INTRODUCTION
Medical students are known to have a substantially lower mental quality of life than similar-age individuals in the general population.
123 Up to 50% of medical students experience burnout, 25% have depression, and many suffer from chronic anxiety and a poor mental quality of life.
34 The prevalence of depression (6.5%) is also higher in medical students compared to other college students in Korea.
5 Distress in medical students is associated not only with education-related stressors such as workload, competition, sleep deprivation, the emotional impact of the dissection course, or the suffering and dying of patients
367 but also with relational stressors such as discord with faculty, peers, or classmates
89 and work-family conflicts.
10 In Korea, the experience of failure (drop-out) during medical school has been reported to make students feel as if their status has declined, their self-concept has changed, and their social network has become restricted.
11
Burnout is defined by Maslach and his colleagues as a pathologic syndrome in response to chronic interpersonal stressors on the job.
12 Burnout can be a predictor of psychological impairments such as depression and low self-esteem among medical students.
1314 Burnout can also lead to medical students' dropping out of school and to suicidal ideation.
4 In contrast, students who are resilient to burnout are less likely to experience other dimensions of distress and are more likely to have a higher quality of life.
15 Although burnout is prevalent among medical students, only a small proportion of medical students with depression use mental health services.
16 Social support, including faculty, family, and friends, has been found to be one of the most crucial factors for dealing with stress and psychological impairments in medical students.
1718 Students who perceive higher levels of social support are more likely to be resilient to and to recover from burnout than other students.
15
As the medical education system in Korea is competitive and performance-driven, it is presumed that Korean medical students may experience high levels of burnout, as is observed in other countries. Further, medical students who have tensions with faculty or peers may experience the high level of burnout observed in other countries. The main objectives of this study were to examine association between educational and relational stressors and burnout, and to examine social support as a moderator between stressors and burnout in medical students. Therefore, it is hypothesized that educational and relational stressors will be associated with an increased level of burnout (H1), and social support will moderate the association between stressors and burnout (H2).
DISCUSSION
Although the prevalence of burnout among medical students has been well documented in other countries,
2202122 there has been no such study conducted in Korea. The current study is the first to report on burnout in Korean medical students. Our results show that Korean medical students report greater risk of burnout when defining burnout as high mean scores on EE or DP.
223 The proportion of Korean medical students with EE burnout (28.1%) in the present study is lower than that observed in the USA (34.7%) but higher than the UK (12.9%)
21 and Spain (17.8%).
20 Furthermore the proportion of Korean medical students with DP burnout (40.4%) is higher than that in the USA (25.8%),
2 the UK (7.1%),
21 and Spain (10.0%).
20 There are differences in the curriculum and the demography of medical students across countries. Most medical schools, including those in Korea, have a similar curriculum to that of the United States, which requires a preliminary Bachelor's degree.
2 However, in the UK and Spain, students begin their medical studies without any preliminary higher education.
132021 Medical schools in Korea and in America emphasize clinical practice at the graduate level for students with the Bachelor's degree;
2 this could explain why the level of burnout in Korea and America is higher than that of European countries. Most studies of burnout in medical students in the USA have considered burnout as high scores on EE or DP.
24915 Previous research has noted that medical students develop a sense of PA as they progress through medical school, which appears to counterbalance the burnout resulting from EE and DP.
18 While the PA scale can distinguish between people who are clinically burned out and those who are not, students were considered to have burnout symptoms if they scored highly on the DP or EE subscales of the MBI.
15
Levels of EE are higher than DP in other countries.
2024 In the present study, however, levels of DP were higher than EE. Although DP was higher than EE in the total sample, the level of EE was not different among fourth-year students in the present study; this was similar to the findings among medical students in the USA.
24 In the present study, the students reported EE burnout (28.1%), DP burnout (40.4%), and PA burnout (40.8%). In a seven-institution study in the USA, 40.1% had high EE, 31.8% had high DP, and 30.6% had a low sense of PA.
4 Although a low sense of PA was not considered as burnout in medical students, low PA was present in 30.6-52.0% of medical students in the USA.
424 The EE level of medical students in the USA is higher compared to our study, which found higher levels of DP burnout and PA burnout. However, the high level of PA burnout in our study is similar to one study conducted in the USA that reported 52.1% of students with PA burnout.
24 In Korean medical schools, medical students rotate through clinical departments during their third and fourth years of training, and medical students as observers are not allowed to participate directly in providing patient care as do medical students in Spain.
20 Therefore, the higher level of PA burnout in our study might be associated with the observer or bystander role of medical students without direct practice and patient care.
There is considerable variability in how researchers have defined burnout.
25 In the present study, 9.9% of medical students were "totally burned out" according to the three subscales, using a definition of burnout as having a high score on both EE and DP and a low score on PA on the MBI; this could result in an underestimation of burnout.
1718 The level of burnout on the three subscales, 9.9%, is lower than the level of mild depression, 15.9%, among Korean medical students.
25 As burnout is a predictor of depression, it is acceptable to use only EE and DP measures, as other studies do. Nevertheless, as Korean medical students must pass clinical practice for qualification of the National Licensing Examination, it is meaningful to examine the PA burnout level of medical students.
Longitudinal studies consistently show higher rates of burnout, depression, and suicidal ideation in second-, third-, and fourth-year students than in first-year students.
4232426 Longitudinal study among Korean first- and second-year medical students shows that depression and anxiety increase significantly over the year, irrespective of academic year.
25 In the present study, there were no significant differences in the rate of burnout risk in terms of EE and PA among fourth-year medical students, but the burnout risks in terms of the DP subscale in second-year and fourth-year students were higher than in first-year and third-year students. This might be related to the frequency of exams in the second-year and fourth-year curricula. The second-year students must take 16 exams in one year, and the fourth-year students must prepare for the National Licensing Examination. Longitudinal study is needed to further identify more accurate relationships between school year and burnout level among medical students.
Main sources of distress in medical students are the learning environment and study conditions.
1327 Dissatisfaction with the learning environment is strongly correlated with burnout.
27 Academic factors such as an overly extensive curriculum, frequent examinations, and homework overload can act as catalysts for burnout.
2829 Educational stressors are more strongly associated with burnout in terms of EE, whereas relational stressors are more strongly related with burnout in terms of PA. Levels of EE and DP are related to the faculty or peers, discrimination, or alienation.
2229 In the present study, educational and relational stressors were also significantly related to the risk of burnout in medical students after controlling for socio-demographics and health characteristics. Over-competitiveness and performance-driven academic conditions in Korean medical schools
25 lead to medical students having higher DP and discord with others. The specific learning environment characteristics most strongly related to burnout vary between preclinical and clinical students.
27 However, our results showed no difference in burnout risk between preclinical and clinical students. The difference was present in the roles of medical students in Korea as observers versus active learners during clinical training in the USA.
Besides educational and relational stressors, socio-demographic and health behaviors are significantly associated with burnout level in medical students.
242728 Conflicting results have been reported with regard to the relationship between gender and burnout.
17242728 Burnout in terms of DP is more frequent in male students than in female students,
24 although no difference has been observed in female and male students in Spain.
19 In the present study, female students had high scores on EE. Female students showed significantly higher levels of EE and DP burnout in a previous study.
10 This result may be associated with coping strategies of female students in medical schools. Female medical students have reported higher stress scores as well as higher use of emotion-focused coping strategies than male students.
29
Roman-Catholic students had the highest scores on EE, whereas Buddhist students showed the lowest scores on EE. Self-rated health was significantly associated with EE and PA burnout but not with DP, signifying that the worse the health status, the higher the burnout. Another plausible explanation is that burnout might affect the health status of medical students.
The present study found that social support is a moderator between stressors and PA. Medical students who received help or social support coped well with psychological problems and burnout.
1528 Social support played a crucial role in buffering the stressors on PA burnout of medical students in the present study. PA was highest among the first-year students, suggesting that intervention programs might be of most benefit if initiated in the first year.
27 Therefore, early signs of burnout in medical students should be detected in a timely way, and appropriate measures should be taken to mitigate stressors, especially educational stressors contributing to PA burnout. Scholars have emphasized the need for organizational and individual interventions to avoid burnout.
13 Students should be encouraged to utilize adequate facilities and counseling services to get help. One study reported that physicians who attended a counseling intervention for burnout significantly reduced their levels of emotional exhaustion, job stress, and emotion-focused coping strategies.30 More studies are needed on creating a learning environment that cultivates student well-being.
The present study has several limitations. One is that the present study cannot overcome the definitional problem of burnout. There is considerable variability in the definition of burnout in the research literature. Defining burnout as having a high score on both EE and DP and a low score on PA on the MBI can result in an underestimation of burnout.
12 This study was a cross-sectional study conducted in one medical school, and it is thus difficult to directly compare burnout level of other countries. Second, this study was conducted with a cross-sectional design and therefore, definite conclusions cannot be drawn as to the predictors of burnout; we can only infer the association with burnout. Third, since this study was based on a single medical school, the results might not be representative of other medical students in other universities in South Korea.
Nevertheless, the present study has several important points. First, this is the first study to investigate the risk of burnout in medical students in South Korea. Furthermore, our study provides some information about stressors, social support, and burnout in medical students. In conclusion, the burnout level is notably high among Korean medical students. Our results showed that educational and relational stressors as well as social support are significantly associated with burnout risk in medical students. Further studies are needed on detection of early burnout symptoms in medical students and how best to help them with appropriate social support.