Medical students, as well as resident and practicing physicians, are frequently exposed to pressures that predispose them to a variety of stress-related challenges. One that has been extremely prevalent in the healthcare field is “burnout,” a psychological syndrome that results from a prolonged response to occupational or educational stressors. Burnout has been identified and researched primarily in the occupational psychology literature and has only recently begun to attract interest in the biomedical arena (1). It consists of three dimensions: emotional exhaustion, depersonalization, and a lack of personal or professional efficacy (2). High levels of emotional exhaustion or depersonalization are considered indicative of clinically significant burnout (3), and there has been a growing recognition that practicing physicians and trainees are especially susceptible (4–7).

Recent studies have also found high rates of burnout in medical students. One survey found that 50% of medical students are expected to experience some form of burnout during their training (4). Because of the increased levels of burnout in medical students, house-staff, and physicians, a natural next step is to identify whether the risk begins in medical school or earlier—in the undergraduate years. Although premedical students have not been studied with regard to burnout, there are several reasons to investigate burnout in this population. First, the requirements for medical school admission naturally result in high academic and community-service pressures.

Second, burnout has found to be associated with future suicidal ideation, and suicide is the third-leading cause of death among college students in the United States, behind accidents and homicides (4, 8, 9). Finally, few empirical data have been collected regarding premedical undergraduates and burnout. To begin to rectify these gaps in our knowledge, this study surveys premedical and non-premedical undergraduates at University of California San Diego (UCSD). A preliminary report on this population found that depressive symptoms were common in undergraduates, particularly in the premedical student population (10, 11). Here, we focus on the differences in burnout between premedical and non-premedical students, controlling for depression severity. Our primary hypothesis is that premedical students will exhibit greater burnout severity than non-premedical students. As a secondary aim, we will also explore the interactions of premedical-student status with gender and ethnicity in the context of burnout.

Participants and Procedure

The original survey sample consisted of 2,427 participants. Students who did not consent, did not complete all items of the MBI-SS and PHQ-9, declined to state their age or ethnicity, or were of multiple ethnicities, were excluded, leaving a total of 2,059 participants to be included in the analyses (Table 1). All participants were recruited through three means: 1) the UCSD Psychology Department course credit program; 2) an invitational e-mail: sent to all members of the Health & Medical Professions Preparation Program; and 3) an invitational e-mail sent to all undergraduate students who declared at least one of the eight majors in the biology department. Those who were recruited through the Psychology Department received additional class credit, and those who were recruited through e-mail: were entered into a raffle to win gift cards. All recruitment methods were approved by the UCSD Human Subjects Protections Committee, and this study was approved by the IRB at UCSD.

The questionnaire consisted of demographic questions, the Maslach Burnout Inventory Student Survey (MBI-SS), and the nine-item Patient Health Questionnaire (PHQ-9). Demographic information included gender, ethnicity, age, major, and premedical status.

Measuring Burnout

The Maslach Burnout Inventory General Survey (MBI-GS) is considered the gold standard for measuring burnout. The MBI-SS is a modified version of this survey that is specifically designed for students, and its reliability and validity have been established (12, 13). The MBI-SS consists of 15 questions that target the three dimensions of student burnout: emotional exhaustion, cynicism, and (lack of) personal efficacy. Standard procedures were used to total the MBI-SS subscales; higher scores indicated more severe burnout. Total possible scores ranged from 0 to 30 for the Emotional Exhaustion scale, 0 to 24 for the Cynicism scale, and 0 to 36 for the Personal Efficacy scale. We note that because burnout falls along a spectrum, there are no critical threshold values to designate when a person has become “burnt out” (14, 15).

Measuring Depression

The nine-item Patient Health Questionnaire (PHQ-9) is a reliable and well-validated depression screening tool that was based on the DSM-IV criteria for a major depressive episode (16–18). Each of the nine questions of the PHQ-9 targets the symptoms of depression. A higher score on the PHQ-9 suggests more severe depression; scores range from 0 to 27. Although depression and burnout are distinct disabilities, depression must be taken into account when assessing burnout because of their intimate relationship, especially because depression has been known to affect job performance (19–23).

Data Analysis

An analysis of variance was used to compare groups and test interactions. Components of the MBI-SS subscores for Emotional Exhaustion, Cynicism, and Personal Efficacy were analyzed for premedical status, gender, and ethnic group. Tukey's honestly significant difference was used for post-hoc analysis when appropriate. Although MBI-SS data were not normally distributed, parametric analysis was utilized because the F value is robust enough to violations of the normality assumption with large sample sizes (24). All tests were two-sided, with a Type I error rate of 0.05 and were done with SPSS Version 17.00.

The sample consisted of 618 premedical and 1,441 non-premedical undergraduates. As shown in Table 1, premedical students were significantly younger than non-premedical students (19.96 versus 20.52 years), and the two groups had different ethnic and school-year profiles. However, no significant three-way interactions were found between premedical status, ethnicity, and gender.

Overall, premedical students experienced more Emotional Exhaustion (F[1, 2057]=17.11; p<0.001) and greater depression severity (F[1, 2057]=17.29; p<0.001), but had a greater sense of Personal Efficacy (F[1, 2057]=8.24; p=0.004) than non-premedical students. Even after adjusting for depression levels, premedical students still experienced greater Personal Efficacy F[1, 2056]=17.93; p<0.001, and Emotional Exhaustion, F[1, 2056]=4.82; p=0.028) than non-premedical students. No differences were found in the levels of Cynicism between premedical and non-premedical students.

Gender and Burnout

There was a significant interaction between premedical status and gender with regard to Emotional Exhaustion (F[1, 2052]=4.41; p=0.036) and Cynicism (F[1, 2052]=7.19; p=0.007). There was also a strong trend for depression severity (F[1, 2052]=3.71; p=0.054). Specifically, women premedical students scored significantly higher on Emotional Exhaustion and Cynicism than non-premedical females. Premedical women were also more burned out on the dimension of Emotional Exhaustion than men. However, when depression severity was entered as a covariate in the general-linear model, the interactions of premedical status and gender became a statistical trend for Cynicism (F[1, 2051]=3.82; p=0.051), and Emotional Exhaustion became nonsignificant (F[1, 2051]=1.55; NS). No significant interactions were found between premedical status and gender with regard to personal efficacy.

Ethnicity and Burnout

There was a significant interaction between premedical status and ethnicity with respect to Cynicism (F[3, 2051]=4.55; p=0.003) and depression severity (F[3, 2051]=3.15; p=0.02). Specifically, premedical Hispanic students were found to have higher scores on Cynicism and depression than non-premedical Hispanics. However, when adjusted for depression, the interaction on Cynicism became a statistical trend (F[3, 2050]=2.26; p=0.080). No significant interactions were found between ethnicity and premedical status with respect to Emotional Exhaustion and Personal Efficacy.

This cross-sectional study is the first we are aware of that examines burnout in undergraduate premedical students and is one of few to control for depression. The results support our main hypothesis that premedical students experience more burnout than non-premedical students. Even after adjusting for depression severity, premedical students experienced greater burnout than other students, but they also exhibited greater personal efficacy. Being a premedical student, and perhaps especially a woman or Hispanic premedical student, may place one at increased risk for burnout. Yet it is clear that the risk is not attributable to burnout alone, but rather to a complex interaction between burnout and depression.

Premedical Student Burnout

Premedical students were found to have greater burnout scores in the dimension of Emotional Exhaustion than non-premedical students, even after controlling for depression severity. This is consistent with the findings that medical students and residents have moderate-to-high levels of burnout in the form of emotional exhaustion and cynicism, as compared with the working population (4, 6), but is the first report suggesting that problems with emotional exhaustion begin even before formal medical training. However, a similar level of cynicism in premedical and non-premedical students was unexpected, since the majority of research on medical students and residents report increased levels of cynicism (6). The finding that premedical students have higher levels of emotional exhaustion with similar levels of cynicism may hint at an increased stress experience (exhaustion) without a significant change in the student's response (cynicism) (2). It is feasible that if this stress experience is prolonged, burnout in the form of cynicism will emerge in premedical students, although longitudinal research must be done to support this conjecture. Our finding that premedical students had a greater sense of personal efficacy than non-premedical students is consistent with past studies on residents that have shown patterns of high emotional exhaustion with above-average levels of personal efficacy (25). The heightened sense of personal efficacy enjoyed by premedical students may be related to their academic success and involvement in a variety of extracurricular activities, possibly resulting in a greater sense of personal reward and accomplishment.

Gender and Premedical Status Interaction

The literature on gender and burnout is inconsistent. Some studies have found men to have greater cynicism and women with greater emotional exhaustion, whereas others have reported no differences (26). However, this is the first study to examine gender and premedical status together and is one of the few to also control for levels of depression. In this study, premedical women experienced more exhaustion and cynicism than non-premedical women. At this time, one can only speculate whether such early signs of exhaustion and cynicism are in any way related to the alarmingly high suicide rate found in women medical students and physicians (4, 27–29). We note that because there were no differences in emotional exhaustion or cynicism between premedical and non-premedical men, this interaction between premedical status and gender may be strictly a female phenomenon. However, these results must be interpreted with caution. When adjusted for depression severity, male and female premedical and non-premedical students had comparable personal efficacy and exhaustion levels, and cynicism became a statistical trend. Thus, these differences cannot specifically be attributed to burnout, but rather to differences in depression and, possibly, other factors.

Ethnicity and Premedical Status Interaction

When depression level was not considered, Hispanic premedical students were found to have higher levels of overall burnout and cynicism than Hispanic non-premedical students. Although the majority of differences in burnout disappeared when depression severity was added as a covariate, burnout levels have been shown to differ among ethnicities in undergraduate students (11). Research into a better understanding of the complex relationship between culture, depression, and burnout could provide enormous public health benefits.

Limitations

Several limitations must be considered in the context of these findings. First, an accurate response rate could not be specified because of difficulties in determining the number of students enrolled in psychology courses who participated in the course-credit program. Second, this study used the MBI-SS, whereas studies involving medical students, residents, and physicians rely on the Maslach Burnout Inventory Human Services Survey (MBI-HSS). Thus, the MBI-SS and the MBI-HSS may measure slightly different constructs. However, given that undergraduate students have different duties from those in medical school and beyond, the MBI-SS was the most appropriate measure. Third, the ethnic distribution of the responders was not representative of the U.S. population, making generalization to other student groups challenging. Fourth, the survey population consisted primarily of students with interests in biology, psychology, or medicine. Thus, results may not be generalizable to all undergraduates at UCSD or premedical students at other universities. Finally, the cross-sectional nature of this study precludes the possibility of making causal connections. These caveats aside, the substantial sample, and the implementation of validated and psychometrically sound measures of depression and burnout, provide important preliminary findings in a clinically meaningful area of investigation.

Factors related to premedical status could contribute to the development of burnout in undergraduates, which could lead to further physical and mental health sequelae in medical school and beyond. Given the substantial levels of burnout among residents and physicians, it is imperative to uncover when the seeds for burnout begin, and risk factors that may be potentially attenuated. Large-scale, multi-institutional, longitudinal research on these important areas must be done to better understand the causes and implications of premedical student burnout as well as to develop successful coping models (30). This research will aid in the ultimate purpose of developing methods to minimize the development of burnout and, when it cannot be prevented, to recognize, support, and treat those in need of help. Academic psychiatrists may play a key role in these important tasks.

Funding for this study was provided though the John A. Majda, M.D., Memorial Fund. The authors have no conflicts of interest.