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The prevalence and correlations of

medical student burnout in the pre-
clinical years: A cross-sectional study
a a a
Rebecca Mazurkiewicz , Deborah Korenstein , Robert Fallar &
a
Jonathan Ripp
a
Department of General Internal Medicine , The Mount Sinai
School of Medicine , New York , NY , USA
Published online: 25 Jul 2011.

To cite this article: Rebecca Mazurkiewicz , Deborah Korenstein , Robert Fallar & Jonathan
Ripp (2012) The prevalence and correlations of medical student burnout in the pre-
clinical years: A cross-sectional study, Psychology, Health & Medicine, 17:2, 188-195, DOI:
10.1080/13548506.2011.597770

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 Psychology, Health & Medicine
Vol. 17, No. 2, March 2012, 188–195

The prevalence and correlations of medical student burnout in the

pre-clinical years: A cross-sectional study
Rebecca Mazurkiewicz*, Deborah Korenstein, Robert Fallar and Jonathan Ripp

Department of General Internal Medicine, The Mount Sinai School of Medicine, New York,
NY, USA
(Received 9 August 2010; final version received 14 June 2011)

Burnout is a psychological syndrome of emotional exhaustion, depersonalization,

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and impaired personal accomplishment induced by repeated workplace stressors.

Current research suggests that physician burnout may have its origins in medical
school. The consequences of medical student burnout include both personal and
professional distress, loss of empathy, and poor health. We hypothesized that
burnout occurs prior to the initiation of the clinical years of medical education.
This was a cross-sectional survey administered to third-year medical students at
the Mount Sinai School of Medicine (MSSM) in New York, New York
(a traditional-style medical school with a marked division between pre-clinical
and clinical training occurring at the beginning of the third year). Survey included
an instrument used to measure job burnout, a sleep deprivation screen, and
questions related to demographic information, current rotation, psychiatric
history, time spent working/studying, participation in extracurricular activities,
social support network, autonomy and isolation. Of the 86 medical students who
participated, 71% met criteria for burnout. Burnt out students were significantly
more likely to suffer from sleep deprivation (p ¼ 0.0359). They were also more
likely to disagree with the following statements: ‘‘I have control over my daily
schedule’’ (p ¼ 0.0286) and ‘‘I am confident that I will have the knowledge and
skills necessary to become an intern when I graduate’’ (p ¼ 0.0263). Our findings
show that burnout is present at the beginning of the third year of medical school,
prior to the initiation of the clinical years of medical training. Medical student
burnout is quite common, and early efforts should be made to empower medical
students to both build the knowledge and skills necessary to become capable
physicians, as well as withstand the emotional, mental, and physical challenges
inherent to medical school.
Keywords: medical student; medical education; burnout

Introduction
Burnout is a psychological syndrome of emotional exhaustion, depersonalization,
and impaired personal accomplishment induced by repeated workplace stressors
(Maslach, Schaufeli, & Leiter, 2001). People suffering from burnout feel emotionally
depleted, cynical toward their coworkers and clients, ineffectual at their tasks, and
generally dissatisfied with their work (Maslach et al., 2001). Burnout can lead to
deterioration in job performance, patient satisfaction, and employee morale and may

*Corresponding author. Email: [email protected]

ISSN 1354-8506 print/ISSN 1465-3966 online

Ó 2012 Taylor & Francis
http://dx.doi.org/10.1080/13548506.2011.597770
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 Psychology, Health & Medicine 189

be associated with impairment in physical health, alcohol and drug abuse,

relationship difficulties, and other social problems (Maslach, Jackson, & Leiter,
1996). This syndrome has been described in a wide array of professionals, including
social workers, civil servants, members of the military, and technologists. The rate of
burnout among practicing physicians is particularly high (Boundreau, Grieco,
Cahoon, Roberson, & Wedel, 2006; Campbell, Sonnad, Eckhauser, Campbell, &
Greenfield, 2001; Deckard, Hicks, & Hamory, 1992; Gabbe, Melville, Mandel, &
Walker, 2002; Gundersen, 2001; Spickard, Gabbe, & Christensen, 2002).
The prevalence of burnout among medical and surgical residents has been
reported to range from 30 to 80% (Gopal, Glasheen, Miyoshi, & Prochazka, 2005;
Shanafelt, Bradley, Wipf, & Back, 2002; Thomas, 2004; West et al., 2006; Willcock,
Daly, Tennant, & Allard, 2004). Resident burnout is associated with self-reported
suboptimal patient care (Shanafelt et al., 2002) and self-perceived medical errors
(West et al., 2006). Several potential predictors of burnout among resident
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physicians have been proposed, including workload and duty hours, demographic
factors such as age and gender, and personality characteristics such as obsessive or
passive-aggressive traits, but few meaningful correlations have been made (Thomas,
2004). Burnout rates may have decreased slightly after the Accredidation Council
for Graduate Medical Education (ACGME) work-hour restrictions mandated in
2003, suggesting that longer duty hours may contribute to burnout (Gopal et al.,
2005; Myers et al., 2006). In addition, depression appears to be positively correlated
with burnout (Thomas, 2004; Willcock et al., 2004).
Current research suggests that physician burnout, with its associated con-
sequences, may actually have its origins in medical school (Dahlin, Joneborg, &
Runeson, 2007; Dahlin & Runeson, 2007; Daly & Willcock, 2002; Dyrbye, Thomas,
Huntington et al., 2006; Dyrbye, Thomas, Huschka et al., 2006; Dyrbye, Thomas, &
Shanafelt, 2006; Guthrie et al., 1998; Thomas et al., 2007). Previous studies of
medical students have reported burnout prevalence to range from 13 to 70% (Dahlin
& Runeson, 2007; Dahlin et al., 2007; Dyrbye, Thomas, Huntington et al., 2006;
Guthrie et al., 1998). Several researchers have attempted to examine how
demographics (Dyrbye, Thomas, Huschka et al., 2006), depression (Dahlin &
Runeson, 2007; Dyrbye, Thomas, Huntington et al., 2006; Dyrbye, Thomas,
Huschka et al., 2006; Guthrie et al., 1998), personality traits (Dahlin & Runeson,
2007; Dahlin et al., 2007; Daly & Willcock, 2002), alcohol and drug use (Dyrbye,
Thomas, Huntington et al., 2006), personal life events (Dyrbye, Thomas,
Huntington et al., 2006), and interactions with faculty and residents (Dyrbye
et al., 2008) may be correlated with medical student burnout. The consequences of
medical student burnout include both personal and professional distress (including
an increased risk of suicidal ideation (Dyrbye et al., 2008)), less empathy (Thomas
et al., 2007), and poor health (Dahlin & Runeson, 2007).
While the link between personal risk factors and medical student burnout has
been explored, only one study has examined the impact of student work
environments on medical student burnout and found that satisfaction with learning
climate was associated with medical student burnout (Dyrbye et al., 2009). However,
these authors did not explore other factors that we hypothesized to be related
to educational satisfaction, such as control over one’s learning environment.
Furthermore, while a relationship between social support systems and burnout in
attending and resident physicians has been examined (Collier, McCue, Markus, &
Smith, 2002; Geurts, Rutte, & Peeters, 1999; Thomas, 2004), no studies have
 190 R. Mazurkiewicz et al.

explored the connection between social supports and burnout in medical students.
We hypothesized that burnout occurs prior to the initiation of the clinical years of
medical education. We additionally hypothesized that lack of control over one’s
work schedule and environment would be associated with burnout among medical
students.

Methods
Participants
All entering third-year medical students in the 2008–2009 academic year at the
Mount Sinai School of Medicine (MSSM) in New York, NY (n ¼ 123) were eligible
to participate in this study; our participants represent a convenience sample within
this cohort. We chose to study students at the beginning of their third year, as at our
institution, it marks the beginning of clinical training. Eligible students were invited
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to participate during an orientation session delivered at the beginning of the third

year of medical school. Participation was voluntary, and the Mount Sinai
Institutional Review Board approved the study.

Procedures
The survey was administered at the beginning of the school year in August of 2008.
To maximize response rates, the surveys were distributed during an orientation
session during which the entire class was present. Participant responses were
anonymous. Non-identifying numerical codes were used for data collection and
entry in order to maintain anonymity. None of the investigators or other MSSM
faculty had access to identifying information for individual participants of this study.

Survey measures
The survey consisted of an instrument used to measure job burnout, a sleep
deprivation screen, and questions related to demographic information, current
medical rotation, psychiatric history, time spent working/studying, participation in
extracurricular activities, social support network, autonomy and isolation. The
survey was based, in part, on a similar study of resident physician burnout at our
same institution (Ripp et al., 2010).
The Maslach Burnout Inventory – General Survey (MBI-GS) contains 16
questions requiring respondents to rate the frequency with which they experience
certain feelings related to their work from ‘‘never’’ to ‘‘always’’ on a seven-point
Likert scale (Maslach et al., 1996). This questionnaire has been designed to measure
the three domains of burnout in people of all occupations. The MBI-GS has been
previously validated in large populations of health-care professionals and other
hospital personnel. It also has been used in studies of military populations and
technologists (Leiter & Schaufeli, 1996; Schaufeli, Leiter, & Kalimo, 1995). Previous
work has revealed stability coefficients of 0.65 for the Exhaustion subscale, 0.60 for
the Cynicism subscale, and 0.67 for the Efficacy subscale (Maslach et al., 1996). We
felt that this version of the MBI, which has been validated in professions that do not
involve customer/patient interaction, was most appropriate given the limited patient
interaction of the typical medical student at the start of third year. In contrast, the
MBI – Health Services Survey, which was designed to measure burnout in workers in
 Psychology, Health & Medicine 191

human service occupations, was not used as questions in this survey (as opposed to
the MBI-GS) included items related to patient interactions. We defined burnout as a
high score on either of the MBI Exhaustion (score 4 3.2) or Cynicism (score 4 2.2)
scales in keeping with the definition most commonly used in the literature (Maslach
et al., 1996).
The Epworth Sleepiness Scale (Johns, 1991) is a validated instrument used to
measure sleep deprivation. In this instrument, respondents are asked to rate how
likely they are to fall asleep in eight different scenarios on a four-point Likert scale
ranging from ‘‘no chance of dozing’’ to ‘‘high chance of dozing’’. The higher the
score, the more likely the respondent has a sleep disorder or excessive fatigue.
Previous work has shown this scale to be very reliable with a Cronbach’s alpha of
0.88 (Johns, 1991).
The medical student characteristics questions were based on previously published
studies of burnout in resident physicians (Ripp et al., 2010; Thomas, 2004) and were
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formulated to identify factors that might place one at risk for, or be protective
against, burnout. While these one-item questions are not part of a validated
instrument (Ripp et al., 2010), they do have face validity. Topics addressed in these
questions included demographic information (including age, gender, ethnicity,
marital status, and if the participant had children), social support networks, work
environment, medical school rotations completed, career plan, mentorship, and if
the student had a psychiatric history. We chose not to use a formal measure of
depression because of our concern that new cases of depression diagnosed through
such an instrument would not be able to receive an appropriate referral for
treatment. Our questions were aimed at establishing a connection between burnout
and a history of a psychiatric disorder. We chose a simple, one-item question to
explore a link with social supports rather than a lengthy validated instrument in
order to limit survey length and encourage participant response.
Six time-schedule questions were designed by the primary investigators to
determine how medical students spend their time. Participants were asked to
estimate how many hours they spend working/studying, participating in personal
activities, and with loved ones in an average week. These questions have not been
validated, and no validated scales for this measure currently exist.

Statistical analysis
Multiple comparison chi-square tests were conducted to identify statistically
significant differences in proportions (p 5 0.05) of burnout across survey items.
Fisher’s exact test was utilized when cell sizes were small (n 5 5). Data analysis was
generated using SAS for Windows statistical software, version 9.1. (SAS Institute,
Inc., Carey, NC).

Results
Of the 123 eligible medical students in the MSSM class of 2010, 86 (70%)
participated in this study (see Table 1). The average age of participants was 26 years.
Fifty-seven percent of participants were women, 66% were Caucasian, 67% were not
married or did not have an unmarried partner, and only two (2.3%) participants had
children. Three participants (3.5%) reported a personal history of depression, and
six (7%) had a personal history of an anxiety disorder. Sixty-one of the 86 medical
 192 R. Mazurkiewicz et al.

Table 1. Demographic characteristics.

% of total % of those who were

population burnt out p
Gender
Female 57 57 0.9068
Male 43 43
Marital status
Married 15 18 0.2368
Single 66 67
Divorced 0 0
Unmarried partner 19 15
Break 4 1 year between undergraduate and medical school
Yes 47 44 0.5136
No 53 56
Science-based undergraduate major
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Yes 62 62 0.8425
No 38 38
Children
Yes 2 3 1
No 98 97
History of depression
Yes 3 5 0.553
No 97 95
History of anxiety
Yes 7 10 0.1746
No 93 90
Family in local area
Yes 59 59 0.9328
No 41 41

student participants (71%) met criteria for burnout at the beginning of their third
year of medical school. There were no significant differences in burnout in terms of
gender.
Students who met criteria for burnout were significantly more likely to suffer
from sleep deprivation as indicated by high scores on the Epworth Sleepiness Scale
(p ¼ 0.0359) (see Figure 2). In addition, medical students who were burnt out were
more likely to disagree with the following statements from the medical student
characteristics questions: ‘‘I have control over my daily schedule’’ (p ¼ 0.0286) and
‘‘I am confident that I will have the knowledge and skills necessary to become an
intern when I graduate’’ (p ¼ 0.0263) (see Table 2).

Discussion
This cross-sectional study demonstrated a high prevalence of burnout in this
population of medical students prior to the initiation of the clinical years of medical
school. Further, to the best of our knowledge, ours is the first study to demonstrate a
correlation between burnout and medical student confidence in becoming a capable
intern as well as a correlation between burnout and lack of control over one’s daily
schedule. Such correlations are surprising in this population given that prior to the
initiation of clinical rotations, medical students enjoy more freedom than they will
have for the remainder of their careers.
 Psychology, Health & Medicine 193

Table 2. Correlates of medical student burnout.

% of total population % of those who were burnt out p

Overall sample burnout 71
Epworth Sleepiness Scale
Adequate 67 61 0.0359
Inadequate 33 39
‘‘I have control over my daily schedule’’.
Disagree 50 58 0.0286
Agree 37 28
‘‘I am confident that I will have the knowledge and skills necessary to become an intern when I
graduate’’.
Disagree 11 15 0.0263
Agree 77 69
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Only one other study has examined the relationship between control over one’s
life and medical student burnout, finding that ‘‘lack of control over one’s life’’ was
significantly related to burnout in their medical student sample (Santen, Holt, Kemp,
& Hemphill, 2010). While the relationship between burnout and control has begun to
be explored in the resident literature (Eckleberry-Hunt et al., 2009; Williams,
Manwell, Konrad, & Linzer, 2007), there has been no research conducted to date
that addresses the issue of confidence in one’s knowledge and skills as was done in
our study. Our question related to confidence in one’s knowledge and skills may be
related to self-efficacy, and additional studies would be necessary to clarify this
relationship further.
Previous studies of medical students have not addressed the relationship between
sleep and burnout in this population; however, sleep has been examined and found
to be associated with burnout in resident physicians (Gopal et al., 2005). While this
relationship may be intuitive, we believe ours to be the first study to demonstrate the
relationship between medical student burnout and sleep deprivation. Unlike
previous studies, we found no correlations between burnout and demographic
characteristics (Dyrbye, Thomas, Huschka et al., 2006), history of anxiety or
depression (Dahlin & Runeson, 2007; Dyrbye, Thomas, Huntington et al., 2006;
Dyrbye, Thomas, Huschka et al., 2006; Guthrie et al., 1998), or negative experiences
with faculty and/or residents (Dyrbye et al., 2008). This lack of association could be
the result of our small sample size or perhaps secondary to characteristics unique to
our cohort.
Our study had important limitations. First, our sample size was small, though it
is comparable to the size of previous studies of medical school burnout. Second, ours
was a cross-sectional study so we cannot comment on trends over time; however,
addressing our hypothesis that burnout is present prior to the clinical years did not
require longitudinal follow up. Further research could follow a cohort of medical
students through all four years of medical school to determine the timing of the
development of burnout. Finally, ours was a single-center study, with surveys
administered only at the MSSM. Findings might be generalizable to other large
urban programs based at large academic medical centers, such as ours, but limited in
comparability to other school settings. Further research should include medical
students at multiple institutions to verify our findings. Given the nature of this
research, it is difficult to determine whether a lack of control and autonomy causes
burnout or vice versa. Additional studies could explore these relationships further.
 194 R. Mazurkiewicz et al.

Despite the limitations to our study, our findings show that burnout is present at
the beginning of the third year of medical school, prior to the beginning of the
clinical years of medical education. Therefore, interventions to address burnout
should begin early in medical training in order to be effective. In addition, these
medical students who had not yet begun clinical clerkships felt a lack of control and
autonomy despite having greater freedom in their schedule relative to more senior
students. Strategies should be developed to decrease workload while maximizing
medical students’ autonomy over their work environment. Such methods could
include fostering medical student ownership of patients by encouraging their
participation in rounds and developing plans for their patients. In addition, it would
be prudent to minimize the time medical students spend in the clinic or hospital that
is not related to direct patient care. Overall, medical student burnout is quite
common and may begin early in medical school. Therefore, early efforts should be
made to empower medical students to both build the knowledge and skills necessary
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to become capable physicians, as well as withstand the emotional, mental, and

physical challenges inherent in medical education.

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