Medical students with higher levels of distress (burnout) were more likely to self-report unprofessional conduct related to patient care and less altruistic professional values, according to a study in the September 15 issue of JAMA, a theme issue on medical education.

"Professionalism is a core competency for all physicians. Professionalism includes being honest, acting with integrity, advocating for the needs of patients, reducing barriers to equitable health care, and adhering to an ethical code of conduct," the authors write. "Despite the widely acknowledged importance of professionalism, how personal distress (such as depression or low mental quality of life [QOL]) and professional distress (such as burnout) relate to professionalism is largely unexplored."

Liselotte N. Dyrbye, M.D., M.H.P.E., of the Mayo Clinic College of Medicine, Rochester, Minn., and colleagues conducted a study that measured multiple dimensions of professionalism and assessed its relationship to burnout and other measures of distress. The study included a survey of all medical students attending 7 U.S. medical schools (overall response rate, 2,682/4,400 [61 percent]) in the spring of 2009. Items measured and assessed in the survey included burnout, depression, quality of life, as well as items exploring students' personal engagement in unprofessional conduct, understanding of appropriate relationships with industry, and attitudes regarding physicians' responsibility to society. Among the outcomes assessed included frequency of self-reported cheating/dishonest behaviors and understanding of appropriate relationships with industry as defined by American Medical Association (AMA) policy.

Of the students who responded to the inventory regarding burnout, 1,354 of 2,566 (52.8 percent) had burnout. The researchers found that cheating/dishonest academic behaviors were rare (endorsed by less than 10 percent) in comparison to unprofessional conduct related to patient care (endorsed by up to 43 percent). Only 14 percent (362/2,531) of students' opinions on relationships with industry aligned with the AMA policy for 6 scenarios.

Students with burnout were significantly more likely to have engaged in each of the cheating/dishonest clinical behaviors evaluated (with the exception of taking credit for another person's work), such as copying from a crib sheet or from another student during an exam; or reporting a physical examination finding as normal when it had been omitted. Students with burnout were more likely to report engaging in 1 or more unprofessional behaviors than those without burnout (35.0 percent vs. 21.9 percent). Burned-out students were also less likely to hold altruistic views regarding physicians' responsibility to society, including personally wanting to provide care for the medically underserved (79.3 percent vs. 85.0 percent).

"Burnout was the only aspect of distress independently associated with report of 1 or more cheating/ dishonest clinical behaviors or with disagreeing with 1 or more altruistic attitudes regarding physicians' responsibility to society after adjusting for demographic characteristics (sex, age, parental status, marital status, year in school, student debt load), burnout, positive depression screen, mental QOL, and physical QOL," the authors write.

"In this large, multi-institutional study, self-reported cheating and dishonest clinical behaviors showed a direct association with burnout, while altruistic professional values regarding physicians' responsibility to society showed an inverse relationship with burnout," the researchers write. "In addition to exploring these associations further, future research should investigate whether interventions designed to reduce burnout help students cultivate professional values and behavior."