we divided articles into Asian and Western groups based on the source of population. However, the Asian group merely included articles found in Chinese database, and we did not search a database in the language of another Western country specifically due to the language barrier. Thus, the results of this sub-group meta-analysis may have some biases. Lastly, the risk of bias of the included studies was relatively high, and the overall evidence and strength of recommendation were rated as limited-quality patient-oriented evidence. Therefore, more high-quality studies with robust randomized controlled trial methodologies are needed to minimize the risk of bias existing in the included studies and enhance the strength of recommendation of MBIs for reducing burnout in medical students.

To sum up, the results of this systematic review and meta-analysis suggested that MBIs can serve as an effective approach for reducing burnout symptoms in medical students. Future high-quality studies with a larger sample size and robust randomized controlled trial methodologies should be obtained to reinforce the effectiveness of MBIs for reducing academic burnout in medical students.

Data availability

The datasets used and/or analyzed during the current study available from the corresponding author/first author on reasonable request.

Abbreviations

Mindfulness-Based Interventions

Mindfulness-Based Stress Reduction

Maslach Burnout Instrument

Maslach Burnout Instrument-Student Survey

Learning Burnout of Undergraduate Students

Randomized Controlled Trial

Revised Cochrane Risk-of-Bias Tool for Randomized Trials

Strength of Recommendation Taxonomy

Risk of Bias in Non-Randomized Studies of Interventions

Standard Deviation

Standardized Mean Differences

Confidence Intervals

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Acknowledgements

We sincerely thank the Provincial Education Department of Fujian for financial support.

This study has been funded by Undergraduate Educational Teaching Research Project of Fujian Medical University (J23042), and Undergraduate Educational Teaching Research Project of Fujian Province (FBJG20220065). The funders played no role in study design or conduct.

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Zhizhuo Wang and Peiyun Wu are co-first authors of the article. CL designed and supervised the study. ZZW conducted the data collection. YTH and JG analyzed and interpreted the data. ZZW and PYW equally contributed to drafting the manuscript. CL critically revised the manuscript. All authors read and approved the final manuscript.

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Wang, Z., Wu, P., Hou, Y. et al. The effects of mindfulness-based interventions on alleviating academic burnout in medical students: a systematic review and meta-analysis. BMC Public Health 24 , 1414 (2024). https://doi.org/10.1186/s12889-024-18938-4

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When the PhD path leads to career struggles

A doctoral degree is a major commitment. Think carefully.

I appreciated reading Kara Miller’s The Big Idea column “PhD: Pretty heavily disappointed” (Business, May 22), about people with doctoral degrees struggling to build careers in academia. It made me think back to a conversation I had when I was about to graduate from high school.

I happened to run into a former track coach of mine, and as we were reminiscing he asked me what I planned as a major in college. “History,” I responded. He said, “Why don’t you take some computer classes also? It never hurts to be able to do something useful.”

I did not reflect on his motivation at the time, but my track coach was a young guy, and he was probably giving me advice straight from his own life, as a parent trying to raise his own young children. I did take computer classes in college and ultimately received a PhD in chemical engineering. I always remember that conversation as being a kind of turning point.

Earning a doctoral degree is a life commitment of great proportion. It can take, as Miller notes, between four and seven years. If we think of working life as roughly between the ages of 22 and 65, then a PhD requires more than 10 percent of a person’s working life. People need to think carefully about that investment.

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Two powerful arguments in favor of the path of science, technology, engineering, and math are that there tend to be more STEM jobs for PhDs, and many universities’ STEM departments are generous in covering their PhD students’ tuition and cost of studies, including a stipend toward food, rent, and other expenses.

Stuart Gallant

Not much has changed in 30 years

As I prepared to graduate in 1995 with a doctor of education degree from the Harvard Graduate School of Education, my mother memorably said to me, “Of my four children, you are the one with the most education and the smallest salary.” Apparently not much has changed in 30 years.

I must congratulate these students, however, on following their passion rather than following the money. I can’t help but think that their lives, though stressful, may contain greater happiness.

Peggy Clark

Lawyers & electricians & philosophers, oh my!

Kara Miller’s column on the career challenges for people with doctoral degrees generated more than 260 comments on Boston.Globe.com. The following is an edited sample of readers’ reactions:

Lots of law school grads are underemployed as well. (PL)

So true, PL. The market in Massachusetts is flooded with talented lawyers seeking work. (Roforma)

Supply and demand, the market at work. (guk)

Investing in education and research in all fields is the hallmark of a society with staying power. Disinvesting from these endeavors signals decline and decay. (Massachusetts citizen)

Electricians, plumbers, mechanics, and other skilled technical professions have no problems getting $100k jobs with great benefits. (ramsen)

Not enough turnover from tenured professors, leaving little space for new faculty. Although the tenured, well-established professors are needed, it’s the junior faculty who are hungry and with new ideas that help build new programs. The whole graduate program model is a bad model. I worked two jobs, had my tuition and some type of minimal student health insurance and could barely cover the rent with my stipend, and the second job paid for everything else. Though I was working on many faculty projects, it was the faculty who said this would be good for me. Never did they say it was also good for them. (TravelerofNJ2)

I just retired from a tenured faculty position in science. I’m in my early 70s. I have colleagues who are still doing what they do well into their 70s, a couple approaching 80. There is no active incentive from the university to move the older faculty on, to make way for a new generation. (Lola-lola)

The next step is for adjuncts to go on strike across the nation and hold colleges and universities accountable. The current system is completely absurd. (Wordsmith2358)

Universities should be required to release disclosure data about the fate of their PhD graduates. (davidman820)

I knew an attorney who managed a Cheesecake Factory. She had worked in food services through school. As an attorney, she really did not make that much money and was not doing the field of law of her choice. How many real estate closings can you do without dying of boredom? She went into management in the food industry and makes the same salary. (Antietem)

It was always a question and puzzling to me why people study philosophy. (Blazer27)

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May 21, 2024

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The case for 'math-ish' thinking

by Stanford University

For everyone whose relationship with mathematics is distant or broken, Jo Boaler, a professor at Stanford Graduate School of Education (GSE), has ideas for repairing it. She particularly wants young people to feel comfortable with numbers from the start—to approach the subject with playfulness and curiosity, not anxiety or dread.

"Most people have only ever experienced what I call narrow mathematics—a set of procedures they need to follow, at speed," Boaler says. "Mathematics should be flexible, conceptual, a place where we play with ideas and make connections. If we open it up and invite more creativity, more diverse thinking, we can completely transform the experience."

Boaler, the Nomellini and Olivier Professor of Education at the GSE, is the co-founder and faculty director of Youcubed, a Stanford research center that provides resources for math learning that has reached more than 230 million students in over 140 countries. In 2013 Boaler, a former high school math teacher, produced How to Learn Math, the first massive open online course (MOOC) on mathematics education . She leads workshops and leadership summits for teachers and administrators, and her online courses have been taken by over a million users.

In her new book, " Math-ish: Finding Creativity, Diversity, and Meaning in Mathematics ," Boaler argues for a broad, inclusive approach to math education, offering strategies and activities for learners at any age. We spoke with her about why creativity is an important part of mathematics, the impact of representing numbers visually and physically, and how what she calls "ishing" a math problem can help students make better sense of the answer.

What do you mean by 'math-ish' thinking?

It's a way of thinking about numbers in the real world, which are usually imprecise estimates. If someone asks how old you are, how warm it is outside, how long it takes to drive to the airport—these are generally answered with what I call "ish" numbers, and that's very different from the way we use and learn numbers in school.

In the book I share an example of a multiple-choice question from a nationwide exam where students are asked to estimate the sum of two fractions: 12/13 + 7/8. They're given four choices for the closest answer: 1, 2, 19, or 21. Each of the fractions in the question is very close to 1, so the answer would be 2—but the most common answer 13-year-olds gave was 19. The second most common was 21.

I'm not surprised, because when students learn fractions, they often don't learn to think conceptually or to consider the relationship between the numerator or denominator. They learn rules about creating common denominators and adding or subtracting the numerators, without making sense of the fraction as a whole. But stepping back and judging whether a calculation is reasonable might be the most valuable mathematical skill a person can develop.

But don't you also risk sending the message that mathematical precision isn't important?

I'm not saying precision isn't important. What I'm suggesting is that we ask students to estimate before they calculate, so when they come up with a precise answer, they'll have a real sense for whether it makes sense. This also helps students learn how to move between big-picture and focused thinking, which are two different but equally important modes of reasoning.

Some people ask me, "Isn't 'ishing' just estimating?" It is, but when we ask students to estimate, they often groan, thinking it's yet another mathematical method. But when we ask them to "ish" a number, they're more willing to offer their thinking.

Ishing helps students develop a sense for numbers and shapes. It can help soften the sharp edges in mathematics, making it easier for kids to jump in and engage. It can buffer students against the dangers of perfectionism, which we know can be a damaging mindset. I think we all need a little more ish in our lives.

You also argue that mathematics should be taught in more visual ways. What do you mean by that?

For most people, mathematics is an almost entirely symbolic, numerical experience. Any visuals are usually sterile images in a textbook, showing bisecting angles, or circles divided into slices. But the way we function in life is by developing models of things in our minds. Take a stapler: Knowing what it looks like, what it feels and sounds like, how to interact with it, how it changes things—all of that contributes to our understanding of how it works.

There's an activity we do with middle-school students where we show them an image of a 4 x 4 x 4 cm cube made up of smaller 1 cm cubes, like a Rubik's Cube. The larger cube is dipped into a can of blue paint, and we ask the students, if they could take apart the little cubes, how many sides would be painted blue? Sometimes we give the students sugar cubes and have them physically build a larger 4 x 4 x 4 cube. This is an activity that leads into algebraic thinking.

Some years back we were interviewing students a year after they'd done that activity in our summer camp and asked what had stayed with them. One student said, "I'm in geometry class now, and I still remember that sugar cube, what it looked like and felt like." His class had been asked to estimate the volume of their shoes, and he said he'd imagined his shoes filled with 1 cm sugar cubes in order to solve that question. He had built a mental model of a cube.

When we learn about cubes, most of us don't get to see and manipulate them. When we learn about square roots, we don't take squares and look at their diagonals. We just manipulate numbers.

I wonder if people consider the physical representations more appropriate for younger kids.

That's the thing—elementary school teachers are amazing at giving kids those experiences, but it dies out in middle school, and by high school it's all symbolic. There's a myth that there's a hierarchy of sophistication where you start out with visual and physical representations and then build up to the symbolic. But so much of high-level mathematical work now is visual. Here in Silicon Valley, if you look at Tesla engineers, they're drawing, they're sketching, they're building models, and nobody says that's elementary mathematics.

There's an example in the book where you've asked students how they would calculate 38 x 5 in their heads, and they come up with several different ways of arriving at the same answer. The creativity is fascinating, but wouldn't it be easier to teach students one standard method?

That narrow, rigid version of mathematics where there's only one right approach is what most students experience, and it's a big part of why people have such math trauma. It keeps them from realizing the full range and power of mathematics. When you only have students blindly memorizing math facts, they're not developing number sense.

They don't learn how to use numbers flexibly in different situations. It also makes students who think differently believe there's something wrong with them.

When we open mathematics to acknowledge the different ways a concept or problem can be viewed, we also open the subject to many more students. Mathematical diversity, to me, is a concept that includes both the value of diversity in people and the diverse ways we can see and learn mathematics.

When we bring those forms of diversity together, it's powerful. If we want to value different ways of thinking and problem-solving in the world, we need to embrace mathematical diversity.

Provided by Stanford University

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Sheena Zeng selected 2024-2028 Self Graduate Fellow

Sheena Zeng, first-year doctoral student in mathematics, was selected along with fourteen doctoral students to receive the University of Kansas' prestigious Madison and Lila Self Graduate Fellowship for the 2024-2025 academic year.

The fellowship is a four-year package awarded to incoming or first-year doctoral students who demonstrate leadership, initiative and passion for achievement. The fellowship covers full tuition and fees, provides graduate research assistant support of $34,850 per year, a $5,500 professional development award, a first-year $5,000 start-up award, $1,000 textbook and technology awards (years 2-4), and a unique professional development program.

The Fellow Development Program provides general education and training in communication, management, innovation, policy and leadership to assist Self Graduate Fellows in preparation for future leadership roles. The role of the development program is to complement the specialized education and training provided in doctoral programs. The total value of the four-year doctoral fellowship exceeds $200,000.

The late Madison “Al” and Lila Self launched and permanently endowed the Self Graduate Fellowship in 1989, motivated by their strong belief in the vital importance of developing leadership for tomorrow. Madison Self was a 1943 KU graduate in chemical engineering. Lila Self attended KU with the Class of 1943.

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• Published: 27 May 2024

Associations between medical students’ stress, academic burnout and moral courage efficacy

• Galit Neufeld-Kroszynski   ORCID: orcid.org/0000-0001-9093-1308 1   na1 ,
• Keren Michael   ORCID: orcid.org/0000-0003-2662-6362 2   na1 &
• Orit Karnieli-Miller   ORCID: orcid.org/0000-0002-5790-0697 1  

BMC Psychology volume  12 , Article number:  296 ( 2024 ) Cite this article

52 Accesses

Metrics details

Medical students, especially during the clinical years, are often exposed to breaches of safety and professionalism. These contradict personal and professional values exposing them to moral distress and to the dilemma of whether and how to act. Acting requires moral courage, i.e., overcoming fear to maintain one’s core values and professional obligations. It includes speaking up and “doing the right thing” despite stressors and risks (e.g., humiliation). Acting morally courageously is difficult, and ways to enhance it are needed. Though moral courage efficacy, i.e., individuals’ belief in their capability to act morally, might play a significant role, there is little empirical research on the factors contributing to students’ moral courage efficacy. Therefore, this study examined the associations between perceived stress, academic burnout, and moral courage efficacy.

A cross-sectional study among 239 medical students who completed self-reported questionnaires measuring perceived stress, academic burnout (‘exhaustion,’ ‘cynicism,’ ‘reduced professional efficacy’), and moral courage efficacy (toward others’ actions and toward self-actions). Data analysis via Pearson’s correlations, regression-based PROCESS macro, and independent t -tests for group differences.

The burnout dimension of ‘reduced professional efficacy’ mediated the association between perceived stress and moral courage efficacy toward others’ actions. The burnout dimensions ‘exhaustion’ and ‘reduced professional efficacy’ mediated the association between perceived stress and moral courage efficacy toward self-actions.

Conclusions

The results emphasize the importance of promoting medical students’ well-being—in terms of stress and burnout—to enhance their moral courage efficacy. Medical education interventions should focus on improving medical students’ professional efficacy since it affects both their moral courage efficacy toward others and their self-actions. This can help create a safer and more appropriate medical culture.

Peer Review reports

Introduction

In medical school, and especially during clinical years, medical students (MS) are often exposed to physicians’ inappropriate behaviors and various breaches of professionalism or safety [ 1 , 2 , 3 ]. These can include lack of respect or sensitivity toward patients and other healthcare staff, deliberate lies and deceptions, breaching confidentiality, inadequate hand hygiene, or breach of a sterile field [ 4 , 5 ]. Furthermore, MS find themselves performing and/or participating in these inappropriate behaviors. For example, a study found that 80% of 3 rd– 4th year MS reported having done something they believed was unethical or having misled a patient [ 6 ]. Another study showed that 47.1–61.3% of females and 48.8–56.6% of male MS reported violating a patient’s dignity, participating in safety breaches, or examining/performing a procedure on a patient without valid consent, following a clinical teacher’s request, as a learning exercise [ 5 ]. These behaviors contradict professional values and MS’ own personal and moral values, exposing them to a dilemma in which they must choose if and how to act.

Taking action requires moral courage, i.e., taking an active stand or acting in the face of wrongdoing or moral injustice jeopardizing mental well-being [ 7 , 8 , 9 , 10 ]. Moral courage includes speaking up and “doing the right thing” despite risks, such as shame, retaliation, threat to reputation, or even loss of employment [ 8 ]. Moral courage is expressed in two main situations: when addressing others’ wrongdoing (e.g., identifying and disclosing a past/present medical error by colleagues/physicians); or when admitting one’s own wrongdoing (e.g., disclosing an error or lack of knowledge) [ 11 ].

Due to its “calling out” nature, acting on moral courage is difficult. A hierarchy and unsafe learning environment inhibits the ability for assertive expression of concern [ 12 , 13 , 14 ]. This leads to concerning findings indicating that only 38% of MS reported that they would approach someone performing an unsafe behavior [ 12 ], and about half claimed that they would report an error they had observed [ 15 ].

Various reasons were suggested to explain why MS, interns, residents, or nurses, hesitate to act in a morally courageous way, including difficulty questioning the decisions or actions of those with more authority [ 12 ], and fear of negative social consequences, such as being disgraced, excluded, attacked, punished, or poorly evaluated [ 13 ]. Other reasons were the wish to fit into the team [ 6 ] and being a young professional experiencing “lack of knowledge” or “unfamiliarity” with clinical subtleties [ 16 ].

Nevertheless, failing to act on moral courage might lead to negative consequences, including moral distress [ 17 ]. Moral distress is a psychological disequilibrium that occurs when knowing the ethically right course of action but not acting upon it [ 18 ]. Moral distress is a known phenomenon among MS [ 19 ], e.g., 90% of MS at a New York City medical school reported moral distress when carrying for older patients [ 20 ]. MS’ moral distress was associated with thoughts of dropping out of medical school, choosing a nonclinical specialty, and increased burnout [ 20 ].

These consequences of moral distress and challenges to acting in a morally courageous way require further exploration of MS’ moral courage in general and their moral courage efficacy specifically. Bandura coined the term self-efficacy, focused on one’s perception of how well s/he can execute the action required to deal successfully with future situations and to achieve desired outcomes [ 21 ]. Self-efficacy plays a significant role in human behavior since individuals are more likely to engage in activities they believe they can handle [ 21 ]. Therefore, self-efficacy regarding a particular skill is a major motivating factor in the acquisition, development, and application of that skill [ 22 ]. For example, individuals’ perception regarding their ability to deal positively with ethical issues [ 23 ], their beliefs that they can handle effectively what is required to achieve moral performance [ 24 ], and to practically act as moral agents [ 25 ], can become a key psychological determinant of moral motivation and action [ 26 ]. Due to self-efficacy’s importance there is a need to learn about moral courage efficacy, i.e., individuals’ belief in their ability to exhibit moral courage through sharing their concerns regarding others and their own wrongdoing. Moral courage efficacy was suggested as important to moral courage in the field of business [ 27 ], but not empirically explored in medicine. Thus, there is no known prevalence of moral courage efficacy toward others and toward one’s own wrongdoing in medicine in general and for MS in particular. Furthermore, the potential contributing factors to moral courage efficacy, such as stress and burnout, require further exploration.

The associations between stress, burnout, and moral courage efficacy

Stress occurs when people view environmental demands as exceeding their ability to cope with them [ 28 ]. MS experience high levels of stress during their studies [ 29 ], due to excessive workload, time management difficulties, work–life balance conflicts, health concerns, and financial worries [ 30 ]. Studies show that high levels of stress were associated with decreased empathy [ 31 ], increased academic burnout, academic dishonesty, poor academic performance [ 32 ], and thoughts about dropping out of medical school [ 33 ]. As stress may impact one’s perceived efficacy [ 34 ], this study examined whether stress can inhibit individuals’ moral courage efficacy to address others’ and their own wrongdoing.

An aspect related to a poor mental state that may mediate the association between stress and MS’ moral courage efficacy is burnout. Burnout includes emotional exhaustion, cynicism toward one’s occupation value, and doubting performance ability [ 35 ]. Burnout is usually work-related and is common in the helping professions [ 60 ]. For students, this concept relates to academic burnout [ 36 ], which includes exhaustion due to study demands, a cynical and detached attitude to studying, and low/reduced professional efficacy, i.e. feeling incompetent as learners [ 37 ].

Burnout has various negative implications for MS’ well-being and professional development. Burnout is associated with psychiatric disorders and thoughts of dropping out of medical school [ 33 ]. Furthermore, MS’ burnout is associated with increased involvement in unprofessional behavior, eroding professional development, diminishing qualities such as honesty, integrity, altruism, and self-regulation [ 38 ], reducing empathy [ 31 , 39 ] and unwillingness to provide care for the medically underserved [ 40 ]. Thus, burnout may also impact MS’ views on their responsibility and perceived ability to promote high-quality care and advocate for patients [ 41 ], possibly leading them to feel reluctant and incapable to act with moral courage [ 42 ]. Earlier studies exploring stress and its various outcomes, found that burnout, and specifically exhaustion, can become a crucial mediator for various harmful outcomes [ 43 ]. Although stress is impactful to creating discomfort, the decision and ability to intervene requires one’s own drive and power. When one is feeling stress, leading to burnout their depleted energy reserves and diminished sense of professional worth likely undermine their perceived power (due to exhaustion) or will (due to cynicism) to uphold professional ethical standards and intervene to advocate for patient care in challenging circumstances, such as the need to speak up in front of authority members. Furthermore, burnout may facilitate a cognitive distancing from professional values and responsibilities, allowing for moral disengagement and reducing the likelihood of morally courageous actions. This mediation role requires further exploration.

This study examined associations between perceived stress, academic burnout, and moral courage efficacy. In addition to the mere associations among the variables, it will be examined whether there is a mediation effect (perceived stress → academic burnout → moral courage efficacy) to gain more insight into possible mechanisms of the development of moral courage efficacy and of protective factors. Understanding these mechanisms has educational benefit for guiding interventions to enhance MS’ moral courage efficacy.

H1: Perceived stress and academic burnout dimensions will be negatively associated with moral courage efficacy dimensions.

H2: Perceived stress will be positively associated with academic burnout dimensions.

H3: Academic burnout dimensions will mediate the association between perceived stress and moral courage efficacy dimensions.

Materials and methods

Sample and procedure.

A quantitative cross-sectional study among 239 MS. Most participants were female (60%), aged 29 or less (90%), and unmarried (75%). About two thirds (64.3%) were at the pre-clinical stage of medical school and about a third (35.7%) at the clinical stage. In December 2019, the research team approached MS through email and social media to participate in the study and complete an online questionnaire. This was a part of a national study focused on MS’ burnout [ 44 ]. The 239 participants were recruited by a convenience sampling. Data were collected online through Qualtrics platform, via anonymous self-reported questionnaires. The University Ethics Committee approved the study, and all participants signed an informed consent form.

Moral courage efficacy —This 8-item instrument, developed for this study, is based on the literature on moral courage, professionalism, and speaking-up, including qualitative and quantitative studies [ 7 , 13 , 45 , 46 , 47 ], and discussions with MS and medical educators. The main developing team included a Ph.D. medical educator expert in communication in healthcare and professionalism; an M.D. psychiatrist expert in decision making, professionalism, and philosophy; a Ph.D. graduate who analyzed MS’ narratives focused on moral dilemmas and moral courage during professionalism breaches; and a Ph.D. candidate focused on assertiveness in medicine [ 14 ]. This allowed the identification of different types of situations MS face that may require moral courage.

As guided by instructions for measuring self-efficacy, which encourage using specific statements that relate to the specific situation and skill required [ 48 ], the instrument measures MS’ perception of their own ability, i.e., self-efficacy, to act based on their moral beliefs when exposed to safety and professionalism breaches or challenges. Due to our qualitative findings indicating that students change their interpretation of the problematic event based on their decision to act in a morally courageous way and that some are exposed to specific professionalism violations while others are not when designing the questionnaire, we decided to make the cases not explicit to specific types of professionalism breaches – e.g., not focused on talking above a patient’s head [ 1 ], but rather general the type of behavior e.g., “behaves immorally”. This decreases the personal interpretation if one behavior is acceptable by this individual; and also decreases the possibility of not answering the question if the individual student has never seen that specific behavior. Furthermore, to avoid “gray areas” in moral issues, we wrote the statements in a manner where there is no doubt whether there is a moral problem (“problematic situation”) [ 47 ], and thus the focus was only on one’s feeling of being capable of speaking up about their concern, i.e., act in a moral courage efficacy (see Table  1 ).

The instrument’s initial development consisted of 14 items addressing various populations, including senior MDs. The 14-item tool included questions regarding the willingness to recommend a second opinion or to convey one’s medical mistake to patients and their families. These actions are less relevant to MS. Thus, we extracted the questionnaire to a parsimonious instrument of 8 items.

The 8 items were divided into two dimensions: others and the self. This division is supported by the literature on moral courage that distinguishes between courage regarding others- vs. self-behavior. Hence, the questionnaire was designed to assess one’s perceived ability to act/speak up in these two dimensions: (a) situations of moral courage efficacy relating to others’ behavior (e.g., “ capable of telling a senior physician if I have detected a mistake s/he might have made ”); (b) situations of moral courage efficacy relating to self (e.g., “ capable of disclosing my mistakes to a senior physician ”). This two-dimension division is important and was absent in former measurements of moral courage. It was also replicated in another study we conducted among MS [ 49 ]. Furthermore, factor analysis with Oblimin rotation supported this two-factor structure (Table  1 ). All items had a high factor loading on the relevant factor (it should be mentioned that item 4 was loaded 0.59 on the relevant factor and 0.32 on the non-relevant factor).

All items are rated on a 5-point Likert scale (0 = to a small extent; 4 = to a very great extent) and are calculated by averaging the answers on the dimension, with higher scores representing higher moral courage efficacy. Internal reliability was α = 0.80 for the “others” dimension and α = 0.84 for the “self” dimension.

Perceived stress —This single-item questionnaire (“How would you rate the level of stress you’ve been experiencing in the last few days?” ) evaluates MS’ perceived stress currently in their life on an 11-point Likert scale (0 = no stress; 10 = extreme stress), with higher scores representing higher perceived stress. It is based on a similar question evaluating MS’ perceived emotional stress [ 29 ]. Even though a multi-item measure might be more stable, previous studies indicated that using a single item is a practical, reliable alternative, with high construct validity in the context of felt/perceived stress, self-esteem, health status, etc [ 43 , 50 , 51 ].

Academic burnout —This 15-item instrument is a translated version [ 44 ] of the MBI-SS (MBI–Student Survey) [ 37 ], a common instrument used to measure burnout in the academic context, e.g. MS [ 52 , 53 ]. It measures students’ feelings of burnout regarding their studies on three dimensions: (a) ‘exhaustion’ (5 items; e.g., “ Studying or attending a class is a real strain for me ”), (b) ‘cynicism’ (4 items; e.g., “ I doubt the significance of my studies ”), (c) lack of personal academic efficacy (‘reduced professional efficacy’) (6 items; “ I feel [un]stimulated when I achieve my study goals ”). Each item is rated on a 7-point Likert scale (0 = never; 6 = always) and is calculated by summing the answers on the dimension (after re-coding all professional efficacy items), with higher scores representing more frequent feelings of burnout. Internal reliability was α = 0.80 for ‘exhaustion’, α = 0.80 for ‘cynicism’, and α = 0.84 for ‘reduced professional efficacy’.

Statistical analyses

IBM-SPSS (version 25) was used to analyze the data. Pearson’s correlations examined all possible bivariate associations between the study variables. PROCESS macro examined the mediation effects (via model#4). The significance of the mediation effects was examined by calculating 5,000 samples to estimate the 95% percentile bootstrap confidence intervals (CIs) of indirect effects of the predictor on the outcome through the mediator [ 54 ]. T -tests for independent samples examined differences between the study variables in the pre-clinic and clinic stages. The defined significance level was set generally to 5% ( p  < 0.05).

This study focused on understanding moral courage efficacy, i.e., MS’ perceived ability to speak up and act while exposed to others’ and their own wrongdoing. The sample’s frequencies demonstrate that only 10% of the MS reported that their moral courage efficacy toward the others was “very high to high,” and 54% reported this toward the self. Mean scores demonstrate that regarding the others, MS showed relatively low/moderate levels of moral courage and higher levels regarding the self. As for the variables tested to be associated with moral courage efficacy, MS showed relatively high perceived stress and low-to-moderate academic burnout (see Table  2 for the variables’ psychometric characteristics).

Table  2 also shows the correlations among the study variables. According to Cohen’s (1988) [ 55 ] interpretation of the strength in bivariate associations (Pearson correlation), the effect size is low when r value varies around 0.1, medium when it is around 0.3, and large when it is more than 0.5. Hence, regarding the associations between the two dimensions of moral courage efficacy: we found a moderate positive correlation between the efficacy toward others and the efficacy toward the self. Regarding the associations among the three academic burnout dimensions: we found a strong positive correlation between ‘exhaustion’ and ‘cynicism,’ a weak positive correlation between ‘exhaustion’ and ‘reduced professional efficacy,’ and a moderate positive correlation between ‘cynicism,’ and ‘reduced professional efficacy.’

As for the associations concerning H1, Table  2 indicates that one academic burnout dimension, i.e., ‘reduced professional efficacy,’ had a weak negative correlation with moral courage efficacy toward the others, thus high burnout was associated with lower perceived moral courage efficacy toward others. Additionally, perceived stress and all three burnout dimensions had weak negative correlations with moral courage efficacy toward the self—partially supporting H1.

As for the associations concerning H2, Table  2 indicates that perceived stress had a strong positive correlation with ‘exhaustion,’ a moderate positive correlation with ‘cynicism,’ and a weak positive correlation with ‘reduced professional efficacy’—supporting H2.

Based on these correlations, we conducted regression-based models to examine the unique and complex relationships among the study variable, including their various dimensions, while focusing on the examination of whether academic burnout mediates the association between perceived stress and moral courage efficacy (see Tables  3 and 4 ; and Figs.  1 and 2 ).

A model presenting the association between perceived stress and moral courage efficacy toward others, mediated by academic burnout. Note full arrows contain significant β coefficient values (fractured arrows mean nonsignificance

Focusing on moral courage efficacy toward others

Table  3  and Fig.  1 indicate that perceived stress was positively associated with all three academic burnout dimensions: ‘exhaustion’ (path a 1 ), ‘cynicism’ (path a 2 ), and ‘reduced professional efficacy’ (path a 3 ). These paths support H2. In turn, ‘reduced professional efficacy’ was negatively associated with moral courage efficacy toward the others (path b 3 ), supporting H1. The CIs of the indirect effect (paths a 3 b 3 ) did not contain zero; therefore, perceived stress had a significant indirect effect on moral courage efficacy toward the others, through the burnout dimension ‘reduced professional efficacy.’ This path supports H3.

A model presenting the association between perceived stress and moral courage efficacy towards self, mediated by academic burnout. Note full arrows contain significant β coefficient values (fractured arrows mean non-significance

Focusing on moral courage efficacy toward the self

Table  4  and Fig.  2 also indicate that perceived stress was positively associated with all three academic burnout dimensions: ‘exhaustion’ (path a 4 ), ‘cynicism’ (path a 5 ), and ‘reduced professional efficacy’ (path a 6 ). These paths support H2. In turn, ‘exhaustion’ and ‘reduced professional efficacy’ were negatively associated with moral courage efficacy toward the self (paths b 4 , b 6 respectively). These paths support H1 The CIs of the indirect effects (paths a 4 b 4 , a 6 b 6 ) did not contain zero; therefore, perceived stress had a significant indirect effect on moral courage efficacy toward the self, through the burnout dimensions ‘exhaustion’ and ‘reduced professional efficacy.’ These paths support H3. It should be noted that in this analysis, the initially significant association between perceived stress and moral courage efficacy toward the self (path c 2, representing H1) became insignificant in the existence of academic burnout dimensions (path c’ 2 ). These results demonstrate complete mediation and also support H3.

In addition to examining the complex relationships between stress, academic burnout, and moral courage efficacy among MS, we tested the differences between MS in the pre-clinical and clinical school stages in all study variables. The results indicate non-significant differences in moral courage efficacy. However, medical-school-stage differences were found in stress [t(197.4)=-4.36, p  < 0.001] and in one academic burnout dimension [t(233)=-2.40, p  < 0.01]. In that way, MS at the clinical stage reported higher levels of perceived stress ( M  = 7.32; SD  = 2.17) and exhaustion ( M  = 19.67; SD  = 6.58) than MS in the pre-clinical stage ( M  = 5.94; SD  = 2.59 and M  = 17.48; SD  = 6.78, respectively).

This study examined the associations between perceived stress, academic burnout, and moral courage efficacy to understand MS’ perceived ability to speak up and act while exposed to others’ and their own wrongdoing. The findings show that one dimension of burnout, that of ‘reduced professional efficacy,’ mediated the associations between perceived stress and moral courage efficacy toward both others and self. ‘Exhaustion’ mediated the association between perceived stress and moral courage efficacy only toward the self.

Before discussing the meanings of the associations, this study was an opportunity to explore moral courage efficacy occurrence. The findings indicated fairly low/moderate mean scores of perceived ability to speak up and act while confronted with others’ wrongdoing and moderate/high scores of perceived ability while confronted with one’s own wrongdoing. This implies that students do not feel capable enough to share their concerns regarding others’ possible errors and feel more able, but still not enough, to share their own flaws and needs for guidance. These findings require attention, from both patient safety and learning perspectives.

Regarding patient safety, feeling unable to act while confronted with others or self- wrongdoing means that some errors may occur and not be addressed. This is in line with former findings that showed that less than 50% of MS would actually approach someone performing an unsafe behavior [ 12 ], or report an error they had observed [ 15 ]. These numbers are likely to improve in postgraduates as studies showed that between 64 and 79% of interns and residents reported they would likely speak up to an attending when exposed to a safety threat [ 56 , 57 ].

Regarding learning, our MS’ scores must improve for various reasons. First, moderate scores may indicate a psychologically unsafe learning environment, which prevents or discourages sharing uncertainties, especially about others’ behavior, and creates difficulty for students to share their own concerns, limitations, mistakes, and hesitations when feeling incapable or unqualified for a task [ 58 ]. Second, limited sharing of errors may be problematic because by not disclosing their error, students miss the chance to learn from it; [ 59 ] they lose the opportunity for reflective guidance to explore what worked well, what did not, and how to improve [ 59 , 60 ]. Third, if they do not discuss others’ errors or their own, they may deny themselves the necessary support to learn the all-important skills of how to deal with the emotional turmoil and challenges of errors, and how to share the error with a patient or family member [ 61 ]. Furthermore, if MS feel incapable of sharing their concern about a senior’s possible mistake, they miss other learning opportunities—e.g., the senior’s reasoning and clinical judgment may show that a mistake was not made. In this case, the student would miss being shown why they were wrong and what they did do well. Thus, identifying what can enhance moral courage efficacy and practice is needed. The fact that there are no significant differences between pre-clinical and clinical years students in their perceived ability to apply moral courage, may indicate that there is a cultural barrier in perceiving the idea of sharing weakness or of revealing others’ mistakes as unacceptable. Thus, the socialization, in the medical school environment, both in pre-clinical and clinical years, perhaps lacks the encouragement to speak up and provision of safe space.

This study examined the associations between perceived stress, academic burnout, and moral courage efficacy among MS. The findings indicate that, like earlier studies, stress is not directly connected to speaking up [ 62 ] or moral courage. It rather contributes to it indirectly, through the impact of burnout. Beyond the well-established role of stress in explaining burnout [ 63 , 64 ], we identified a negative consequence of burnout—hindering moral courage efficacy. This may help explain the path in which previous studies found burnout to impair MS’ quality of life, how it leads to dropout, and to more medical errors [ 65 ]. When individuals experience the burnout dimension of ‘reduced professional efficacy,’ they may feel less confident and fit, leading them to feel more disempowered to take the risk (required in courage) and share their concerns and hesitations about others’ mistakes and their own challenges. This fits earlier studies indicating that being a young professional experiencing “lack of knowledge” or “unfamiliarity” with clinical subtleties is a barrier to moral courage [ 11 ]. This may have various negative implications, of limited moral courage efficacy, as seen here, as well as paying less attention and not fully addressing their learning needs, leading to a vicious cycle of “feeding” the misfit feeling, potentially increasing their moral distress. Furthermore, those who feel they know less and, therefore, need more support to fill the gap in knowledge and skills, are less inclined to ask for help.

Beside the negative associations between ‘reduced professional efficacy’ and both dimensions of moral courage efficacy (toward others and the self), another dimension of academic burnout—‘exhaustion’—was negatively associated with moral courage efficacy toward the self. This is worrying because when learners are exhausted, their attention is reduced and they are at greater risk of error, as proven in an earlier study [ 65 ]. The current study adds to this information another worry, showing that MS are less willing to share their hesitations about themselves or the mistakes they already made, thus perhaps not preventing the error or fixing it. MS might create an unspoken contract with senior physicians about not exposing each other’s mistakes, with various possible negative implications. Some MS’ tendency to defend physicians’ mistakes was identified elsewhere [ 66 ].

The findings concerning medical-school-stage differences demonstrated that MS in the clinical stage had higher perceived stress and exhaustion levels than MS in the pre-clinical stage. These results support previous studies indicating stress, academic burnout, and more challenging characteristics among more senior students, including a decline in ideals, altruistic attitudes, and empathy during medical school studies; or more exhaustion, cynicism, and higher levels of detached emotions and depression through the years of medical school [ 67 , 68 , 69 ]. These higher levels of stress and exhaustion, can be explained by the senior students’ exposure to the rounds in the hospitals, which requires ongoing learning, more pressure, and a sense of overload in their academic life.

Limitations and future studies

Despite the importance of the findings, the study has several limitations. First, the participants were from one university, and recruited via convenience sampling, including only MS who voluntarily completed the questionnaires, undermining generalizability. To address this limitation, future research should aim to include a more diverse and representative sample of medical students from multiple universities and geographical regions. This would enhance the external validity and applicability of the findings across different educational and cultural contexts. Second, future studies are recommended to follow up on medical students’ stress, academic burnout, and moral courage efficacy over time. Exploring the development of professional efficacy and the barriers to exposing one’s and others’ weaknesses and flaws within the medical environment can help improve the medical culture into a safer space. Third, an intriguing avenue for future research is the exploration of the construct of ‘moral courage efficacy’ within different cohorts of healthcare students throughout their undergraduate and postgraduate years to learn about their moral courage efficacy development as well as and to verify the association between the findings from this newly developed scale and actual moral courage behavior. Additionally, experimental designs, such as interventions to reduce stress and burnout among medical students, could be employed to observe the impact on moral courage efficacy.

Conclusions and implications

This study is a first step in understanding moral courage efficacy and what contributes to it. The study emphasizes the importance of promoting MS’ well-being—in terms of stress and burnout—to enhance their moral courage efficacy. The findings show that the ‘reduced professional efficacy’ mediated the association between perceived stress and moral courage efficacy, toward both the others and self. This has potential implications for safety, learning, and well-being. To encourage MS to develop moral courage efficacy that will potentially increase their morally courageous behavior, we must find ways to reduce their stress and burnout levels. As the learning and work environments are a major cause of burnout [ 38 ], it would be helpful to focus on creating safe spaces where they can share others- and self-related concerns [ 70 ]. The first step is a learning environment promoting students’ overall health and well-being [ 71 ]. Useful additions are processes that support MS while dealing with education- and training-related stresses, improving their academic-professional efficacy, and constructively helping them handle challenging situations through empathic feedback [ 70 ]. This can lead them to a stronger belief in their ability to share safety and professionalism issues, thus enhancing their learning and patient care.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The authors wish to thank Dr. Lior Rozental in helping in recruiting students to the study. This study was done as part of Orit Karnieli-Miller’s Endowed chair of the Dr. Sol Amsterdam, Dr. David P. Schumann in Medical Education, Tel Aviv University. This study is written in the blessed memory of Oshrit Bar-El, devoted to enhancing Moral Courage.

The manuscript was partially supported by a grant by the by the Israel Science Foundation (grant no. 1599/21).

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Galit Neufeld-Kroszynski and Keren Michael contributed equally to this work.

Authors and Affiliations

Department of Medical Education, Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, 69778, Israel

Galit Neufeld-Kroszynski & Orit Karnieli-Miller

Department of Human Services, Max Stern Yezreel Valley College, Yezreel Valley, Israel

Keren Michael

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GNK: conception and design, interpretation of data, drafting and revision of the manuscript, and final approval of the version to be published; KM: analysis and interpretation of data, drafting and revision of the manuscript, and final approval of the version to be published; OKM: conception and design, interpretation of data, drafting and revision of the manuscript, and final approval of the version to be published.

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Correspondence to Orit Karnieli-Miller .

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This study was conducted in accordance with the principles outlined in the Declaration of Helsinki and received ethical approval by the Ethics Committee of Tel-Aviv University on 31/10/2019. Informed written consent was obtained from all participants before their participation in this study.

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Study findings were presented at the Academy for Professionalism in Healthcare Conference, June 2nd, 2022, virtual; and the 7th International Conference on Public Health, August 8th, 2021, virtual.

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The authors declare no competing interests.

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Neufeld-Kroszynski, G., Michael, K. & Karnieli-Miller, O. Associations between medical students’ stress, academic burnout and moral courage efficacy. BMC Psychol 12 , 296 (2024). https://doi.org/10.1186/s40359-024-01787-6

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Received : 03 December 2023

Accepted : 13 May 2024

Published : 27 May 2024

DOI : https://doi.org/10.1186/s40359-024-01787-6

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