Introduction

Burnout syndrome is defined as a “psychological syndrome that implies emotional exhaustion, cynicism and a feeling of little personal accomplishment, in people who perform their work in dynamic relationships with other people, in professionally demanding situations” [1]. Symptoms of emotional exhaustion are central and accompanied by depersonalization and a feeling of reduced personal accomplishment [2,3]. Emotional exhaustion is marked by a feeling of emotional overspending due to work. Depersonalization is characterized by emotional indifference and dehumanization of those receiving services. Reduced personal achievement is reflected in feelings of professional stagnation, incompetence and lack of fulfillment. Emotional exhaustion refers to feeling emotionally “stretched” and exhausted from contact with other people and it represents the “stressful” component of burnout. Depersonalization (i.e., cynicism, dehumanization), representing the interpersonal component of burnout, involves emotional distance in professional roles and refers to an emotionless and indifferent attitude towards those receiving help, which can turn into rude or even inappropriate behavior toward patients, as well as other people at work [2,4]. Reduced personal accomplishment, the self-evaluative component of burnout, refers to the perceived decline in skillfulness and successful achievement at jobs that involve working with people, which can lead to a profound sense of failure, due to persistent relational stressful events at workplace [2–4].

Due to intense, strenuous studying and psychophysical exhaustion, medical students may experience a certain degree of burnout syndrome, as academic stress. Burnout can have serious professional and personal consequences – it can affect students’ attitudes toward a career in medicine, and lead to thoughts of dropping out, depression, alcohol and drug abuse and suicide [5,6]. Among medical students, burnout often arises from the intense stress they have experienced and the expectations of high standards placed on individuals involved in careers in helping professions [2,7]. The medical school curriculum and some components of training/practice can lead to chronic stress and burnout in some medical students [8,9]. Some studies report that, in the developed world, at least every second medical student experiences some form of burnout during their studies [10–13].

A meta-analysis that pooled data from 24 studies, comprising 17,431 medical students, found high prevalence of emotional exhaustion, depersonalization and personal accomplishment (40.8%, 35.1% and 27.4%, respectively) [11]. More recently, one larger meta-analysis showed that the frequency of emotional exhaustion, depersonalization, and personal accomplishment in medical students was 38.08%, 35.07%, and 37.23%, respectively [14].

Some studies have reported associations between burnout prevalence and gender [14,15], year of study [16,17], personal life events and the learning environment [18], but results were not consistent [11,19,20]. Additionally, some authors found no association between burnout and marital status, smoking, presence of chronic diseases in personal health history or completed high school [15]. Among students, findings regarding the association between burnout dimensions and gender are conflicting. While some authors [21] reported a significant association between male gender of students and depersonalization, other authors found no significant association [14,18].

Studies on burnout syndrome among medical students in Serbia are relatively scarce, and only a few of have utilized the validated MBI-SS questionnaire [19]. Existing research shows that burnout is prevalent in medical students in Serbia, with studies reporting high rates of emotional exhaustion, cynicism, and academic inefficacy [20,21]. Factors contributing to this risk include older age, alcohol use, stress related to training conditions, specific factors such as male gender and higher study years, but these findings have not been consistent across studies [20–22]. This study aimed to assess the prevalence of high levels of emotional exhaustion, cynicism, and academic ineffectiveness among medical students in Serbia, as well as their association with characteristics of medical students.

Methods

Results

Table 1 presents the triad of symptoms of burnout syndrome. Mean subscale scores were: MBI EE (12.8 ± 7.2; range 0–30), MBI CY (3.6 ± 4.9; range 0–24) and MBI rAE (9.1 ± 8.3; range 0–36).

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Table 1. A cross-sectional study of burnout syndrome in medical students: mean of MBI-SS subscale scores.

https://doi.org/10.1371/journal.pone.0344119.t001

According to the risk categories for burnout syndrome, a high risk of emotional exhaustion was recorded in 308 medical students (40.5% of respondents) (Table 2). The cynicism subscale showed a high risk of burnout in 266 participants (i.e., 35.0%). The academic inefficacy subscale showed that 37.7% of students were in the high risk of burnout category.

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Table 2. Level of risk for burnout syndrome in medical students, by subscales.

https://doi.org/10.1371/journal.pone.0344119.t002

A significant association was found between gender and lower cynicism: compared to men, fewer women showed high levels of cynicism (31.6% vs. 41.3%; p = 0.007) (Table 3). Age significantly correlated with all three burnout dimensions – cynicism and academic inefficacy increased significantly with age (p < 0.001), while emotional exhaustion decreased significantly with age (p < 0.001). The self-funded way of study financing was significantly associated with greater cynicism and greater academic inefficacy (p < 0.05).

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Table 3. Distribution of medical students with a high burnout score by domain and by sociodemographic characteristics.

https://doi.org/10.1371/journal.pone.0344119.t003

Senior academic year, average length of study, training level, and number of exams passed were significantly associated with high emotional exhaustion, high cynicism, and high academic ineffectiveness (p < 0.05) (Table 4). Re-enrollment of a study year was associated with high cynicism and academic inefficacy. A higher GPA was significantly associated with lower cynicism and academic inefficacy (p < 0.05).

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Table 4. Distribution of medical students with a high burnout score by domain and by academic performance.

https://doi.org/10.1371/journal.pone.0344119.t004

Compared to non-smokers, cigarette smokers more frequently exhibited high cynicism (40.7% vs. 32.3%; p = 0.023), and high academic inefficacy (43.6% vs. 35.0%; p = 0.022) (Table 5). Medical students who consumed alcohol more frequently showed high emotional exhaustion (p = 0.001), high cynicism (p = 0.003), and high academic inefficacy (p = 0.013). A positive personal medical history (for the presence of any chronic disease) was significantly associated with high academic inefficacy (p = 0.017). Sedative use was significantly associated with high emotional exhaustion (p = 0.026), high cynicism (p = 0.001), and lower academic efficacy (p = 0.022). Substance use showed significant associations with all three dimensions of burnout, with medical students who used psychoactive substances showing high emotional exhaustion (p = 0.046), high cynicism (p = 0.002), and high academic inefficacy (p = 0.029).

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Table 5. Distribution of medical students with a high burnout score by habits and personal medical history.

https://doi.org/10.1371/journal.pone.0344119.t005

The risk for high level for all three burnout dimensions (emotional exhaustion, cynicism, and academic inefficacy) in medical students was significantly increased with higher frequency of alcohol consumption (p for trend = 0.008, p = 0.030, p = 0.040, respectively) (Table 6). Risk for high level of emotional exhaustion was associated with clinical training level of studies (OR = 1.82, 95%CI = 1.38–2.80, p = 0.007) and use of sedatives (OR = 3.08, 95%CI = 1.29–7.38, p = 0.011). Among medical students, length of study >6 years was associated with high risk of cynicism (OR = 1.98, 95%CI = 1.08–3.62, p = 0.027). Also, the use of sedatives was linked to high risk of cynicism in study participants (OR = 3.19, 95%CI = 1.31–7.75, p = 0.010). A higher grade point average (>8) was significantly more frequently reported by medical students with lower risk of academic inefficacy (OR = 0.65, 95%CI = 0.44–0.95, p = 0.026). Positive personal medical history (presence of any chronic disease) was significantly more often noted in study participants who had high risk of academic inefficacy (OR = 2.45, 95%CI = 1.30–4.61, p = 0.006).

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Table 6. High burnout score by domains, according to multivariate logistic regression analysis.

https://doi.org/10.1371/journal.pone.0344119.t006

Discussion

This study revealed that high level of all three burnout dimensions (emotional exhaustion, cynicism, and academic inefficacy) was significantly associated with higher frequency of alcohol consumption among medical students. The risk for high level of emotional exhaustion was associated with clinical training level of studies and use of sedatives. High level of cynicism in medical students was significantly associated with the length of study of >6 years and use of sedatives. Medical students who had high risk of academic inefficacy more often reported a positive personal medical history (presence of any chronic disease).

A recent meta-analysis on burnout among medical students reported current prevalence of 40.8% for emotional exhaustion, 35.1% for cynicism, and 27.4% for personal achievement [11]. Similarly, a study in medical and dentistry university students found overall prevalence of burnout syndrome dimensions to be 55.4%, 31.6% and 30.9% for emotional exhaustion, cynicism, and academic efficacy, respectively [26]. In line with these findings, the present study, using the MBI-SS questionnaire, reported prevalence of high risk of 40.5% for emotional exhaustion, 35.0% for cynicism and 37.7% for academic inefficiency. When compared to medical students in Kragujevac, those studying at two universities in Brazil [27,28], the United Kingdom [29], Saudi Arabia [18] and Malaysia [30] exhibited higher prevalence of emotional exhaustion, cynicism and academic inefficacy. In contrast, dentistry students in Turkey [31,32] and medical students in Colombia [33] showed lower prevalence rates. Among general medicine students from four hospitals and universities of medicine in Hungary, 38.6% showed medium or high emotional exhaustion, 34.0% cynicism and 24.0% reduced academic efficiency [34]. Several factors may account for the observed variations in the frequency of dimensions of burnout syndrome in medical students. These include differences across countries, in study populations, culture and socio-economic status. Another explanation could be the high level of heterogeneity in research on medical students’ burnout. For instance, while some studies included medical students from only one or only a few study years, the present study encompassed students from all six years of study. Moreover, studies have employed different instruments for measuring burnout and applied varying cutoff-criteria for burnout. A challenge in comparing findings across studies may also be in the use of different definitions of burnout. While some authors assessed burnout using all three dimensions, others evaluated only two dimensions, or even just one (most commonly emotional exhaustion [35–37]. Additionally, there is a conceptual divergence in how burnout is understood: health professionals often regard burnout as a dichotomous phenomenon, whereas other researchers mostly consider burnout as a continuous phenomenon with ranges from absence to medium to high [35–37]. Further on, variability in sample sizes across studies could also contribute to the observed differences in prevalence of certain dimensions of burnout syndrome [38].

Several studies have identified an association between alcohol use and burnout syndrome [29,39]. In a national cohort of medical students in the USA, high levels of burnout syndrome domains emotional exhaustion and depersonalization were strongly associated with alcohol abuse/dependence [39]. Similarly, greater alcohol consumption was associated with higher emotional exhaustion and depersonalization among the first-year family medicine residents in the USA [40]. At the University of Cyprus, medical students who consumed alcohol exhibited a higher level of cynicism and lower level of efficacy compared to those who did not consume alcohol, whereby among those who did consume alcohol increasing consumption was significantly associated with lower efficacy [41]. Among 547 medical students in Kazakhstan, 127 (23.2%) reported alcohol consumption, whereby a significant association was found between alcohol consumption and all dimensions of burnout: for high exhaustion and for high disengagement according to the Oldenburg Burnout Inventory for college students, and for personal burnout, studies-related burnout, colleague-related burnout, and teacher-related burnout according to the Copenhagen Burnout Inventory-Students survey [42]. In the present study, high frequency of alcohol use was the main factor that was independently associated with high levels of all three dimensions of burnout syndrome in medical students (every day consumption, P < 0.05; with a significant upward trend – P < 0.05). Similar to this study, a study on burnout syndrome involving 290 medical students from all six years of study in Serbia reported a statistically significant positive correlation between Emotional Exhaustion and alcohol use, as well as between Cynicism and alcohol use [43]. In contrast, research conducted among British medical students found that higher levels of alcohol binge drinking were significantly associated with higher scores of personal accomplishment [29]. But, this link must be interpreted with a lot of caution because even though some studies pointed to the association between alcohol use and burnout syndrome in medical students, there remains the above stated inconsistency in their results and the fact that some studies did not inquire about the use of alcohol due to alcohol consumption being against law and religion [44,45]. Moreover, variations in how the consumption of different forms of alcoholic beverages was assessed across studies may contribute to the differences between reported findings. In addition, given that the mentioned research employed cross-sectional design, it still remains to be determined whether the association between alcohol consumption and burnout syndrome is unidirectional. Namely, some studies suggest that certain individuals use alcohol as a way of coping with stress [46,47]. On the other hand, research from the UK found that young drinkers have a “hedonic” approach to excessive alcohol consumption, implying that medical students may engage in drinking for pleasure rather than to cope with stress and burnout [48]. While numerous studies have reported frequent alcohol use among medical students [41,49,50], this finding is not universal [42]. According to the National Health Research Study conducted in Serbia in 2013, approximately 1.3% of individuals aged 15–34 reported daily alcohol consumption in the previous 12 months [51]. In Serbia, drinking alcohol is considered socially acceptable (as part of traditions and customs), which results in a high prevalence of alcohol use, particularly among young people. A recent systematic review showed that alcohol and illicit substance use were strongly related with burnout syndrome in medical students [44], but emphasized that temporal associations could not be confirmed, due to the risk of reverse causality. These temporal associations can be verified by conducting epidemiological studies with a longitudinal design, to clarify whether alcohol consumption directly leads to burnout syndrome in medical students or whether high levels of burnout lead to resorting to alcohol use.

In this study, sedative use was significantly associated with high level of emotional exhaustion and cynicism among medical students. According to French authors, medical students exhibit a high prevalence of substance use, though the underlying motives remain unclear – whether such behavior is due to attempts at self-medication (e.g., in order to cope with stress) or due to motives such as pleasure or looking for something new [52]. A study in India, which surveyed medical students at the beginning and at the end of their first study year, reported significant increases in depression and stress but not in burnout [53]. Some studies have noted that rates of depression are higher among medical students compared to the general population, however they are not more likely to seek treatment – only 22% of students experiencing depression reportedly pursue help, due to concerns about confidentiality, stigma or cost [54–55]. It remains an open question whether the use of drugs (such as antidepressants, anxiolytics, or sedatives) serves as an indicator of the presence of these basic pathologies, which may in turn make the occurrence of symptoms of burnout more likely. It is unclear whether the use of sedatives directly causes more burnout in students, or whether those students already experiencing high levels of stress resort to recreational drugs for comfort [56,57]. Data on the use of psychoactive substances were provided by a total of 8 (1.1%) respondents – 5 students with burnout (4.3% of those with burnout) and 3 students without burnout (0.5% of those without burnout). This did not allow specification or breakdown by type of the substance used, leading to the loss of interpretability of these results. Interpreting the relationship between risk factors such as sedative use and alcohol use and burnout syndrome in medical students requires careful consideration of bidirectionality, since burnout can also trigger sedative and alcohol use. Current studies, like most research on burnout syndrome and substance and alcohol use, employed cross-sectional design and cannot confirm causality among the examined variables [44]. Longitudinal studies are needed to establish a clear understanding of causal relationship and clarify the direction of influence between burnout and alcohol and substance use. Given that education on drug abuse, alcohol use and illicit substances represents a core component of the medical schools’ curriculums [58–60], this association should be explored further in future longitudinal studies.

According to the findings of this study, high level of emotional exhaustion was significantly increased with the clinical training level of studies in medical students. Even though these results align with many prior studies showing that medical students have relatively low burnout rates when enrolling the medical school but experience a significant increase in emotional exhaustion upon exposure to clinical courses [61–63], some authors have reported different findings [38,64]. Contrary to this research, another study on burnout syndrome among medical students of the first and fifth year of studies in Serbia observed statistically significant differences in the values of all three burnout subscales in those students, with MBI EE being higher among first-year students [21]. A study conducted in Brazil recorded higher scores for emotional exhaustion, depersonalization and personal accomplishment among medical students in final stage of their studies [65]. The transition from preclinical to clinical training can be associated with factors such as emotional load due to moving from classroom to clinic, and educational pressure anxiety which is related to performing clinical skills, fear of unintentional harm to patients, wrong treatment, concerns of risk of infections from patients and loss of control over personal time, particularly sleeping hours. Research showed that rates of depression, anxiety and psychological distress are higher in the higher years of studies compared to the general population [66]. In a study conducted in Trinidad and Tobago, medical students had the highest levels of burnout and depression in the final year of study [67].

In this study, a positive personal medical history (presence of any chronic disease) was frequently reported among medical students who had high risk of academic inefficacy. However, only a few studies have examined the relationship between mental and physical health of medical students and burnout [26]. At an academic health center in the USA, both ever diagnosed physical and mental conditions were more associated with higher burnout among medical students, faculty and staff [68]. Regarding the personal accomplishment subscale, significant differences were observed only in relation to psychological health among fourth year medical students at the University of South Africa [69]. A cross-sectional study conducted across 22 medical schools in Brazil found significant associations between personal accomplishment and psychological quality of life and reduced personal distress [65]. The burnout–disease relationship can be regarded as part of a process in which academic demands compromise students’ mental and physical resources, leading to consequences such as academic inefficacy [58].

This study demonstrated significant correlations between medical student characteristics and dimensions of burnout, with the most prominent determinant being high frequency of alcohol use (every day consumption, P < 0.05; with a significant upward trend – P < 0.05). The findings of this study have important implications for student support services, suggesting counsellors should provide useful educational and psychological advice to all medical students, particularly students who are at high risk for burnout. The considerable variability in reported frequency of burnout among medical students can be attributed to the use of different questionnaires for burnout assessment, use of different criteria for identifying the syndrome (in addition to the three-dimensional – the use of one- and/or two-dimensional criteria) by researchers, and the application of non-validated instruments instead of validated ones [11]. For research in the student population, additional longitudinal studies that should use defined criteria and standardized instruments, adhering to a rigorous scientific approach, are necessary.

During the period of online learning necessitated by the COVID-19 pandemic, the prevalence of burnout syndrome in medical students ranged from 16.7 to 59.9% [70]. Available evidence indicates that medical students encountered numerous challenges during distance learning [71–73]. Circumstances that had an impact on the psychological well-being of medical students included transition to distance learning, reduced contact with peers, impaired transfer of knowledge, particularly for clinical courses, and often additional responsibilities such as volunteer work with patients with COVID-19 [71–76]. Throughout medical school, students generally exhibited a trend of consistently high scores on the personal accomplishment and emotional exhaustion subscales, along with an increasing trend on the depersonalization subscale [70,74–77]. In addition to burnout syndrome, medical students during the COVID-19 pandemic reported elevated levels of stress, anxiety, depression, sleep disturbances, lack of social support, suicidal ideation, and lack of physical activity, all of which have been related to burnout [75–77]. To effectively address and prevent these problems in the context of potential future health crises, medical schools should take proactive measures to support students, which include counseling students by promoting mental well-being and healthy lifestyle, planning interventions to prevent burnout syndrome – such as coping strategies and self-motivation, and integrating them into the curriculum. Key findings indicate the need for the development of health-related guidelines, which should include monitoring quality of life of medical students, particularly during the clinical courses, and actively promoting a healthy lifestyle which involves regular exercise, adequate sleep, stress management skills, and a positive learning environment [72,76,78,79].

Conclusions

This study highlights the relationship between the dimensions of burnout syndrome (i.e., high level of emotional exhaustion, cynicism, and academic inefficacy) and certain characteristics of medical students. The identification of modifiable factors that are associated with burnout in Serbian medical students underscores the need for targeted support that would provide medical students the necessary help in order to prevent burnout syndrome. Since this study was conducted at a single Faculty of Medicine in Serbia, the findings cannot be properly generalized, indicating the need for further research involving a national sample of medical students.

Acknowledgments

We want to thank the leadership of the Faculty of Medical Sciences Kragujevac for their support and the medical students for their participation in the study. The authors thank Milena Jovanovic and Zeljko Todorovic, who partially helped in data collection and data entry.