This study contributes several important findings to the current body of knowledge. First, psychological distress predominantly has a direct effect on escalating the burnout level of medical students. Second, academic stress has direct and indirect effects (mainly mediated through psychological distress) on increasing the burnout level of medical students during stressful events. Third, neuroticism predominantly has an indirect effect, mediated through psychological distress and academic stress, on increasing medical students’ burnout levels during stressful periods. Fourth, EI mainly demonstrates a direct effect on reducing the burnout level of medical students during stressful events. Lastly, EI was significantly compromised by the increase of psychological distress and neuroticism, leading to burnout.
First, psychological distress predominantly had direct effects on escalating the burnout level of medical students. In fact, it had the greatest direct standardised effect in positively predicting burnout – making it the strongest predictor of burnout in medical students. This finding corresponds to previous studies that showed a significant positive correlation between psychological distress and burnout (3), a significant negative correlation between psychological wellbeing and burnout (59), a significant positive correlation between burnout and depression (60–64), a significant correlation between anxiety and burnout (64–66), and the strong association of burnout severity with the prevalence of depression (67). These indicate that psychological distress is the major predictor of burnout, highlighting the importance of reducing unnecessary psychological pressures (sources of stress that are not needed to be introduced), thus leading to better psychological health and eventually reducing burnout in medical students (68, 69). Designing a systematic support system, for instance a peer-support system, to support medical students experiencing difficulty may improve their psychological distress by helping to reduce unnecessary psychological pressures (12, 19).
Second, academic stress demonstrated direct and indirect effects (mainly mediated through psychological distress) on increasing the burnout level of medical students during stressful events. In fact, academic stress had the second greatest total effect on burnout. This finding is consistent with previous studies that reported daily hassles positively correlated with burnout (64), academic stress negatively correlated with personal wellness (70), perceived stress associated with burnout (71), and academic stress as the most predictive of burnout (72). These facts suggest that the psychological wellbeing is negatively affected by high academic stress due to the demands of medical training (70, 73). Taib et al. (2020) explained that “Most budding doctors believe that hard work, sweat and dedication would lead to successful careers” (p.66). Unfortunately, many trainees experience medical and mental health problems, which have become more apparent and overwhelming following the demands of clinical training. Thus, empathetic and healing relationships are vital rather than suspicion and hatred when dealing with the unwell student (12). It is possible that lowering superfluous academic stress by reducing unnecessary syllabus, course load, workload, and psychological pressures while fostering psychological support, a healthy learning environment, sufficient learning time, and adequate breaks would improve their psychological wellbeing and prevent them from developing burnout (19).
Third, neuroticism predominantly had an indirect effect (mediated through psychological distress and academic stress) on increasing medical students’ burnout levels during stressful periods. Previous studies reported that certain personal traits can contribute to stress among medical students and reduce their wellbeing (73), for instance, neuroticism demonstrated a positive correlation with emotional exhaustion and cynicism and a negative correlation with professional efficacy (74), burnout risk was strongly associated with neuroticism (75); and neuroticism positively correlated with psychological distress (19). These findings recognize neuroticism as a negative predictor of psychological wellbeing. One possible reason is potentially due to the tendency of individuals with high neuroticism to experience negative feelings and to have poor coping ability in stressful circumstances (77, 78), making them less suitable for medical training that is complicated and stressful (79, 80). On that basis, medical schools should consider including neuroticism as a criterion in the recruitment of candidates into medical programs because it will influence the quality of medical graduates (81).
Fourth, EI demonstrated a direct effect on reducing the burnout level of medical students during stressful events. This finding is aligned with several studies reporting that EI scores correlate inversely with emotional exhaustion and depersonalization (82), that EI was strongly predictive of emotional exhaustion and depersonalization (82), and that higher EI scores were significantly correlated with lower burnout (83). These facts indicate that individuals with higher EI will have a better psychological state and be less vulnerable to developing burnout. Emotionally intelligent persons know how to handle their own and others’ emotions and being able to deal with emotions effectively makes them less vulnerable to developing burnout. Hence, developing a special program to cultivate medical students’ EI could help students to face the demands and challenges of medical training, thus preventing them from developing burnout. Medical schools could also possibly include EI as a criterion for the recruitment of candidates into medical training, thus will minimise the vulnerability of students to develop burnout.
Lastly, EI was significantly compromised by the increase of psychological distress and neuroticism, which led to burnout. It was evident in the literature that EI correlated positively with psychological wellbeing and inversely with depression (82), that self-perceived stress was lower in those with higher EI (84), that psychological distress showed a negative correlation with EI scores (85), and that EI demonstrated negative correlations between anxiety, stress, and depression (86). One important fact from these findings is the indirect mechanism through which psychological distress causes burnout is by lowering the EI of medical students. Similarly, personality contributed significantly to EI, especially neuroticism, which demonstrated the largest independent negative contribution to the increase of burnout (87) via the same indirect mechanism as psychological distress. This is a significant fact for consideration given that medical students usually have high EI but are still vulnerable to burnout if they are consistently exposed to chronic excessive psychological pressure. This is known as a wear and tear phenomenon due to the depletion of the emotional reservoir in handling chronic exposure to prolonged excessive psychological pressures (88), especially in those with high neuroticism.
Based on the SEM, several practical applications can be recommended to medical educators, students, and medical schools. First, medical educators should try their best to avoid introducing psychological pressures that are not needed to students, especially academic-related stress. This approach will minimise the sources of psychological distress and burnout, hence, lead to better mental health. Second, medical students should do their best to develop a positive and healthy mindset towards academic matters that will help them to thrive under pressure. Third, medical schools should introduce programs that help medical students manage their stress and develop their EI. These wellbeing strategies will foster resilience and prevent burnout. Lastly, medical schools maybe should consider including neuroticism and EI as part of the admission criteria to recruit candidates into the medical program. Candidates with low neuroticism and high EI will be able to handle the medical training pressure in a better way, thus minimising the probability of them developing psychological distress and burnout.
It is worthy to mention this research was conducted at a medical school; therefore, any attempt to generalise the results to other settings should be done cautiously. A multi-centre research should be conducted in the future to validate the proposed model. Besides, the sampling technique used was not the ideal method due to the limitation of the non-probability technique due to sampling bias, which may cause imprecision of the obtained results. Hence, future research should use the probability sampling technique to overcome this limitation. Despite these limitations, this research has several strengths. First, the research variables were measured by validated research tools, and the obtained results supported the measurement model fit. Second, the sample size was satisfactory for SEM; thus, the obtained results are trustworthy for the proposed structural model. Third, the analysis was conducted by standard and recommended statistical software; therefore, the obtained results can be trusted and compared with previous studies. Lastly, as far as the author is aware, this is the first attempt to describe the causal-effect relationships of burnout, psychological distress, academic stress, neuroticism, and EI through SEM.