Well-being and Burnout among Pre-clinical Medical Students in a Caribbean Medical School

Evaluate well-being and burnout among preclinical medical students in a Caribbean medical school and identify the associated factors. It was a questionnaire-based, cross-sectional study which was conducted among preclinical medical students of Trinity Medical Sciences University (TMSU), Saint Vincent & the Grenadines. Medical Student Well-Being Index and Maslach Burnout Inventory-Student Survey were used. The total number of participants who gave informed consent was 82. For statisti¬cal analyses, internal consistency of the instruments was tested by Cronbach’s alpha. The Student t - test, Fisher’s exact test, Pearson correlation and multivariate regression model were used. The analysis of well-being index (WBI-MS) showed that during the past month 78% of participants experienced burnout due to emotional exhaustion and 61% due to depersonalization, 63.4% felt depression, 19.5% experienced fatigue, 65.9% suffered from stress. The significant association was found between well-being index, credit hours allotted for the semester, and depersonalization/cynicism. Also, there was significant negative correlation among academic efficacy and cynicism. The analysis also showed that once a week or more often 58.5 % of participants experienced emotional exhaustion, 34.2% depersonalization and 26.8% low professional efficacy. But the level (severity) of emotional exhaustion was less in comparison with depersonalization score. Our study revealed that 65.9% of participants had a low well-being index and high level of burnout with very increased score of cynicism, which negatively affected their academic efficacy. The possible causes of the obtained results were identified and necessary strategies will be implemented to improve the outcomes.


INTRODUCTION
Burnout is characterized by emotional exhaustion, depersonalization and an inadequate sense of personal achievement due to stressful work conditions (Dyrbye, 2019).Burnout, mental sickness, and substance use are more predominant in medical students compared to the common population due to intemperate scholarly, individual, and societal stressors.All these have eventually a negative effect on the student's scholastic execution, physical health, create successful programs to promote the well-being of students if it could identify the pertinent causes of student's distress.

METHODS
The online study using Google form was conducted at Trinity Medical Sciences University (TMSU), Saint Vincent & the Grenadines.The study was approved by the institutional review board of the university.All students in preclinical years (Terms 1 to 4) were invited to participate in this study.Each term in preclinical years is of 15 weeks duration.This study was conducted after the mid-term examination between the 8th to 9th weeks of the term.All participants provided their informed consent after choosing to participate in the study voluntarily.Excluded from this study were students who refused to provide their consent and those who filled out the questionnaire insufficiently.
Participants were also asked to provide information regarding their age, gender and university identification number to find out credit hours allotted for the semester and grade point average (GPA).

Medical Student Well-Being Index (MSWBI)
The 7-items MSWBI is considered as a reliable tool for screening the psychological well-being of the individuals and has been validated to predict and help identify students with severe distress for early intervention.The first two items of the instrument evaluate burnout (emotional and depersonalization), 3 rd item-depression, 4 th item-fatigue, 5 th item-stress and the last two items-qualities of life (mental and physical).This questionnaire consists of 7 yes/no items and responders receive a score from 0 to 7 based on responses.According to earlier research, the MSWBI's specificity for identifying students in extreme distress ranged from 87% to 91% percent at a threshold score of ≥4, and its sensitivity ranged from 59% to 93%.The students who were identified were thought to be at risk for low mental QOL, suicidal ideation, or serious thoughts of quitting medical school, all of which call for recognition and special attention (Dyrbye et al., 2010, Dyrbye et al., 2011).We also used this threshold score to interpret the results.

Maslach Burnout Inventory-Student Survey (MBI-SS)
The 16-items MBI-SS was used for assessing burnout of our medical students (Maslach et al., 1996).This questionnaire was designed to evaluate the emotional exhaustion (5 items: 1, 2, 3, 4 and 6), depersonalization or cynicism (5 items: 8, 9, 13, 14 and 15), and professional efficacy (6 items: 5, 7, 10, 11, 12 and 16).The Emotional exhaustion (EE) subscale evaluates the complaints about feeling on edge and exhausted by work.The depersonalization or cynicism (DP/CY) subscale measures impersonal responses and lack of empathy during professional activity, while the professional efficacy (mentioned as academic efficacy, AE) subscale evaluates the feelings of competence and achievement of success at university.
Participants rate each item on the MBI-SS using a 7-point Likert scale, with 0 being "never" and 6 being "every day."As suggested by previous study, high scores on the EE and DP/CY subscales and low scores on the AE scale indicated the presence of burnout in participants (Schaufeli et al., 2002).We used the reference from previous study which suggested scores of ≥27 for EE and/or ≥10 for DP/CY as threshold to identify students with high level of burnout and having at least one symptom of burnout (Shanafelt et al., 2012;Shanafelt et al., 2015).In addition, we categorized the EE and DP/CY as low (indicated by score 0 to <10), moderate (score 10 to <20) and high (score 20 to 30).

Statistical analysis
Collected data were inputted into a Microsoft Excel spreadsheet before exported to SPSS version 20.Internal consistency of the instruments was measured in terms of Cronbach's alpha.Descriptive statistics were calculated.Fisher's exact test to check the association and Pearson correlation to establish the relationship between independent variables were used.Mean scores of variables were compared using independent sample t tests.Multivariate regression model was used to identify predictive factors related to the variables of interest.

RESULTS
The response rate for online survey was 69%.Among the total number of participants (82), 34.1% were male and 65.9% female.The mean age of the participants was 27.4±5.9years (varying from 20 to 55 years).
Internal consistency of the instruments and subscales used in our study to measure medical students well-being and burnout are shown in Table 1.

Instruments and subscales
Cronbach's alpha Out of maximum possible score of 7, mean score for WBI-MS of the participants was 3.98±1.8.Fisher exact test revealed no association of well-being index of participants with their age, gender, emotional exhaustion, cynicism, academic efficacy, self-reported different stresses.However, the test showed the significant association between well-being index and credit hours allotted for the semester (p= 0.006).
Considering threshold score ≥4 in WBI-MS, we found 65.9% of the students had severe stress and at risk for low mental quality of life, suicidal ideation, or serious thoughts of dropping out of medical school and need individualized interventions.In Fisher exact test, these individuals with severe stress (score ≥4) showed a significant association with their depersonalization/cynicism (p=0.017) and credit hours allotted for the semester (p=0.000).
However, these individuals did not show significant association with their age, gender, emotional exhaustion, academic efficacy and semester GPA of the participants.
The WBI-MS score of the participants is shown in Figure 1. Figure 1.

Well-being index (WBI-MS) score of the medical students at TMSU
Pearson correlation revealed significant positive correlation among well-being index, emotional exhaustion and cynicism.We found academic efficacy was negatively correlated with well-being index, emotional exhaustion and cynicism however the correlation was significant only with cynicism (p= 0.001).Correlations between total well-being index and subscales of MBI are shown below in table 3.In medical students MBI out of 30 maximum possible score, the mean score for emotional exhaustion and cynicism subscales were 18.9 ± 6.1 and 14.5 ± 6 respectively.For academic efficacy, the mean score was 23.4 ± 7 out of maximum possible score of 36.In 0-6 Likert scale, the average score for emotional exhaustion, cynicism and academic efficacy were 3.7, 2.9 and 3.9 respectively.(see table 4) There were no significant differences between male and female in relation to their mean scores of emotional exhaustion, cynicism and well-being index (WBI).However, significant difference (p=0.028) in mean score of academic efficacy was noted between male and female (20.1±7.7 vs. 25.1±6.1) in an independent samples t test.(See table 5) Frequency analysis of MBI-MS showed that the Emotional Exhaustion (EE) was experienced by 17.1% of students every day, 26.8%-a few times a week, 14.6% once a week, 26.8%-a few times a month, 12.2%-once a month or less and 2.4%-a few times a year.Depersonalization or cynicism, which corresponds to impersonal responses and lack of empathy during professional activity, was reported in 7.3% of students every day, 9.8%-a few times a week, 17.1%-once a week, 34.1%-a few times a month and 31.7%-once a month or less.Professional Efficacy, which reflects feelings of competence and achievement of success at work, was indicated by 14.6% of students every day, 29.3%-few times a week, 29.3%-once a week, 17.1%-a few times a month and 9.8%-once a month or less.
How often the participants experienced the emotional exhaustion, cynicism and professional efficacy is shown in figure 2.

Figure 2. Frequency of experienced emotional exhaustion, cynicism and professional efficacy by participants
Scores of ≥27 for emotional exhaustion and/or ≥10 for depersonalization in Maslach Burnout Inventory (MBI) indicates high level of burnout and they are considered to have at least one symptom of burnout according to previous studies.In our study, we found 13.6% participants had score ≥27 for emotional exhaustion and 81.5% of participants scored ≥10 for depersonalization (cynicism) indicating to have high level of burnout and at least one symptom associated with it according to previous studies (Shanafelt et al., 2012;Shanafelt et al., 2015).At threshold of ≥10 for depersonalization, Fisher exact test showed significant association between cynicism and well-being index of the participants (p=0.005).
The of number of participants (%) as per scores of emotional exhaustion, cynicism and academic efficacy in MBI is shown in figures 3-5.

The distribution of number of participants (%) as per scores of academic efficacy
We used the following threshold values to categorize the level of emotional exhaustion and cynicism in our participants MBI (shown in table 6).At these threshold values, different levels of emotional exhaustion and cynicism showed significant association (p<0.01)with severe stress indicated by WBI-MS score ≥4.According to these threshold values, 85.7% of participants with high level of emotional exhaustion and cynicism separately had severe stress as indicated by WBI score ≥4.The analysis also revealed 53.3% and 76.9% participants with moderate emotional exhaustion and cynicism respectively also had severe stress (WBI score ≥4).

Academic efficacy DISCUSSION
Term "well-being" reflects the "life satisfaction" and "relies on the standards of the respondent to determine what is the good life" (Dodge et al., 2012).Well-being depends on several factors such as mental health, nutrition, fitness/active life, study skills, goal setting and time management (Karmiyati et al. 2020;Tamba & Iancu, 2023).There are some stress factors which affect well-being, and one of them is an academic stress created by course workload, long teaching hours and limited time for social relaxation.
Our study revealed that 65.9% of our students had low well-being index.The significant association was found only between well-being index and credit hours allotted.It can be explained by the lack of resilience, lack of time to relax to be able to withstand to stress.In the paper of 2021, Merrick et al., stated that at the University of Nottingham with the attempt to support student well-being in the Bachelor of Medical Sciences programme implemented an intensive support services and unique well-being approach is successfully incorporated within the curriculum (Merrick et al., 2021).Their students are encouraged to focus more on own physical health/activities, do some extracurricular activities, which are believed have a positive effect on well-being.Also they encourage students to freely discuss and evaluate their personal well-being (out 10) during the meetings with their personal tutors.
Bhurga (2021) stated that as an important solution to deal with stress is developing resilience.It is an ability to manage stress-facing fear by different methods, such as physical activity, yoga, meditation.Also a having a good role model to follow and be mentored by, mental support of the family, friends and peers can help to strengthens confidence in the stressful situations.(Bhugra et al., 2021).
Our study indicated that the students with severe stress (score ≥4) showed a significant association with their depersonalization/cynicism.
A study by Pöhlmann et al., which was conducted at the universities of Bern, Freiburg and Dresden revealed that the depersonalisation was predominant in 28% of participants (Pohlmann et al., 2005).Depersonalisation is characterized by impaired perception of oneself and may manifest itself as a lack of empathy, loss of motivation, sense of isolation, and even as a disease in response to negative and stressful everyday situations.It can also adversely affect the contact with patients.(Michal et al., 2004;Trueman, 1984).The usual reaction to this feeling is a low sense of work efficacy (Bhugra et al., 2021).
The results of our study also proved this statement and showed that academic efficacy had a significant correlation with cynicism, however there were no significant correlation between emotional exhaustion and academic efficacy.
Also we noticed the significant difference between male and female academic efficacy scores.Gender differences showed that females are more confident with academic efficacy.Despite they are having higher score in well-being index, emotional exhaustion and cynicism though not significant.They are more positive in terms of personal accomplishment/ evaluation, they have more power when dealing with problems in comparison with males.
Probably it is related to a higher level of resilience or motivation.The study of Prinz (2012) and authors shows that symptoms of burnout, anxiety, depression and depersonalisation are serious issues both for students of dentistry and human medicine.The proportion of students who showed elevated values was 22.7% for emotional exhaustion and 25% for the depersonalisation scale (Prinz et al., 2012).In study the corresponding percentages of these values were 13.6% and 81.5%.The number of participants with higher score (≥10) for depersonalization is much higher in comparison with the previous study but the number of participants with higher score (≥27) for emotional exhaustion is Probably that is why our study showed that academic efficacy had a significant correlation only with cynicism, because of our students (81.5%) had a high score for cynicism, but there was no correlation between emotional exhaustion and academic efficacy.As only 13.6% of our students experienced severe emotional exhaustion.
Cynicism (depersonalization dimension) refers to negative, rigid, and/or unemotional attitudes and behaviors of a person against others in the interaction.While the emotional exhaustion dimension is described as feelings of busyness, tiredness, exhaustion, and overload (Bhugra et al., 2021).
Also our analysis showed that once a week or more often 58.5 % of our students experienced emotional exhaustion, 34.2% depersonalization and 26.8% low professional efficacy.But the level (severity) of EE was less in comparison with depersonalization score.Those students (85.7%) who had a high level of emotional exhaustion and cynicism separately had severe stress as indicated by WBI score ≥4.Students with a moderate emotional exhaustion (53.3%) and cynicism (76.9%) also had severe stress (WBI score ≥4).
Our study also revealed that around 63.4% of our participants felt depression and 80.5% of students had feeling of anxiety and irritability.This data also corresponds with the results of Newbury-Birch et al. (2002) and Prinz et al (2012).Their researches indicated that 67% of dental students showed elevated values for the subscales of anxiety and depression.
According to the study of Duru et al., 2014 burnout happens in gradual steps: emotional burnout, cynicism, and then low personal accomplishment (Duru et al., 2014).Also, student burnout relates to the self-regulation skills: personal expectations and control level, regulation of emotions and thoughts.
Therefore, the results of our study may be explained in the following way, that the students with high level of self-regulation skills have a low score of depersonalization (cynicism) and higher academic efficacy.Our study was conducted during the time of a severe Covid-19 pandemic, when students experienced different types of stress.Therefore, the factors which increase the stress level and burnout at the same time lower our students' wellbeing maybe the following: • academic stress: adjustment to the online education (online exams and lectures) • financial stress (unstable worldwide economic/financial situation (fear to be able to pay a school tuition), • health condition (Covid-19 illness, loss/death of relatives/friends due to Covid-19) • social factors (physical and social isolation, time of the uncertainty).All these factors created a high level of burnout and tremendously affected the quality of students' life and their well-being.As a medical education is accompanied by a high academic workload, students are required to develop self-discipline (time management, study plan, sleep schedule), self-regulation skills, and strong resilience (Modna & Scott, 2017;Modna et al., 2019).Academic stress can be minimized by introduction of spaced or deaccelerated learning program, which will reduce a workload and, possibly, prevent burnout.The institutional social support is very important in a medical education, it will help to lower level of the students' depersonalization (cynicism) and increase their academic efficacy.Encouraging students to participate in clubs and social activities may also improve their quality of life in a medical school.As we return back from online teaching to "in person" class settings, we will actively invite students to attend our lectures regarding "Stress management", guide students how to smartly organize time between study hours and extracurricular activities, encourage them to seek help if needed in academic advisors, peers, school psychologists (Modna, 2020).We will implement the block of lectures about the importance of sleep and physical activities in the student's life as well as how to build resilience and work on selfregulation skills to prevent burnout.

CONCLUSION
The results of our study showed that 65.9% of our students had a low well-being index and high level of burnout with very increased score of depersonalization (cynicism), which negatively affected their academic efficacy.Once a week or more often 58.5 % of our students experienced emotional exhaustion, 34.2% depersonalization and 26.8% low professional efficacy.The possible causes of the obtained results were identified and necessary strategies will be implemented to improve the outcomes.

Limitation of study
The study was conducted during the Covid-19 pandemic when students had all classes online.That could affect negatively well-being and increased students' burnout due to an experienced stress of pandemic.Also, the small sample size limits this study's generalizability.
9% suffered stress, 80.5% had negative effect on mental quality of life and 29.3% had negative effect on physical quality of life (See Table2).
4. During the past month, have you fallen asleep while sitting inactive in a public place?Fatigue 16 (19.5%) 5.During the past month, have you felt that all things you had to do were piling up so high that you could not overcome them?Stress 54 (65.9%) 6.During the past month, have you been bothered by emotional problems (such as feeling anxious, depressed, or irritable)?Quality of life-Mental 66 (80.5%) 7.During the past month, has your physical health interfered with your ability to do your daily work at home and/or away from home?Quality of life-Physical 24 (29.3%)

Table 4 .
Participants score on different subscale of medical students MBI

Table 5 .
Gender differences in score of well-being index (WBI) and subscales of medical students MBI