Burnout syndrome, first introduced by psychologist Herbert Freudenberger in 1974 (1), is currently a constantly rising phenomenon that tends to appear in the occupational environment (2) and is worrying healthcare professionals. Although many definitions are under evaluation to describe the term, the widely accepted one seems to be that provided by the WHO and the psychologist Christina Maslach (1, 3). The definition of the syndrome is conceptualized using three basic features of human behavior: chronic fatigue, cynicism including reduced commitment over social interacting, and no satisfaction for personal achievements. The main cause of all these in the definition is chronic workplace stress that has not been successfully managed. Despite this, the syndrome, despite being classified in the ICD-11 inventory, is still not identified as a mental health disorder (4).

One of the first investigations into workplace burnout was carried out in 1973 in air-traffic controllers after many accidents happened that were attributed to human failure or because of inadequate training, automation monotony, and insufficient equipment. This was the first occupational group to mention vocational “burn out”, a type of fatigue that resulted in a deterioration of both the quantity and quality of produced work. Furthermore, there was an increased occurrence of hypertension and indications of mental health problems. The researchers concluded that those who feared burnout were the most qualified employees, while at the same time, burnout concerns, once set in motion, tended to become a self-fulfilling prophecy. In addition, burnout was proven not to be simply a failure of psychological resilience since most air traffic controllers had experienced military service and had faced extremely demanding conditions (5). Finally, the following paradox was highlighted: professionals who endeavor the hardest to accomplish internal and external professional goals could intensify their risk of burnout, which then contributes to the failure of these professional goals.

Moreover, Maslach, as the main ambassador of the syndrome’s terminology, expanded on the disease by investigating how workplace emotions relate to health. Early studies suggested that the clinical symptoms of burnout syndrome were tied to the mental health and social dynamics of both caregivers and recipients in professional settings (6). Oakley also argued that burnout among healthcare personnel could be the result of this particular continuous pressure for altruism (7). It is evident that air-traffic controllers and doctors share many common occupational factors, such as a timetable, long night shifts, and being alert in order to face emergency situations. A recent meta-analysis proved that among staff working in the ICU, where critical changes in vital signs require emergency help and attendance, 40% suffered from the syndrome (8). Indeed, in Greece, as the most recent available literature on healthcare professionals suggests, after the COVID-19 pandemic, nurses experienced high levels of burnout (9). In this context, a more compact meta-analysis, which was also conducted after the pandemic, provided compelling evidence that physician burnout is associated with the poor function and sustainability of healthcare organizations, primarily by contributing to career disengagement and turnover of physicians and secondarily by reducing the quality of patient care (10).

Focusing on future medical staff, medical students are a population of trainees who face psychological stress early in their studies due to patients’ deaths, life-threatening situations, and cynicism in their steps toward clinical practice, which are all factors that correspond to the definition of the syndrome (11). Taking this into account, with medical training going beyond borders and medical students around the world sharing much in common, more and more research proves that the syndrome has become a major concern in the scientific student community too, especially when we observe the parameter of the duration of studies (12, 13). Thus, it was an interesting question whether burnout syndrome is already present among medical students in Greece, as there was no study available on the topic that we were aware of.

Prior research of international student populations demonstrates that burnout is a universal public health matter, affecting all medical students around the globe, despite their religion, cultural standards, or geographical location. From US to Chile and Spain, studies reveal that no less than half of all medical students risk suffering from burnout (21, 22), with women being more at risk than men (11, 23, 24). However, our study revealed that gender does not play a major role in the burnout distribution. In addition, previous studies revealed that increasing years of study seem to be a risk factor for burnout among medical students (18, 25). This is in accordance with our study, which indicated that students in higher years of study may experience slightly higher levels of burnout (11, 26, 27).

We should not forget that burnout may seem to be an innocent health matter, yet it hides serious dangers for the students’ mental health, such as depression, anxiety, substance abuse, sleep disorders, and even suicidality (28, 29). According to a meta-analysis of over 4,000 articles, vulnerability to burnout increases the risk of suicidality by a factor of six. In addition, burnout is associated with numerous negative physical health outcomes, such as coronary heart disease, musculoskeletal pain, and type 2 diabetes (30).

Preventive measures against the syndrome should be applied, with the most highly recommended being cognitive-behavioral therapy (CBT) and mindfulness, which, according to studies, result in decreased circulating levels of C-reactive protein and proinflammatory cytokines, increased telomere length and telomerase activity, and reduced proinflammatory cytokines in those with depression and anxiety. In medical students specifically, stress-related epigenetic expression of SLC6A4, a serotonin transporter gene, has been found to increase after mindfulness interventions while serum cortisol decreased (31).

Over and above that, the academic system in medical schools worldwide, including Greece, should be shaped with this syndrome in mind, as education providers should question whether they are, in reality, creating undergraduate mental health patients instead of healthy doctors. In this direction, curricula should emphasize the inclusion of good quality sleep, physical activity, and extracurricular activities in the everyday routine of students, as their protective role has been repeatedly proven (32). The integration of optional and time-flexible burnout education into the curriculum would equip students with the fundamental knowledge to identify, prevent, and manage burnout early on (33). Screening tools in the form of questionnaires should always be included during the educational trajectory.

Through the three aspects for evaluating the syndrome, i.e., exhaustion, depersonalization, and low satisfaction for self-achievement, it has been observed that the latter may be very protective against the illness. Undergraduates who achieve a high academic performance and, in general, high personal accomplishment, are more protected from the syndrome. As a result, encouraging students to achieve better academic performance despite mental fatigue would also be a protective strategy against the syndrome (21). Moreover, another invaluable solution would be the adult learning theory, consisting of a six-step procedure of education between the learner and the teacher. The procedure tries to organize the plan of the former and seems to play a very protective role, mainly based on the fact that learners should always seek pure desire-focused personal knowledge enrichment (34).

In conclusion, the syndrome’s prevalence, as shown by the survey, is scientifically important, urging the academic community to examine whether, instead of shaping healthy doctors, the academic system in reality produces patients with the syndrome. To address this condition, academics in medical schools should establish greater awareness and understanding of burnout and of the factors that lead to its development. Interventions focusing on generating wellness during medical studies, such as CBT, mindfulness, the six-stage adult learning technique, periodical screening of the syndrome, and encouragement for higher personal achievements, are highly recommended.

Up to now, there are no available studies of the burnout syndrome among medical students in Greece, and as far as we know, this was the first study of its kind.

Yet, the present study had some limitations: i) the lack of many other covariates of interest besides gender and year of study; ii) the impact of the previous lockdown on students’ health and education; iii) the results based on self-report information leading to potential bias; iv) online surveys are subject to criticism regarding data quality; v) the so-called “volunteer-effect” of online surveys, in which respondents participate to surveys when they are particularly interested in the topic or when they identify themselves with the survey’s scope. Therefore, bias linked with self-selection should be taken into consideration, since responders’ characteristics may differ substantially from non-responders, limiting the results’ generalizability.