Introduction

As Hainan Province approaches its 2025 milestone of becoming a fully operational free trade port, the local government has implemented streamlined market access policies for foreign medical and health equipment, alongside legal and visa facilitation measures to support international medical teams’ operations [1]. These initiatives not only provide global medical research institutions with expedited access to China’s vast healthcare market, but also drive substantial improvements in regional healthcare quality and public health infrastructure. Concurrently, they necessitate an upgraded framework for medical talent cultivation, aligning with the heightened demands of this transformative development.

The medical education process constitutes a prolonged, high-stress endeavor. The inherent monotony of medical curricula coupled with heavy academic workloads leads to significant attrition rates, resulting in substantial waste of educational resources and reduced physician workforce output. Excessive academic stress precipitates and exacerbates academic burnout – a critical determinant of learning quality in health professions education [2]. Burnout manifests through three core dimensions: emotional exhaustion, cynicism, and reduced professional efficacy [3].Medical students’ burnout demonstrates strong correlations with stress [4], with contributing factors including course load, assignments, and examination pressures [5,6]. Medical student burnout poses a significant threat not only to the students’ own mental health and professional/academic efficacy [7], but also to the healthcare workforce supply and the smooth functioning of medical systems within their regions. Significant burnout is prevalent from the outset of medical training [8]. Multi-institutional studies indicate an overall burnout prevalence rate of 37.23% among medical students [9], with at least 50% potentially meeting burnout criteria at some point during their studies [10–13]. Compared to students in other disciplines, medical students exhibit a burnout rate 14% higher [14]. Following graduation, burnout rates rise from 56% to 60% among resident physicians, showing only a slight improvement (to 51%) within the first five years of clinical practice [14]. Furthermore, medical students experience higher rates of burnout compared to their age-matched general population peers [15]. One factor associated with burnout is stress [16]. Research demonstrates that burnout, a chronic stress response, leads to dysregulation in immune, cardiovascular, neuroendocrine, and central nervous system functions [17]. Numerous studies have explored the relationship between stress and burnout [18]. Residents experience substantial stress during training, which ultimately diminishes their job satisfaction, increases burnout, and significantly negatively impacts both their mental well-being and the quality of patient care [19,20]. Importantly, research has established that medical students perceive significantly higher stress levels on average than their peers [21], and students report experiencing considerable stress starting from the very first year of medical education [22].In China, 55.16% of university students exhibit academic burnout (mild: 55.16%, severe: 3.55%, extreme: 1.28) [23]. However, no prior studies have investigated stress-burnout dynamics among Hainan medical students. This study addresses this knowledge gap by examining:Stress-burnout relationships in Hainan medical students under Free Trade Port developmentand Socio-demographic moderators of academic stress and burnout. Findings provide empirical support for designing targeted mental health interventions, crucial for sustaining healthcare workforce development in China’s biggest free trade port.

Materials and methods

Results

This study included 551 participants, with demographic characteristics showing a female predominance (64.2%) and a majority of sophomore students (62.8%), as detailed in Table 1. Participants demonstrated a mean academic stress score of 38.69 ± 7.88 and an average burnout score of 59.96 ± 11.03. While no significant stress variations were observed across socio-demographic variables. Significant differences in academic burnout emerged based on only-child status (t = −2.24,p = 0.03), GPA (t = 6.20,p < 0.001), and maternal education (t = 4.07, p = 0.02), with complete distributions presented in Table 2.

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Table 1. Demographic characteristics of study participants.

https://doi.org/10.1371/journal.pone.0335682.t001

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Table 2. Analysis of burnout disparities across socio-demographic variables in medical students.

https://doi.org/10.1371/journal.pone.0335682.t002

Table 3 displays the correlation coefficients between participants’ average stress and academic burnout, as well as the relationships between burnout dimensions and stress components. Results demonstrated a significant positive correlation between overall stress and academic burnout (r = 0.526, p < 0.01), with positive associations observed across all burnout subscales. However, statistical significance was not reached for the following relationships: the ”Low Academic Efficacy” burnout dimension with overall stress (r = 0.513), the perceived tension component of stress (r = 0.521), and the sense of helplessness stress component (r = 0.457).

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Table 3. Correlation analysis between stress and academic burnout.

https://doi.org/10.1371/journal.pone.0335682.t003

Linear regression analysis was conducted to examine the predictive relationships between socio-demographic variables and academic burnout, assessing both the magnitude and directional effects of these predictors. The outcomes of the regression equations are comprehensively detailed in Table 4. As shown in Table 4, GPA < 2 (β = 0.120, p = 0.001), GPA 2–2.49 (β = 0.112, p = 0.002), and perceived stress (β = 0.542, p < 0.01) emerged as significant predictors of academic burnout (F = 36.464, p < 0.001) among Hainan medical students. This regression model collectively explained 34.0% of the total variance in burnout severity. Among the three dimensions of burnout, the predictive factors for the emotional exhaustion dimension were a GPA < 2 (β = 0.083, p = 0.029) and stress (β = 0.464, p < 0.001). For the cynicism dimension, significant predictors included only-child status (β = 0.109,p = 0.006), GPA < 2.0 (β = 0.100, p = 0.009), GPA 2.0–2.49 (β = 0.133, p = 0.001), and stress (β = 0.403, p < 0.001). The low academic efficacy dimension was predicted by GPA < 2.0 (β = 0.132, p < 0.001), GPA 2.0–2.49 (β = 0.178, p = 0.041), and stress (β = 0.506, p < 0.001).

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Table 4. Analysis of burnout disparities across socio-demographic variables in medical students.

https://doi.org/10.1371/journal.pone.0335682.t004

The regression model revealed that GPA < 2.0, GPA between 2.0–2.49, and stress significantly predicted academic burnout, collectively accounting for 34.0% of the variance in overall burnout. Regarding emotional exhaustion, GPA < 2.0 and stress emerged as predictors of cynicism, explaining 22.6% of the variance in emotional exhaustion. For the cynicism dimension, only-child status (β = 0.09), GPA < 2.0, GPA 2.0–2.49, and stress jointly predicted behavioral disengagement, contributing to21.8% of the variance in cynicism. In terms of low academic efficacy, GPA < 2.0, GPA 2.0–2.49, and stress were all significant predictors, explaining 29.7% of the variance in this dimension (Table 4).

Discussion

This study investigated the relationship between stress and academic burnout among medical students. The results showed that the mean stress score of participants was 38.69 ± 7.88, with 34.84% (n = 192) scoring 43−56 indicating high stress levels, and 0.54% (n = 3) scoring 57 demonstrating clinically significant stress. These findings indicate that the surveyed medical students exhibited moderate stress levels, which aligns with Sarah Salih’s research [28] reporting comparable stress profiles in medical students. However, divergent findings exist in other studies where stress prevalence reached 66.8% [29]. This discrepancy may be attributed to the COVID-19 pandemic context, during which medical students faced heightened stress due to pandemic-induced mortality rates and frontline healthcare challenges.

This study revealed medical students’ mean academic burnout score of 59.96 ± 11.03 points. Using the sample median (60points) as the cutoff, 60.66% of participants exceeded this threshold indicating significant burnout. These results suggest elevated academic burnout levels among medical students in Hainan.The literature indicates that many medical students are at risk of burnout or are currently suffering from it [30–32]. However, some literature shows that the overall burnout level among medical students is only 14% [33]. Zaidi reported that the incidence of burnout among medical students reached 52.5% [34]. In a national survey in Israel, the incidence of academic burnout among medical students was 50.6% [35]. Another survey conducted in Romania reported a burnout prevalence rate of 47.8% among medical students [36]. Medical students face numerous stress-related challenges during their studies. These challenges include heavy academic workloads, examinations, internships in hospitals, and night-shift internships. To adjust the mental health status of medical students and alleviate burnout, it is necessary to make adjustments and plans for the medical curriculum. Medical students are usually in a vulnerable stage of life (aged 18–24), during which they are more prone to mental health problems [37].

Also, the study revealed significant variations in academic burnout levels across different GPA groups, with lower-academic performing students demonstrating higher burnout scores, necessitating institutional focus on academically at-risk populations—a pattern consistent with Calcides [38] and Puranitee [39], where academic underachievement and examination failures were identified as burnout catalysts [12]. Contrary to Thun-Hohenstein and Gil-Calder´on’s reports [40,41], no gender- or grade-level disparities in burnout were observed. Methodologically, convenience sampling may introduce selection bias in this research. The results of this study show that different educational levels of parents can affect students’ burnout. The higher the educational level of the mother, the lower the students’ scores in the burnout, dimensions of Cynicism and Low Academic Efficacy. In the existing literature investigation, obtaining support from the family is also a protective factor for students to alleviate burnout [42], and feeling unable to obtain support from the family can also be a protective factor for students to alleviate burnout [43].

This reseach demonstrated a positive correlation between stress and academic burnout scores, specifically indicating that increased stress levels and increased burnout at the same time—a pattern consistent with prior observations in other populations [44,45], suggesting that when doctors are in a state of high professional burnout, their sense of stress is also at a high level. When stress increases, burnout also reaches a high level [46]. Medical education’s unique demands, extending beyond theoretical memorization to intensive basic medical experimentation, significantly amplify academic pressures. In a study investigating the role of stress in burnout, Burnout during rural placement may be a consequence of stress prior to a medical school the placement [47], and the transition to the clinical internship stage is highly stressful for medical students [48].

The regression results are same with the research results of seo [49] and Popa-Velea [45]. Stress can predict academic burnout, similarly, a GPA < 2 and GPA from 2–2.49 can predict academic burnout. The research by Puranitee shows a negative correlation between GPA and academic burnout [39]. Aljadani’s regression study indicates that a higher GPA leads to a lower burnout score [50], and academic performance is also a protective factor for burnout symptoms [51]. To explain this finding, it can be considered that stress and academic performance are crucial to the emergence of burnout symptoms. A lower sense of stress and higher academic performance provide a basis for the reduction of burnout. If the sense of stress among medical students is reduced, their sense of burnout in their studies will be alleviated, and the improvement of academic performance will also affect sense of burnout. When studying the relationship between burnout and academic performance, Thew pointed out that not only grades but also excessive examinations can cause learning burnout [52]. Therefore, helping medical students reduce stress and improve their academic performance could help them avoid academic burnout.

The study demonstrated relationships across burnout dimensions: GPA < 2 and stress significantly predicted emotional exhaustion; only-child status, GPA < 2, GPA 2–2.49, and stress influenced cynicism; while GPA < 2, GPA 2–2.49, and stress predicted low academic efficacy. These findings align with Obregon’s identification of curriculum misalignment as causal to emotional exhaustion/cynicism [53], and Seo’s confirmation of educational/relational stressors impacting all burnout dimensions [50]. Notably, Popa-Velea identified stress as the strongest predictor of exhaustion/low academic efficacy, with perceived social support deficits (particularly among females) driving cynicism [51]. In the research university, Institutional policy changes—shifting from a 40% written exam/60% regular performance pass standard (pre-March 2024) to mandatory 60% written exam thresholds under April’s medical education reform—exacerbated academic stress and indirectly intensified burnout. Contradictory evidence suggests academic performance may only correlate with burnout, as higher GPA students (3.51–4.00) showed lower total burnout scores [53].

Medical students should be cognizant that sustained academic stress and suboptimal academic performance (GPA < 2) substantially increase burnout risks, with chronic underachievement potentially triggering psychological distress through repeated academic setbacks—necessitating systematic interventions targeting burnout etiology for successful educational outcomes. Medical institutions must implement curricular reforms including streamlined curricula, reduced assignment loads, and enhanced extracurricular engagement, while recruiting PhD-qualified faculty to improve instructional quality. Concurrently, stress mitigation requires infrastructural enhancements: provision of sufficient study spaces with air conditioning and drinking water, need-based scholarships for economically disadvantaged students, and institutionalization of mindfulness-based stress reduction programs through campus psychological services. These evidence-based strategies—shown to reduce burnout prevalence—not only foster mental health resilience but also improve licensure exam pass rates, ultimately supporting healthcare workforce development for the Hainan Free Trade Port initiative through increased graduate competency retention.

This investigation has several notable limitations, primarily its single-center design at one medical university which restricts generalizability, compounded by convenience sampling methodology that may introduce selection and sampling biases—thus caution is warranted in interpreting the findings given the non-randomized participant selection and absence of multi-institutional representation. Additional constraints include unmeasured confounders such as personality traits, pre-existing mental health conditions, and medication histories that might influence stress-burnout dynamics.

Future longitudinal multicenter studies should incorporate comprehensive psychosocial assessments to identify novel mediators in medical students’ stress-burnout pathways while controlling for these omitted variables.

Conclusion

This study revealed significant disparities in medical students’ academic burnout across socio-demographic variables, with only-child status, GPA, and maternal education level demonstrating differential impacts, while stress exhibited consistent correlations across all dimensions. Specifically, emotional exhaustion showed GPA-stratified differences (GPA < 2, GPA 2–2.49) and stress association. Cynicism varied by only-child status, GPA thresholds (GPA < 2, 2–2.49), and parental education correlating with stress. Reduced academic efficacy displayed class-leadership, GPA (GPA < 2, 2–2.49), and dual-parent education effects (maternal, paternal), maintaining stress correlation. The predictive capacity of stress and GPA on medical students’ burnout necessitates institutional reforms in curricular structures and pedagogical approaches to mitigate stressors and enhance academic performance. Notably, only-child status emerged as a significant predictor in the cynicism dimension compelling medical educators to integrate these socio-academic determinants when redesigning training programs for burnout prevention. Therefore, medical students should receive support from administrators to reduce stress and improve academic performance in order to reduce academic burnout.

Acknowledgments

The authors wish to thank the medical students who participated in the project and completed the questionnaire.