A scoping review on the relationship between mental wellbeing and medical professionalism

Figures & data

Figure 1. The scoping review consort diagram describes articles’ assortment for this review.

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram for the selection of studies in this review - PRISMA [36]

Table 1. Study eligibility criteria.

Study Characteristics	Inclusion criteria	Exclusion criteria
Period	Published within the period from January 1, 1986, to March 31, 2021.	Outside these dates
(2) Language	English	Other than the English
(3) Title	With the overwhelming theme relating to mental wellbeing and medical professionalism	Not covering both or one of the two themes (mental wellbeing or medical professionalism)
(4) Abstract	Pertaining to the original research and available in a peer-reviewed journal Pertaining to studies conducted internationally or nationally Pertaining to studies within the context of undergraduate medical education Pertaining to studies with medical students and faculty as the participants Pertaining to studies that explored and highlighted mental wellbeing and medical professionalism	Non-peer-reviewed or non-original research Ideas, editorials, opinions, case reports and reviews Pertaining to postgraduate medical education Students and faculty from other health professions
(5) Full-text	With full-text articles available Elaborated the relationship between mental wellbeing and medical professionalism With a robust analysis of the results With a well-designed exploration intervention Reported the effects of mental wellbeing on medical professionalism and/or vice versa	Failed to elaborate the relationship between mental wellbeing and medical professionalism Not having a vigorous analysis of the results. Not reporting effects of mental wellbeing on medical professionalism and/or vice versa

The title, abstract and full text can be considered suitable if they coincide with the applicable study inclusion criteria.

Table 2. List of original medical professionalism articles included as the selected studies for final evaluation with the retrieved information.

S. no.	Author	Year	Location	Aims/objective/background/ purpose (about MHDs)	Sample/study design/tools	Key findings related to the review questions
1	T Kötter, L Kiehn, KU Obst and E Voltmer [39]	2021	Germany	‘In this longitudinal study, we investigated the development of empathy during medical education and assessed [the] potential predictors of empathy at different time points in medical studies.’	43 medical students Longitudinal descriptive study Jefferson Scale of Empathy Student Version (JSE-S; available in the German language); Hospital Anxiety and Depression Scale in the German language (HADS-D); German language version of the Perceived Medical School Stress Scale (PMSS-D); AVEM (Arbeitsbezogenes Verhaltens-und Erlebensmuster [Work-Related Behaviour and Experience Pattern])	A negative association between the depression scores and the empathy scores was found. The study results confirm the earlier finding (negative relationship) regarding the association between depression and empathy at several time points in the study.
2	K Vidhukumar and M Hamza [40]	2020	India	“This study was planned to find the prevalence and correlates of burnout among [the] medical students at a Government Medical College in Kerala.”	375 medical students Cross-sectional survey-based study Copenhagen Burnout Inventory (CBI)	The learning environment and curriculum-related variables were not shown to be associated with burnout, as measured by the perceptions of teaching quality, academic performance and failure in the professional test.
3	Q Wang, L Wang, M Shi, X Li, R Liu, J Liu, M Zhu and H Wu [41]	2019	China	‘The objective of the present study is to explore the correlations of empathy and burnout with life satisfaction and the associated socio-demographic factors among Chinese undergraduate medical students.’	1,271 medical students Cross-sectional study Interpersonal Reactivity Index Chinese version (IRIC), Maslach Burnout Inventory modified Chinese version (MBI-MC), Satisfaction with Life Scale (SWLS) and socio-demographic characteristics	The medical students’ empathy levels decreased in four years, but their burnout levels remained nearly constant. Empathy was linked with pupils’ age and grade level while burnout was linked with maternal education.
4	JW Wahjudi, A Findyartini and F Kaligis [42]	2019	Indonesia	‘Empathy is critical for medical doctors, as it enables them to conduct good patient-centred care. Medical students are expected to learn this ability as part of their education and training.’	464 medical students Cross-sectional design 10-item version of the Perceived Stress Scale (PSS-10) translated into the Indonesian language; Jefferson Scale of Physician Empathy (JSPE) translated into Indonesian	The medical students’ stress levels peaked in their first year in school and then gradually declined over the next few years. The empathy levels climbed in the first three years, dropped dramatically when the students started clinical school and then surged again after the second clinical year. There were no links, however, between the stress and empathy levels.
5	WW Suh, SH Cho, JY Yoo, HS Kim, HR Song, WJ Kim, SM Lee and M Hong [43]	2019	Korea	‘The study aimed to investigate the relationship between empathy and psychosocial factors such as burnout, personality, self-esteem, and resilience.’	271 medical students Cross-sectional study Korean edition of the Jefferson Scale of Empathy student version (JSE-S-K), Maslach Burnout Inventory General Survey (MBIGS), NEO Five-Factor Inventory (NEO-FFI), Rosenberg Self-Esteem Scale (R-SES) and Connor-Davidson Resilience Scale (CD-RISC)	Conscientiousness, depersonalization, personal accomplishment, self-esteem and sex all influenced empathy. Of these, conscientiousness, depersonalisation, personal accomplishment and self-esteem significantly affected empathy.
6	P Rahmatpour, M Chehrzad, A Ghanbari and SR Sadat-Ebrahimi [44]	2019	Iran	‘We aimed to explore the incidence of academic burnout status and its associated factors among [the] Guilan University of Medical Sciences students.’	303 medical science students Cross-sectional study Maslach Burnout Inventory‑Student Survey (MBI‑SS)	Academic burnout in students was found to be substantially associated with marital status, GPA (grade point average), interest in the study field and study time. Students who are disappointed and unhappy due to academic burnout are less likely to participate in class activities, resulting in further academic burnout and lower educational success.
7	H von Harscher, N Desmarais, R Dollinger, S Grossman and S Aldana [45]	2018	USA	‘To understand the relationship between empathy (empathic concern [EC] and personal distress [PD]) and burnout in medical students’	353 medical students Longitudinal relational study Maslach Burnout Inventory (MBI) and Davis Interpersonal Reactivity Scale (IRI)	Over the course of three years, it was observed that the students with high levels of EC had statistically lower burnout scores whereas the students with high levels of PD had statistically higher burnout scores. In this study, EC was found to be associated with lower burnout and PD was found to be associated with higher burnout.
8	S Ebrahimi and F Atazadeh [46]	2018	Iran	‘This study aimed to determine the prevalence of burnout among [the] medical students of Shiraz University of Medical Sciences at the clinical level and its relationship with professionalism.’	230 medical students Cross-sectional study Dimensions of professionalism questionnaires (American Board of Internal Medicine [AIBM] questionnaire), Maslach Job Burnout Inventory	Burnout and professionalism were found to have a negative association with each other.
9	D Richardson, SM Jaber, S Chan, MT Jesse, H Kaur and R Sangha [47]	2016	USA	‘To determine how self-compassion and empathy might influence the degree of burnout, secondary traumatic stress and compassion satisfaction among medical students and residents’	88 medical students and residents Cross-sectional study Professional Quality of Life Scale (burnout, secondary traumatic stress and compassion satisfaction), Neff’s Self-Compassion Scale and the empathic concern and personal distress subscales of the Interpersonal Reactivity Index	Compassion for oneself and for those under one’s care reduces burnout and improves work satisfaction.
10	KH Park, DH Kim, SK Kim, YH Yi, JH Jeong, J Chae, J Hwang and H Roh [48]	2015	Korea	‘To examine the relationship between stress, social support, and empathy among medical students’	2,692 medical students Cross-sectional, relational study Jefferson Scale of Empathy, Perceived Stress Scale and Multidimensional Scale of Perceived Social Support	The stress and social support levels of all the students were found to be strong predictors of empathy. Furthermore, among the female students, there was no significant link between empathy and stress, and among the female students and first-year students, empathy was not significantly predicted by stress.
11	HB Paro, PS Silveira, B Perotta, S Gannam, SC Enns, RR Giaxa, RF Bonito, MA Martins and PZ Tempski [49]	2014	Brazil	“We aimed to assess medical students’ empathy and its associations with gender, stage of medical school, quality of life, and burnout.”	1,350 medical students Cross-sectional, multi-centric, relational study Questionnaires on empathy (Interpersonal Reactivity Index), quality of life (The World Health Organization Quality of Life Assessment) and burnout (Maslach Burnout Inventory)	Personal success was found to have the most significant link with reduced personal discomfort among all the variables that were analysed, and it was also a predicting variable for perspective taking. Empathy and burnout were found to have a substantial inverse relationship with each other.
12	SM Hasan, NI Al-Sharqawi, FA Dashti, M Abdulaziz, A Abdullah, M Shukkur, M Bouhaimed and L Thalib [50]	2013	Kuwait	‘To evaluate the level of empathy among [the] medical students in Kuwait University Medical School and its association with sociodemographic factors, stress levels, and personality’	264 medical students Cross-sectional study Jefferson Scale of Physician Empathy (JSPE-S) medical student English version, Zuckerman-Kuhlman Personality Questionnaire (ZKPQ-50-CC) and Perceived Stress Scale 10-item version (PSS-10)	There was no statistical link between academic achievement and degree of empathy. Students with a higher stress level scored higher on the empathy scale; thus, stress level was found to be significantly and positively connected with empathy.
13	LN Dyrbye, W Harper, C Moutier, SJ Durning, DV Power, FS Massie, A Eacker, MR Thomas, D Satele, JA Sloan, et al [31].	2012	USA	‘The study simultaneously explores the relationship between positive mental health and burnout with professionalism and personal experience.’	2,682 medical students Multi-institutional, exploratory relational study Mental Health Continuum Short Form (MHC-SF), Maslach Burnout Inventory (MBI), Medical Students’ Attitudes toward Providing Care for the Underserved (MSATU) instrument	Positive mental health was found to mitigate some of the negative effects of burnout. Non-flourishing students were more likely to have acted in an unprofessional manner (i.e., cheating and dishonest behaviours). Except for one of the seven behaviours analysed (signing an attendance sheet for a friend who was not present), mental health status did not correlate with professional conduct among the students with burnout. In general, a higher percentage of the flourishing students agreed with the five altruistic professional views about physicians’ societal responsibilities. As the students’ mental health improved, the prevalence of each professional belief grew as well. Three of the five categories involving physicians’ societal responsibilities were found to have a statistically significant relationship with mental health in the students with professional burnout. These findings imply that good mental health may help mitigate some of the detrimental effects of burnout, particularly in terms of certain characteristics of professionalism.
14	CM Brazeau, R Schroeder, S Rovi and L Boyd [51]	2010	USA	‘Medical student burnout is prevalent, and there has been much discussion about burnout and professionalism in medical education and the clinical learning environment. Yet, few studies have attempted to explore [the] relationships between those issues using validated instruments.’	105 medical students Relational study Maslach Burnout Inventory, Jefferson Scale of Physician Empathy – Student Version and the professionalism climate instrument	Burnout, empathy and professionalism climate were all found to be linked with each other. The empathy scores of the people who were burnt out were lower. The burnout scores were found to have substantially significant negative relationships with the professionalism climate scores. Students that are burnt out have a pessimistic outlook and are more inclined to doubt the professionalism of other students and of the residents and instructors in the learning environment; this attitude can also affect what they will learn. The students’ empathy levels were linked with their professionalism.
15	LN Dyrbye, FS Massie, Jr., A Eacker, W Harper, D Power, SJ Durning, MR Thomas, C Moutier, D Satele, J Sloan, et al [52].	2010	USA	‘To determine the relationship between measures of professionalism and burnout among US medical students’	2,682 medical students Multi-institutional, cross-sectional study Maslach Burnout Inventory (MBI), 2-item Primary Care Evaluation of Mental Disorders (PRIMEMD), psychometrically sound Medical Outcomes Study Short Form (SF-8, range 0–100), Medical Students’ Attitudes toward Providing Care for the Underserved (MSATU) instrument, American Medical Association (AMA) Ethical Guidelines of Gifts to Physicians from Industry	Burnout was linked with unprofessional behaviour and a lack of altruistic professional attitude among medical students. It was also found to be linked with self-reported cheating and dishonest clinical behaviour and to be inversely related to altruistic professional values related to physicians’ societal responsibilities.
16	MR Thomas, LN Dyrbye, JL Huntington, KL Lawson, PJ Novotny, JA Sloan and TD Shanafelt [53]	2007	USA	‘To determine whether [the] lower levels of empathy among a sample of medical students in the United States is associated with personal and professional distress and explore whether a high degree of personal wellbeing is associated with higher levels of empathy’	1,098 medical students Multi-institutional, cross-sectional survey Interpersonal Reactivity Index (IRI), Maslach Burnout Inventory and Linear Analogue Self-Assessment (LASA), a 10-item questionnaire measuring quality of life	Empathy was found to be inversely connected to the burnout domains. Medical student empathy was found to be linked with both discomfort and well-being. Rather than advancement through the training curriculum alone, the decline in empathy was found to be linked with student discomfort and quality of life. Burnout in the workplace may be more closely linked with loss of empathy than sadness is.

Figure 2. Graphic representation of themes and subthemes yielded as a result of text interpretations.

Figure 3. Illustrative depiction of the interrelationship model of mental well-being and medical professionalism attributes.

Table 3. The most utilised data collection tools within the included studies.

Inventory/survey	Studies
Maslach Burnout Inventory	[31,41,43–46,49,52–54]
Jefferson Scale of Empathy	[39,42,43,48,50,54]
Interpersonal Reactivity Index	[41,47,49,53]
Perceived Stress Scale	[42,48,50]
Medical Students’ Attitudes toward Providing Care for the Underserved (MSATU) instrument	[31,52]

Table

Appendix A
Details of finalised search strategy and tools utilised 1986–2021
DATABASE	SEARCH TERMS/STRINGS	DOCUMENTS RETRIEVED
Web of Science	ALL=(‘mental wellbeing’ OR ‘medical professionalism’ AND ‘undergraduate’ AND ‘student’) Refined by: Document type: Articles Language: English Publication year: 1986–2021 Web of Science category: Psychology Clinical or Psychiatry QUERY LINK: https://www.webofscience.com/wos/woscc/summary/dea1a98d-7a37-4a10-822c-cca81ef811ac-10699566/relevance/1	n = 6,234
PubMed	(((((((((((”Health”[Mesh]) OR “Health/psychology”[Mesh]) OR (”Mental Health/standards”[Mesh] OR “Mental Health/trends”[Mesh])) OR “Burnout, Professional”[Mesh]) OR “Occupational Stress/education”[Mesh]) AND (”Professionalism/education”[Mesh] OR “Professionalism/standards”[Mesh] OR “Professionalism/trends”[Mesh])) OR “Ethics, Medical”[Mesh]) OR “Professional Misconduct/trends”[Mesh]) OR “Professional Competence”[Mesh]) AND “Students, Medical”[Mesh]) AND “Education, Medical, Undergraduate”[Mesh]) OR (”Education, Medical, Undergraduate/standards”[Mesh] OR “Education, Medical, Undergraduate/trends”[Mesh]) Filters: Journal article, within the period from 1986 to 2021	n = 5,795
ScienceDirect	‘mental AND wellbeing’ AND ‘medical AND professionalism’ AND ‘undergraduate’ AND ‘medical AND student’ Published within the period from 1986 to 2021	n = 629 This search history was saved on the ScienceDirect website (My search history).
Scopus	ALL (‘mental AND wellbeing’ AND ‘medical AND professionalism’ AND ‘undergraduate’ AND ‘medical AND student’)	n = 418

Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLOS Med. 2009;6(7):e1000097.

 PubMed Web of Science ®Google Scholar

Kötter T, Kiehn L, Obst KU, et al. The development of empathy and associated factors during medical education: a longitudinal study. J Med Educ Curric Dev. 2021;8:23821205211030176.

 Web of Science ®Google Scholar

Vidhukumar K, Hamza M. prevalence and correlates of burnout among undergraduate medical students - a cross-sectional survey. Indian J Psychol Med. 2020;42(2):122–127.

 PubMedGoogle Scholar

Wang Q, Wang L, Shi M, et al. Empathy, burnout, life satisfaction, correlations and associated socio-demographic factors among Chinese undergraduate medical students: an exploratory cross-sectional study. BMC Med Educ. 2019;19(1):341.

 PubMed Web of Science ®Google Scholar

Wahjudi JW, Findyartini A, Kaligis F. The relationship between empathy and stress: a cross-sectional study among undergraduate medical students. Korean J Med Educ. 2019;31(3):215–226.

 PubMedGoogle Scholar

Suh WW, Cho SH, Yoo JY, et al. Relationship between psychological correlates and empathy in medical students: a cross-sectional study. Psychiatry Investig. 2019;16(10):766–772.

 PubMed Web of Science ®Google Scholar

Rahmatpour P, Chehrzad M, Ghanbari A, et al. Academic burnout as an educational complication and promotion barrier among undergraduate students: a cross-sectional study. J Educ Health Promot. 2019;8:201.

 PubMedGoogle Scholar

von Harscher H, Desmarais N, Dollinger R, et al. The impact of empathy on burnout in medical students: new findings. Psychol Health Med. 2018;23(3):295–303.

 PubMed Web of Science ®Google Scholar

Ebrahimi S, Atazadeh F. Medical students’ occupational burnout and its relationship with professionalism. J Adv Med Educ Prof. 2018;6(4):162–167.

 PubMedGoogle Scholar

Richardson D, Jaber SM, Chan S, et al. Self-compassion and empathy: impact on burnout and secondary traumatic stress in medical training. Open J Epidemiol. 2016;06:161–166.

 Google Scholar

Park KH, Kim DH, Kim SK, et al. The relationships between empathy, stress and social support among medical students. Int J Med Educ. 2015;6:103–108.

 PubMed Web of Science ®Google Scholar

Paro HB, Silveira PS, Perotta B, et al. Empathy among medical students: is there a relation with quality of life and burnout? PLoS ONE. 2014;9(4):e94133.

 PubMed Web of Science ®Google Scholar

Hasan SM, Al-Sharqawi NI, Dashti FA, et al. Level of empathy among medical students in Kuwait University, Kuwait. Med Princ Pract. 2013;22:385–389.

 PubMed Web of Science ®Google Scholar

Dyrbye LN, Harper W, Moutier C, et al. A multi-institutional study exploring the impact of positive mental health on medical students’ professionalism in an era of high burnout. Acad Med. 2012;87(8):1024–1031. DOI:10.1097/ACM.0b013e31825cfa35

 PubMed Web of Science ®Google Scholar

Brazeau CM, Schroeder R, Rovi S, et al. Relationships between medical student burnout, empathy, and professionalism climate. Acad Med. 2010;85(10 Suppl):S33–36.

 PubMed Web of Science ®Google Scholar

Dyrbye LN, Massie FS Jr., Eacker A, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA. 2010;304(11):1173–1180. DOI:10.1001/jama.2010.1318

 PubMed Web of Science ®Google Scholar

Thomas MR, Dyrbye LN, Huntington JL, et al. How do distress and well-being relate to medical student empathy? A multicenter study. J Gen Intern Med. 2007;22(2):177–183.

 PubMed Web of Science ®Google Scholar

Brazeau CM, Schroeder R, Rovi S, et al. Relationships between medical student burnout, empathy, and professionalism climate. Acad Med. 2011;86(10 Suppl):S42–45.

 PubMed Web of Science ®Google Scholar