Burnout Syndrome Amongst Medicine Students in Lithuania and Germany

Summary. Background. The research provides comparative analysis of the burnout syndrome among medical students in Lithuania and Germany and determines relations between burnout and lifestyle, health complaints and seeking for psychological help. Materials and methods. The research was conducted in April 2019 using an anonymous self-administered e-based questionnaire. The sample size was 261 medical students (age mean 20,5 ± 1,8, 46 males, 215 females): 131 from Vilnius University (VU), 67 from Lithuanian University of Health Science (LSMU) and 63 from Heidelberg University (HU), Germany. The 15 items MBI-SS scale was used to identify burnout syndrome among students (Cronbach α =0,74). Emotional exhaustion (>14), cynicism (>6), and professional efficacy (<23) scores were calculated for academic burnout. The participants were also asked additional questions related to lifestyle and well-being. Descriptive statistics were analysed using MS Office Excel, SPSS and R Commander, results were statistically significant when p<0,05. Results. 51 (38,9%) VU, 25 (37,3%) LSMU and 10 (15,9%) HU students were ascertained as burnt-out (p=0,004). 76 (90,6%) respondents complained of feeling study induced mental stress (p=0,0002). Furthermore, 67 (77,9%) respondents indicated having a bad mood (p=0,043), 54 (62,7%) general weakness (p=0,024), 44 (51,1%) digestive problems (p=0,003). Sleep duration was strongly associated with burnout (p=0,002) with over half (n=51, 59,3%) of the burnout respondents sleeping <7 hours a day. 87 (33,3%) students considered consulting a psychologist, but only 24 (9,2%) reached out for help. Conclusions. More than 1/3 of medical students in the research group had signs of burnout. The highest prevalence of burnout was among VU and lowest among HU students. Burnt-out respondents complained of mental stress, weakness, bad mood, digestive problems. The university studies and the duration of sleep can impact the occurrence of burnout syndrome. Only every forth student, willing to consult a psychologist, sought assistance.


Introduction
In our busy day and age, the number of people that suffer from stress, anxiety and negative emotions is increasing every single day [1][2][3]. All of these reasons can encourage the manifestation of burnout [4,5]. Burnt-out people start to feel incompetent, sad and guilty. They lose their motivation and purpose. Burnout has a negative effect not only to a person suffering from it but also towards his/her relationships. This dreary state can initiate the end of relationships, the rise of depressive or suicidal thoughts. A study conducted in Poland discovered that people who are not prone to "burning-out" or are burnt-out at a minor level, are more content with their relationships, health and work. On the other hand, people experiencing medium to high levels of burnout are usually dissatisfied with their financial situation, complain of the lack of free time and troubled relationships with their friends and family. In other words, burnout syndrome, in one way or another, impacts the quality of person's life [6].
Maslach and Jackson described burnout as a syndrome composed of three dimensions: depersonalization (cynicism), emotional exhaustion, and a lack of personal accomplishment [7]. C. Maslach's -one of the most notorious researchers of this syndrome -research revealed that during burnout one of the first symptoms is the loss of emotions and senses, and only later is it followed by a negative outlook towards one's self and others. In that sense, burnout is regarded not as a disease, but as an organic whole of symptoms (a syndrome).
Academic burnout is a far newer (2002) and more rarely discovered topic in literature in comparison to the earlier described professional burnout [8]. It is worth noting that academic burnout is becoming a common problem among university and college students alike. The indications of academic burnout include emotional drain, cynicism and a decrease in learning productivity. Academic burnout varies from professional as only the well-being related towards the study process is considered, whilst relationships are excluded. Medical students are often selected as study subjects of the matter as due to the vast amount of information, high standards and limited free time, they are among the most prone to lose connection with themselves and to burnout [9]. Studies show that even 33% medical students abuse alcoholic substances, whereas only 16% of nonmedical students in the same age group face this problem [10]. Burnt-out students experience the following psychological and clinical symptoms: depression, insomnia, anxiety, inability to concentrate, headaches and digestion issues [11].

Study design and population
This was an observational cross-sectional study which was carried out at three medical schools: Vilnius University (VU), Lithuanian University of Health Sciences (LSMU) and Heidelberg University (HU). The study was conducted in April 2019 and involved 261 medical students.

Eligibility criteria
Students included in the study were those enrolled in the six years undergraduate medical course who voluntarily agreed to answer the questionnaire.

Instrument
Medical students were asked to complete a self-administered e-based questionnaire. The academic burnout was assessed using MBI-SS (Maslach Burnout Inventory-Student Survey). WB. Schaufeli, M. Salanova, BA. Bakker in 2002 had adapted MBI-GS to Spanish, Portuguese and Dutch students [8]. The MBI-SS consists of 15 statements divided into three subscales representing academic burnout: emotional exhaustion (five statements), cynicism (four statements), and professional efficiency (six statements). Responses on the MBI-SS range on a six-point Likert-scale from never to always. The three dimensions (high scores for emotional exhaustion and cynicism and low scores for academic efficiency) were used as the criteria for the diagnosis of academic burnout. The alpha Cronbach statistic for emotional exhaustion items was 0,9 while that for cynicism items was 0,91, and for professional efficiency items was 0,84. When three subscales were combined, the Cronbach's alpha value for this study was 0,74. The sociodemographic characteristics also were assessed: gender, age, marital status, leisure time, physical activity, sleep duration, eating habits, smoking, drinking, health issues. In order to evaluate academic work and regime students were asked about the attendance of lectures and time spent for self-study.

Data analysis
Various statistical variables were evaluated: sample size, median, mean, standard deviation and frequency. The Kolmogorov-Smirnov test was used to test the normality of quantitative variables, as the sample contains 261 medical students. For qualitative variables the frequencies and percentages were calculated. Categorical variables were compared using Chi-square (χ2) and Fisher exact tests, and qualitative variables were compared using Wilcoxon test. The MS Office Excel, SPSS statistics and R Commander were used for the analysis. Differences were considered as statistically significant when p< 0,05.
Also, more than a third (n=100, 38,3%) of the respondents do not know what kind of health status is determined by the term "burn-out syndrome".
In Figure 2 the necessity of a psychologist help between student groups with and without burnout is shown. It can be seen that the majority of respondents have not consulted with a psychologist. Students with burnout are more likely to get psychological help. 87 (33, 3%) of the medical students who participated in the study would be willing to consult a psychologist, but only 24 (9,2%) reached out for help.

Discussion
Th e aim of the presented study was to investigate the prevalence of burnout syndrome among Lithuanian and German medical students by assessing their lifestyle and other sociodemographic characteristics. Th e study showed that burnout syndrome has a signifi cant impact on well-being and mental health of the surveyed students. Th ere are many causes of burnout and each additional stressor increases the risk of more serious consequences for mental health, but there is also a signifi cant causeand-eff ect diff erence between developed and developing countries. In terms of developed countries, in Lithuania and Germany we have noticed reduced sleep time, alcohol abuse and irregular meals during the day. Medical studies are heavily burdened with psychological stress factors, and the addition of confl icts between family and career could lead students to a higher risk of being burnt out. According to another study, if medical students were encouraged to adopt healthier lifestyle changes in their daily lives from the very beginning of their studies, burnout outbreaks and their following consequences could be prevented or at least reduced in their further careers [12].
It should be noted, that it is significant not only to understand the causes and consequences of burnout, but also ways to reduce the risk of experiencing psychological distress or mitigate the already existing negative psychological consequences.
Nowadays, burnout syndrome is increasingly being recognised as a significant mental health issue in global health around the world. However, like several mental health disorders, this syndrome is highly neglected. Most interviewees with established burnout syndrome do not seek psychological help or claim that psychologist services were ineffective, especially at Lithuanian universities. Although some students clearly understand the need and benefits of psychological help, there are some barriers that discourage young people from seeking professional psychologist's or psychotherapist's advice. According to another study, the most common barrier to seeking psychotherapy seems to be public and self-stigma. Some decide to stop consulting psychologists after a first visit they believe to be unsuccessful, because they no longer believe in the success of the process. Yet other medical students choose not to seek for specialists because of financial costs, especially when the sources of income are extremely limited and studying takes up most of their time [12]. So even if medical students are usually aware of the advantages of psychotherapy for their patients, they often do not accept themselves as people who also need professional help.

Conclusions
The results of the study confirm that more than a third of medical students in the research group had signs of burnout. The highest prevalence of the burnout was among VU and the lowest one among HU students. Burnt-out respondents complained of mental stress, weakness, bad mood, digestive problems. The study also revealed that the university studies and duration of sleep can impact the occurrence of burnout syndrome. Only every forth student, willing to consult a psychologist, sought assistance.