Burnout Syndrome and Associated Sociodemographic Factors in Medical Students: A Cross-Sectional Study †

: The study was conducted to determine the demographic factors associated with burnout among medical students at the Faculty of Medical Sciences in Kragujevac, Serbia. A cross-sectional study was conducted in 2014. Burnout syndrome was assessed using the Maslach Burnout Inventory Student Survey. Statistical evaluation was performed through chi-square and t -test. The study included 760 of the 836 medical students from the ﬁrst to the sixth year who met the criteria for participation (response rate was 90.9%). Female sex was signiﬁcantly associated with less cynicism compared to men ( p = 0.007). Age was signiﬁcantly associated with all dimensions of burnout; while cynicism and academic inefﬁciency increased with age ( p < 0.001), emotional exhaustion decreased signiﬁcantly with age ( p = 0.030). The self-ﬁnancing way of studying was signiﬁcantly associated with greater cynicism ( p = 0.018) and academic inefﬁciency ( p < 0.001). Our research conﬁrmed the association of sociodemographic characteristics and the level of burnout syndrome in medical students.


Introduction
Burnout syndrome is a psychological term that means emotional exhaustion, depersonalization and reduced professional efficiency, which arise in response to chronic stress in jobs related to directly work with people [1]. Burnout syndrome is especially a characteristic of occupations that are linked to working with people in emotionally demanding situations [1,2].
Previous studies showed that medical students are included in the group of students with very stressful studies and, as such, may be at increased risk of developing burnout syndrome [3,4]. Burnout syndrome is firstly associated with academic tasks and refers to a feeling of exhaustion due to demands of studies, a cynical attitude towards the studies and self-perception of incompetence as a student. Burnout syndrome among medical students comprises the following three dimensions: (1) emotional exhaustion (due to studying/educational demands), (2) cynicism (indifference/apathic attitude towards academic activities) and (3) low academic efficacy (perception of incompetence as a student) [3].
Systematic literature reviews have shown that about 50% of medical students have burnout syndrome [2,4]. Emotional exhaustion, depersonalization and overall burnout were significantly more common in medical students compared to other students [5].
Some studies have found that older medical students were more likely to have burnout syndrome [6], unlike other studies that found no association between age and burnout [7]. While the results of studies in Lebanon [5], India [8] and Pakistan [9] showed that female gender is significantly associated with a high risk of burnout in medical students, studies in the United Kingdom [10] and Brazil [11] have shown significantly higher prevalence of burnout syndrome in male than in female students. Santen and coauthors [12], as well as Galán and coauthors [13], did not find a significant association between burnout syndrome and gender. According to the results of numerous studies, the determinants of burnout syndrome in medical students were family duties [9,11].
Research on burnout syndrome in medical students in Serbia is scarce. The fast development of medical sciences in recent decades, along with the fact that burnout syndrome is insufficiently investigated in our environment, points to the need to estimate the prevalence of burnout syndrome in medical students and research the possible association between burnout syndrome and certain sociodemographic characteristics.
The study was conducted to determine the demographic factors associated with burnout syndrome among medical students at the Faculty of Medical Sciences of Kragujevac (University of Kragujevac, Kragujevac, Serbia). The main goal was to examine whether there is a high risk of burnout syndrome in female medical students, as well as in older students.

Materials and Methods
A cross-sectional, analytical study, using the Maslach Burnout Inventory Student Survey (MBI-SS) [3,6,14] and epidemiological questionnaire on basic sociodemographic characteristics (age, sex, place of residence, completed secondary school, marital status, children, housing, study financing), was conducted in 2014 for the purpose of this research.
Data collection was conducted in the auditorium of the Faculty of Medical Sciences. Medical students who met the criteria for inclusion in the study were asked to complete an epidemiological questionnaire and an MBI-SS questionnaire. The respondents had 15 min (with a range of ±5 min, depending on the cooperation of the respondents) to complete the questionnaire. Respondents independently filled out questionnaires by a paper-and-pencil method, in the presence of researchers-the authors of the paper-who were available in case of difficulties in understanding to clarify any issues. All medical students (from the first to the sixth year of study) were invited to participate in this study on the first day of the lectures, when all students are present at the beginning of the semester according to their schedules and classrooms.
Students in any year of undergraduate study of medicine at the Faculty of Medical Sciences, University of Kragujevac, who gave their voluntary consent and signed an informed consent form were included in the study.
Criteria to include participants in the study were: over 18 years of age, enrolled in academic year, status of student, attendance to classes, provided voluntary written consent to participate and absence of exclusion criteria.
Exclusion criteria were: under 18 years of age, absence from classes or presence of any other objective reason which did not allow or hindered participation in the study.
The study included 760 of the 836 medical students from the first to the sixth year who met the criteria for participation (response rate was 90.9%).
Burnout syndrome is defined as a triad of symptoms: emotional exhaustion (EE), cynicism (CY) and academic inefficiency (rAE) [1,3]. Validity and reliability of the Serbian version of the MBI-SS questionnaire was confirmed in this research [15]. The scale MBI-SS, which is used in this research, has good psychometric characteristics, with reliability, as expressed by Cronbach's alpha coefficient, that is acceptable and very high for all domains (0.852-0.869). Cronbach's alpha coefficient for all three subscales was higher than 0.7 (i.e., it was 0.869 for MBI EE, for MBI CY it was 0.856, and for MBI EF it was 0.852).
Statistical evaluation was performed through chi-square and t-test. For all factors, the level of statistical significance was considered p < 0.05. All statistical analyses were performed using the program SPSS 20.0 (SPSS, Chicago, IL, USA).

Results
Out of the 760 medical students who completed the questionnaire, the majority (491; 64.6%) were females, while every third student (256; 33.7%) was 25 years old or older (Table 1). Burnout syndrome, as a triad of symptoms (i.e., emotional exhaustion, cynicism and academic inefficacy), is shown in Table 2. In this research, the mean results on subscales were: MBI EE (12.8 ± 7.2; range 0-30), MBI CY (3.6 ± 4.9; range 0-24) and MBI rEF (9.1 ± 8.3; range 0-36). Gender was significantly less often associated with lower cynicism, with fewer women showing high levels of cynicism compared to men (31.6% versus 41.3%; p = 0.007) ( Table 3). Age was significantly associated with all dimensions of burnout; while cynicism and academic inefficacy increased with increasing age (p < 0.001), emotional exhaustion decreased significantly with age (p = 0.030). Students who lived in a dormitory (20.8%) were the least likely to show a high level of cynicism (p = 0.028). Self-funding as the way of study financing was significantly associated with higher cynicism (p = 0.018) and academic inefficacy (p < 0.001).

Discussion
In our study, a high risk for emotional exhaustion was most often seen in medical students aged 22-24 years. A high risk for cynicism was most common in male students, those aged 25 and more years, those living with parents and those self-funding their studies. A high risk for academic inefficacy was most common in students aged 25 years or older and those self-funding their studies.
Among all the studied demographic variables, age was the one most consistently associated with burnout syndrome. Some studies have found that older students experienced burnout syndrome more often [6], in contrast to other research which did not find an association between age and burnout [7]. In this study, a high risk for burnout syndrome was significantly more often found in medical students aged 22-24 years compared to younger and older students. These findings must be interpreted with caution. Firstly, older age is interconnected with experience in studying, so there is always the question of a secondary association with burnout syndrome. Additionally, one of the possible explanations is that the students who experience burnout syndrome at the beginning of studies will most likely leave their studies, while those with a lower risk of burnout will stay at the faculty [14]. Correspondingly, the results of this research also show that burnout syndrome can occur at the beginning of studies of medicine, which points to the justification for screening and prevention of burnout syndrome in the youngest students.
Some studies did not find a statistically significant association between the prevalence of burnout syndrome (i.e., high risk for cynicism) and gender [16,17], in contrast to our study and some other studies [7,13,18]. A large systematic review and meta-analysis which comprised 24 studies with 17,431 medical students hypothesized that the reason for not finding a significant difference in burnout prevalence between sexes could be due to the insufficient statistical power of primary studies [4].
In our study, none of the components of burnout syndrome were significantly associated with place of residence, having completed secondary school, marital status or children. Similarly, some studies [17,19,20] have found that burnout was not significantly associated with marital status. In contrast, some studies have confirmed the association between burnout syndrome and marital status [21].
It is difficult to compare the results of this study with similar studies in the world, due to numerous reasons: different research designs, use of different questionnaires, use of unvalidated questionnaires, different methodologies, different response rates, differences in studied populations (regarding age, gender, socioeconomic status, etc.), studying all or just selected study years, study curriculums, length of studies, etc. All of these reasons hamper international comparisons, as noted by Erschens et al., who were therefore unable to perform a broad meta-analysis of burnout in medical students [22].
The results of this research will enable medical doctors to successfully make decisions on providing psychological support to medical students at a high risk for burnout syndrome, with the aim of timely prevention for many students, primarily females, who live in dormitories and self-fund their studies.
Our study is one of the few studies dedicated to evaluation of the association between the high risk of burnout syndrome with demographic characteristics of medical students in Serbia. Additionally, in this study, the validated Serbian version of MBI-SS was applied, with a high response rate (90.9%). However, this study has several limitations; in addition to the known shortcomings of the cross-sectional study design, the limitation of this study is in the use of the self-report questionnaire and not providing data on other circumstances that could influence the onset of burnout in medical students (such as socioeconomic status, etc.).

Conclusions
This study is one of the first attempts to assess the level of risk for burnout syndrome in medical students in Serbia and to analyze the role of sociodemographic characteristics of burnt-out students. The results of this study show that a high risk of burnout syndrome is significantly associated with male gender, age, living with parents and the self-funding type of study financing in medical students. It is important to repeat similar studies in the future, especially with longitudinal studies, which are recommended to confirm the association found in our prevalence study. Therefore, research that enables early detection of burnout syndrome is needed in order to encourage the adoption of preventive measures that can be shared with the scientific community.