International Journal of

Environmental Research
and Public Health

Article
Burnout and Its Relationships with Alexithymia,
Stress, and Social Support among Romanian Medical
Students: A Cross-Sectional Study
Ovidiu Popa-Velea *, Liliana Diaconescu, Alexandra Mihăilescu, Mara Jidveian Popescu and
George Macarie
Department of Medical Psychology, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”,
050474 Bucharest, Romania; [email protected] (L.D.); [email protected] (A.M.);
[email protected] (M.J.P.); [email protected] (G.M.)
* Correspondence: [email protected]; Tel.: +40-727-930-456

Academic Editors: Sharon Lawn and Carla Sabariego

Received: 1 March 2017; Accepted: 22 May 2017; Published: 25 May 2017

Abstract: Medical school students often experience emotional difficulties when handling the
challenges of their formation, occasionally leading to burnout. In this study, we measured
the prevalence of burnout and its relationships with perceived stress, perceived social support,
and alexithymia in medical students from the largest academic medical community in Romania.
A cross-sectional survey was administered to a randomized sample of 299 preclinical medical students
at the University of Medicine in Bucharest. Participants completed four standardized questionnaires.
In addition to the assessment of burnout prevalence, stepwise backward regression was used to
establish which variables had the highest correlation to burnout components. Further, t-tests were
run to assess gender-related differences. Overall, burnout prevalence was 15.05%. Perceived stress
was found to be the strongest predictor of emotional exhaustion and lack of accomplishment, while
the strongest predictors of depersonalization were low perceived social support (in women) and
alexithymia (in men). Women appear to be more vulnerable to two of the components of burnout
(emotional exhaustion and low personal accomplishment) and associate higher perceived stress and
alexithymia. These results suggest that interventions addressing academic burnout could benefit
from being gender-specific, with focus on key elements, such as perceived stress and alexithymia.

Keywords: medical students; burnout; perceived stress; social support; alexithymia; gender

1. Introduction
Medical education is considered to be one of the most demanding fields of specialized training,
in terms of program length and emotional requirements [1,2], particularly during the preclinical
years [3,4]. The distress experienced during this period has consistently been reported [5–7] and has
gained constant attention in recent decades [8]. A significant outcome of the cumulative distress
experienced throughout the academic track [1,9] is represented by the burnout syndrome, defined
as the presence of emotional exhaustion, depersonalization, and impaired personal accomplishment,
following repeated exposure to workplace stressors [10,11]. In medical academic environments, even
though the prevalence of burnout ranges widely [8,12–15], it is consistently referred to as a worrisome
issue, because of its consequences [15–17]. At the individual level, burnout is often associated with
poor health [14], alcohol, drug abuse [18], and an increased risk of suicidal ideation [12], all of which
can in turn impair professional life via increased risk of dropping out [19], cynicism, low empathy [20],
and a global deterioration of job performance. Numerous studies suggest that the high prevalence of
burnout in physicians may often originate in medical school [3,13–15,19,21–23], including during the
preclinical years [24,25].

Int. J. Environ. Res. Public Health 2017, 14, 560; doi:10.3390/ijerph14060560 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2017, 14, 560 2 of 10

The causes of burnout in medical students are often described in literature as having an
overwhelming association with specific characteristics of the academic environment, such as the
significant demands of the medical educational process, school schedule, the long duration of
studies [1], the vast nature of the curriculum and its potentially “hidden content” [26], frequent
examinations [27], lack of control [8], massive workload [28], and the difficulties in adapting to a new
social sphere.
Still, literature data [29–31] consistently suggest that personal factors could also have a decisive
importance on the onset of burnout, as they can moderate and alleviate the challenges of integrating
into a changing social environment. These often underexplored factors could be used as a potentially
significant resource in the prevention of burnout, especially when the social determinants of burnout
are unreachable or unchangeable. In this sense, alexithymia, perceived social support, and perceived
stress are all remarkable, because they share the property of being a reflection of the individual’s
position in relation to the surrounding circumstances. Additionally, these factors have been previously
described in the literature as potentially related to the onset and outcome of the burnout syndrome:

• Alexithymia is characterized by (a) difficulty identifying one’s feelings and distinguishing

them from bodily sensations and (b) difficulty communicating one’s emotions to others [32,33].
Its prevalence rises up to 17% in some reports [34–36], and it seems to be positively correlated
with the perception of subjective distress [34,37] and depression [38]. In the general population,
alexithymia is associated with higher global scores of burnout [38,39], or at least with some of its
components (e.g., depersonalization [40]). Moreover, this relationship has also been observed in
students [41,42]. In particular, medical students may be more susceptible to alexithymia, given
their lack of adjustment to the challenging situations encountered in their training.
• Perceived stress (along with lower levels of social support) has been described as being more
prevalent in academic contexts when compared to the general population [7] and being related
to higher levels of overall burnout or its components [8,13,14,17,43]. Generally, in the context of
professional life, it is often associated with a loss of interest for work, difficulties in interpersonal
relationships, and a poor physical condition [16,44].
• Perceived social support is reported to represent a protective factor against stressors [45,46],
for both youngsters [47] and students [48–50], while a lack thereof may be a risk factor for
burnout [13,14]. These findings, in conjunction with the fact that medical students report greater
needs of support than students from other academic domains [49], make this parameter important
to examine, in connection to burnout and perceived stress.

Although each of the three abovementioned variables seems to be individually related to burnout
(or at least to the predisposition towards it), little is known about their comparative importance,
particularly in academic environments. Consequently, research focused on describing their associations
to burnout appears relevant, especially since (a) students may be vulnerable to the cumulative effects
of burnout throughout their training [1–3,15] and (b) finding these relationships may provide targets
for a potential intervention, either specific (individual or group psychotherapy) or more general
(e.g., institutional strategies).
The current study aims to examine (a) the prevalence of academic burnout in Romanian medical
students during their preclinical years of training and (b) the comparative impact of perceived stress,
perceived social support, and alexithymia on the burnout scores of these subjects. Additionally,
our analysis is oriented towards identifying the possible role that gender plays in regard to these
associations. We hypothesized that the prevalence of academic burnout in Romanian medical students
is within ranges reported in current literature [8,12–15] and that perceived stress, alexithymia and
perceived social support contribute to the scores of burnout, with a distinctive influence of gender.
Int. J. Environ. Res. Public Health 2017, 14, 560 3 of 10

2. Materials and Methods

2.1. Participants
Participants were undergraduate students undergoing their preclinical training at the University
of Medicine and Pharmacy “Carol Davila” Bucharest, Romania (UCD). We focused on this study
group, since this university is the largest medical school in Romania, gathering students from all
regions of the country. Four hundred students were randomly selected from a total of 2000, with
a class of 12–15 students as the primary selection unit. Finally, 299 students (94 men, 205 women;
mean age = 19.23, SD = 0.59) agreed to participate in the study (74.75% response rate). All participants
met the inclusion criteria, set as being at least 18 years of age, having no self-reported psychiatric
morbidity, cognitive deficits or any other impairments which would render the understanding and
completion of the study questionnaires difficult.
Almost 70% of the participants were women, which is consistent with the higher proportion of
female enrollment in Romanian medical schools. The sex ratio between men and women in our sample
(94/205 = 1:2.18) was not significantly different from the sex ratio of all students (1:1.99) (χ2 = 0.546,
p = 0.461, ns).

2.2. Procedure
The study was performed in 2015 and 2016, at the beginning of the second school semester.
All participants completed informed consent forms before they took part in the study. The study was
run in accordance with the World Medical Association Declaration of Helsinki and with the ethical
guidelines published by the Committee of Ethics at the UCD.
The participants received sealable envelopes containing an explanatory statement, the written
consent form and the questionnaires. They were instructed to return the completed questionnaires,
together with the written consent form in the sealable envelope. The responses were processed
anonymously and a numerical code was assigned for each participant. The collected data were
accessible exclusively to study researchers (LD, AM, and MJP). Regular didactic staff was not present
during the distribution, collection, or interpretation of questionnaires.

2.3. Measurement Tools

All participants received four questionnaires: Maslach Burnout Inventory [10], Toronto
Alexithymia Scale [51], Perceived Stress Scale [52], and Duke-UNC Functional Social Support
Questionnaire [53]. The rationale for choosing them was based on the following existing data:
(1) Maslach’s 22-item Burnout Inventory (MBI) is a widely used tool to assess burnout. It contains
three subscales, reflecting one’s personal feelings and attitudes: emotional exhaustion (EE) (9 items),
depersonalization (DP) (5 items), and lack of personal accomplishment (LPA) (8 items). The answers
can range from 0 (never) to 6 (every day), with each subscale score computed through summation.
The test is generally easy to perform and has a good reported test–retest reliability of up to 0.82 and
high validity [54,55]. In our study, we considered the criteria of burnout to be met if the participants
had a score above 30 on the EE scale and if at least one of the scores of the other two dimensions were
above the recommended cut-off points (DP: 11; LPA: 35).
(2) TAS-20 is currently considered to be one of the most valid measures of alexithymia [56]. It is
a self-report scale with 20 items, on which scores higher than 61 indicate alexithymic characteristics.
This test has been reported to have good internal consistency (Cronbach’s alpha = 0.81) and test–retest
reliability (0.77, p < 0.01) [51], as well as adequate levels of convergent and concurrent validity.
(3) Perceived Stress Scale (PSS) is a 14-item self-report instrument, designed to measure the degree
to which situations in one’s life are appraised as stressful. Each item is rated using a 5-point Likert
type scales, the total of which may range between 0 and 56. This psychometric tool has been described
to depict convergent validity, indicated by its solid relationships with depressive (r = 0.76, n = 332) and
physical (r = 0.70, n = 64) symptomatology scales [52].
Int. J. Environ. Res. Public Health 2017, 14, 560 4 of 10

(4) The Duke-UNC Functional Social Support Questionnaire (FSSQ) measures the strength of the
person’s social support network. It consists of 8 items, scored on a 1 to 5 scale, with higher scores
corresponding to a greater perceived social support. This instrument has been reported to have high
construct validity and high internal reliability (Cronbach’s alpha = 0.81–0.92) [53].

2.4. Design and Analysis

This cross-sectional study measured burnout, alexithymia, perceived stress, and perceived
social support, with burnout as a dependent variable, and the other three as independent variables.
Responses were processed using the SPSS Statistics 17.0.1 software package (SPSS, Inc., Chicago, IL,
USA). The analysis included firstly a descriptive level, focused on assessing where our study variables
lie in the normality–abnormality continuum. Next, a series of t-tests for independent samples were
run to assess gender-related differences and their significance. Later, stepwise backward regression
analysis was used to establish the strength of associations between variables. This analysis was also
run separately by gender. Missing data were handled through listwise deletion. Assumptions of data
normality and linearity were confirmed using histograms and partial plots. The independence of errors
was checked through the Durbin–Watson test and homoscedasticity using *ZRESID and *ZPRED plots.
For all calculations, the threshold of statistical significance was p < 0.05.

3. Results

3.1. Descriptive Analysis

15.05% of the participants met all criteria for burnout. Emotional exhaustion was encountered in
16.72% of study participants (10.63% men, 19.51% women), depersonalization in 28.42% (men: 39.36%,
women: 23.41%), and lack of personal accomplishment in 10.70% (men: 11.70%, women: 10.24%). Total
prevalence of clinical alexithymia was 6.02% (men: 2.12%, women: 7.80%). The percentage of perceived
stress above the 3rd quartile was 26.42% (men: 15.95%, women: 31.22%). The percentage of respondents
with perceived social support below the 1st quartile was 25.41% (men: 25.53%, women: 25.36%).

3.2. Gender Differences

Women had higher mean values for two out of the three components of burnout (emotional
exhaustion and lack of personal accomplishment) but also for alexithymia and perceived stress.
Significantly lower means were found in men at emotional exhaustion (t = −3.219, p < 0.001),
alexithymia (t = −0.414, p < 0.016), and perceived stress (t = −3.065, p < 0.002) (Table 1).

Table 1. Gender differences.

Variables Men (n = 94) M (SD) Women (n = 205) M (SD) p*

Burnout components
EE 18.66 (7.87) 22.20 (9.23) 0.001
DP 12.34 (6.52) 11.01 (7.00) 0.120
LPA 18.88 (8.40) 20.24 (8.01) 0.182
Alexithymia 43.99 (8.09) 46.93 (10.47) 0.016
Perceived social support 38.55 (7.05) 38.268 (6.72) 0.738
Perceived stress 17.40 (7.08) 20.05 (6.85) 0.002
* t-test for independent samples (df = 297); M = Mean, SD = standard deviation; EE = emotional exhaustion;
DP = depersonalization; LPA = low personal accomplishment.

3.3. Burnout and Its Associations

First, we ran separate Pearson’s correlations between the three components of burnout (EE,
DP, and LPA) and perceived stress, alexithymia, and perceived social support, respectively. These
correlations were statistically significant, suggesting that the studied dimensions were not confounding
(Table 2).
Int. J. Environ. Res. Public Health 2017, 14, 560 5 of 10

Table 2. Pearson’s correlation matrix.

EE DP LPA
Variables
Men Women Men Women Men Women
Perceived stress 0.285 * 0.386 § 0.240  ns 0.503 § 0.300 §
Alexithymia 0.218 † 0.186 † 0.241  ns ns 0.231 §
Perceived social support ns −0.200 * −0.222 † −0.163  ns −0.177 *
Only correlations of the dependent variables (EE, DP and LPA) were included. EE = emotional exhaustion;
DP = depersonalization; LPA = low personal accomplishment. * p < 0.003; § p < 0.0005; † p < 0.002;  p < 0.01.

Next, we ran a hierarchical multiple regression (backward method), in order to assess the
weight of each contributing factor on the scores of the burnout components, as recommended by
the author of the questionnaire [57]. Using this procedure, all independent variables (alexithymia,
perceived stress, and perceived social support) were introduced into one model and the non-significant
relationships among them were eliminated, resulting in a final model that ensured a minimum number
of significant predictors.
For emotional exhaustion in men, the only significant predictor was perceived stress (p < 0.005),
whereas in women the significant predictors were perceived stress (p < 0.0005) and alexithymia
(p < 0.030). In men, regression eliminated, at the first step, perceived social support (coefficient = 0.002,
95% confidence interval [CI] = −0.222 ÷ 0.226) and, at the second step, alexithymia (coefficient = −0.116,
95% CI = −0.302 ÷ 0.070). In women, regression eliminated, at the first step, perceived social support
(coefficient = −0.117, 95%, CI = −0.301 ÷ 0.067).
Concerning depersonalization, the significant predictors among men were perceived stress
(p < 0.029) and alexithymia (p < 0.028), while for women the only predictor was perceived social
support (p < 0.020). In men, regression eliminated, at the first step, perceived social support
(coefficient = −0.165, 95% CI = −0.349 ÷ 0.018); for women, regression eliminated, at the first step,
alexithymia (coefficient = 0.021, 95% CI = −0.073 ÷ 0.115) and, at the second step, perceived stress
(coefficient = 0.070, 95% CI = −0.074 ÷ 0.214).
On the scale describing lack of personal accomplishment, the only significant predictor in men was
perceived stress (p < 0.0005), whereas for women it was perceived stress (p < 0.0005) and alexithymia
(p < 0.003). In men, regression eliminated, at the first step, perceived social support (coefficient = 0.057,
95% CI = −0.160 ÷ 0.275) and, at the second step, alexithymia (coefficient = −0.116, 95% CI = −0.302 ÷
0.070). In women, regression eliminated, at the first step, perceived social support (coefficient = −0.081,
95% CI = −0.244 ÷ 0.083).
The detailed results are displayed in Table 3.

Table 3. Predictors of burnout components (hierarchical multiple backward regression) *.

Regression Standardized
Gender Variables in the Model 95% CI p R2
Coefficient Beta
Emotional exhaustion
Men Perceived stress 0.317 0.080 ÷ 0.516 0.285 0.005 0.119
Perceived stress 0.496 0.325 ÷ 0.668 0.369 0.0005
Women 0.168
Alexithymia 0.124 0.012 ÷ 0.237 0.141 0.030
Depersonalization
Perceived stress 0.203 0.021 ÷ 0.385 0.221 0.029
Men 0.106
Alexithymia 0.178 0.019 ÷ 0.337 0.222 0.028
Women Perceived social support −0.170 −0.312 ÷ −0.027 −0.163 0.020 0.027
Low personal accomplishment
Men Perceived stress 0.597 0.385 ÷ 0.809 0.503 0.0005 0.245
Perceived stress 0.323 0.171 ÷ 0.475 0.276 0.0005
Women 0.129
Alexithymia 0.151 0.052 ÷ 0.251 0.198 0.003
* Variables included in the analysis were perceived stress, alexithymia, and perceived social support. p-value for
inclusion in the model was 0.05.
Int. J. Environ. Res. Public Health 2017, 14, 560 6 of 10

4. Discussion
This study examined the prevalence of burnout and its relationships to alexithymia, perceived
stress, and perceived social support among Romanian undergraduate medical students.
We found the prevalence of burnout in our sample to be 15.05%, which is at the lower end
among rates reported in other publications concerning this issue [8,12–15]. Among the individual
burnout components, depersonalization was met in the highest percentage of participants (both men
and women), suggesting that counseling strategies should focus on this dimension, for example,
through exploring the individual discrepancies between expectations regarding medical school and
its demands.
Among the three studied variables, perceived stress was found to exhibit the strongest association
with burnout, in all of its components, and to single handedly explain 10–24% of the variance in
burnout. This finding is sustained by other literature data that report a solid correlation between
perceived stress and various components of burnout [13,16,31,58,59]. The hierarchy of predictors was
completed by alexithymia, which, together with perceived stress, accounted for an additional part
of burnout variance (up to 16% in women, for the component of emotional exhaustion). In contrast
to the aforementioned variables, perceived social support played a much smaller role, contributing
only to a minor proportion (2%) of the variance of depersonalization in women. This order suggests
that, in medical academic contexts, to prevent and address burnout, it is crucial to prioritize (1) the
alleviation of the perception of stress and/or addressing frank symptoms produced by stress (for
example through individual counseling) and (2) the creation of conditions necessary for the secure
expression of one’s emotions (thereby preventing alexithymia).
Gender seems to have a distinctive influence on the development of burnout in women,
particularly in what concerns emotional exhaustion. According to our findings, this can be explained,
at least partially, by the higher perceived stress and alexithymia in this group. Concerning perceived
stress, female medical students obtained significantly higher scores than men (p < 0.002), regardless of
having received a similar degree of perceived social support (p < 0.738, ns). With respect to alexithymia,
young women obtained higher scores than young men (p < 0.016) (in contrast to older adults [60]).
This finding is supported by other studies on this topic [61,62], which claim that young females
could be more prone to alexithymia, particularly in stressful circumstances, due to poorer emotional
expressivity, greater difficulty in identifying and describing their feelings, and an externally oriented
thinking style. As a whole, our findings concerning the higher relative risk of burnout in women
compared to men are backed up by several literature data, especially those identifying women as
processing negative life events in a more emotional way [63]. The inability to identify one’s feelings
in relation to a stressful circumstance or to describe them (both components of alexithymia), or the
feeling of not having support in certain circumstances, seems to predispose young women to focus on
the impossibility to overpass difficulties, which creates the condition for emotional exhaustion and
burnout. Another possible mechanism is the overestimation of one’s own level of stress. In contrast,
alexithymia and perceived social support play a much less significant role (or none) in the dynamic
of burnout in men, giving rise to the hypothesis that burnout in this group is created merely by the
objective elements of the stressful situation.
The limitations of our study stem mainly from its cross-sectional design and the generalizability
of the results. To address this, larger prospective multicenter studies are needed. Ideally, these would
evaluate students prior to the start of their studies, during medical school and then again after the
completion of their degree, as young doctors. Such studies could also assess additional factors that
may influence the onset of burnout (e.g., sense of coherence, optimism) or the reversed relationships
between study variables.
In part, our study limitations are due to the mere heterogeneous nature of the studies regarding
burnout in academic settings, which challenges our ability to collect enough comparable data or to
assess its significance. In this sense, a consensus among researchers in this field could be very useful
Int. J. Environ. Res. Public Health 2017, 14, 560 7 of 10

towards the creation of a gold standard for studying burnout in the academic environment, as well as
a set of recommendations for “best practice.”

5. Conclusions
The results of the current study point out that perceived stress and alexithymia may play a
significant role in the development of burnout syndrome in medical students, particularly in women.
The cumulative risks for burnout brought on by these two psychological characteristics, in conjunction
with the impact of other contextual environmental factors, raise the issue of addressing them in an
early phase, in order to prevent the development of burnout after years of future practice [64,65]. Our
findings provide a basis for a local initiative to develop a series of interventions focused on preventing
burnout in medical students, similar to the established programs for practicing physicians (such as
Narrative Medicine or Balint groups). Designing isomorphic programs dedicated to medical students
that address perceived stress and alexithymia with regard to gender-specificity is indeed a challenging
task, but it is also a strategy useful for minimizing the risk of burnout.

Acknowledgments: This study was conducted from personal funds. The authors would like to thank warmly
Ioana Cioca and Mihaela Staicu for the precious input in the early phase of this study and to Ana Maria Luca and
Noreen Cora Călin for their valuable contribution in the editing process.
Author Contributions: Liliana Diaconescu and Alexandra Mihăilescu participated in data collection, data
interpretation, and wrote sections of the manuscript. Ovidiu Popa-Velea and George Macarie performed the data
analysis and interpretation and wrote sections of the manuscript. Mara Jidveian Popescu participated in data
collection and wrote sections of the manuscript. All authors read and approved the final version of the manuscript.
Conflicts of Interest: The authors declare no conflict of interest.

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