This study showed high prevalence of burnout syndrome among medical interns, affecting more than half of the participants (57.5%). The prevalence of high emotional exhaustion was 33.1% (N=38), 45.7% (N=58) of high depersonalization and 36.2% (N=46) of low personal accomplishment. Students with participation in community services as an extracurricular activity had lower prevalence of high depersonalization (PR 0.61, CI 95% 0.42 - 0.88).
These results are consistent with some studies that found high prevalence of BS among medical students (28,29). Dyrbye et. al. evidenced that medical students were more likely to have burnout syndrome and depression than the general population (30). A recent published meta-analysis including 24 studies and 17,431 medical students showed a prevalence of 44.2% (CI 95% 33.4 - 55.0%) of burnout syndrome, 40.8% of high EE (CI 95% 32.8 - 48.9%), 35.1% of high depersonalization (CI 95% 27.2 - 43.0%) and 27.4% of low PA (CI 95% 20.5 - 34.3%) (31).
The BS prevalence is similar to other Brazilian studies analysing the interns´ population, showing high levels of emotional exhaustion and depersonalization (14,32). The high prevalence of BS observed is concerning since it may also interfere with quality of patients´ care, especially with high depersonalization scores (33). A recent study in Mexico published by Miranda-Ackerman et. al evaluated 176 interns and found prevalence of 43.1% of high EE, 53.9% of high DP and 34.6% of low PA (25).
There are several factors associated with the high prevalence of BS in internship. The internship has particular challenges compared to the early years as a medical undergraduate. Some are related to closer contact with patients´ suffering and deaths, what could cause students´ suffering and internal conflicts (34). Another challenge is the organization of educational process for the workplace training, that is very different of the previous years of medical education. There are increase in responsibilities and demands to the students, greater hours in the workplace, increasing lack of sleep, frustration of working with time constrains, lack of ideal conditions to provide care, low motivated teams and eventually unprofessional attitudes, causing moral distress among students (35,36).
In Brazilian medical education most of internship occurs within the Unified Health System (Sistema Único de Saúde), a public health system of primary, secondary and tertiary care services. Most Brazilian medical schools have partnerships with municipalities to work within these services. These arrangements introduce the opportunity to work with poverty and vulnerable groups, what could be an extra emotional challenge for students to cope with. Another factor associated with BS in health professionals are related to work organization. Management in health services with better work processes organization could influence on health professionals´ and medical students mental health (4).
There is a conceptual model of medical student well-being integrating the idea of coping reserve of each individual that includes negative and positive inputs. Dunn and colleagues suggested that negative inputs include stress, internal conflicts, time and energy demands. And positive inputs include psychosocial support, social and healthy activities, mentorship and intellectual stimulation. These inputs interact with personality traits and temperament factors, as resilience, changing the way that each individual perceive difficulties and demands (20).
Social support could have a protective effect for BS in medical students (16,37). Although this study found a difference of self-rated social support sought by women, which reported to rely more on family and partners than men, this not associated with BS. This study found high frequency of the behaviour of seeking social support, as 94.2% of students reported to rely on colleagues of the same rotation, 79.3% on family, 76.0% on friends within medical school (but different rotation), 74.2% on romantic partner and 68.6% on friends outside medical school. This could be explained by the questions used to evaluate social support or the lack of evaluation of quality or sufficiency of social support. Houpy et. al. evaluated medical interns and found that, after difficult clinical events, interns have the desire to talk about it in the same day (78.1%). Those who are comfortable to talk about stress and BS had higher resilience scores (38). Despite the fact that some evidence shows that social support is an important coping mechanism against BS, there is no evidence in the data of present study that indicates the association of seeking social support and BS among the interns.
Being a medical undergraduate is emotionally challenging and one of the proposed buffers to mental suffering is healthy extracurricular activities, as music programs, theatre or physical activity (20). The extracurricular activities can help or worsen the balance to maintain or achieve a better mental health status. This study observed high frequencies of participation in extracurricular activities related to medical students as 94.3% participated in academic programs, 85.1% in community programs and 47.9% in athletic activities. Individuals with participation in community services had lower prevalence of high depersonalization (PR 0.61, CI 95% 0.42 - 0.88). There is evidence that altruism is associated with happiness, better well-being and health, even longevity (39,40). Although we did not find studies with the exact same results in medical education, Dyrbye et. al. surveyed 4,400 students from seven American medical schools and found that as mental health improves, students had more altruistic professional beliefs, as the desire to work with underserved populations (41). Some possible explanations are that emotional exhaustion and fatigue related to BS could reduce the willingness to work in community services as an extracurricular activity, or the depersonalization could reduce the joy related to these activities. The students with BS could also perceive the workload as critical, reducing some extracurricular activities that are perceived as less important to entrance in residency programs. However, these possibilities are still underexplored in medical education literature.
Our study had some limitations. The response rate was lower than expected, although several studies had response rates similar to our study and lower than 70% (19,24,25). The cross-sectional design had limitations to infer causality. It was not used a validated tool to analyse social support and it was not asked to the students in the present study if the social support were perceived as sufficient or not. The strengths of our study are the use of a validated questionnaire to evaluate BS and the population of interns in the initial approach. The focus on protective factors of BS and its subscales (social support and extracurricular activities) is recent in medical research. More studies with longitudinal design are needed to better understand the BS causality and its association with resilience training, medical schools ́ institutional social support programmes and educational climate.