Chunming et al.

BMC Medical Education (2017) 17:217

DOI 10.1186/s12909-017-1064-3

RESEARCH ARTICLE Open Access

Burnout in medical students: a systematic

review of experiences in Chinese medical
schools
Wang Michael Chunming1, Reema Harrison1*, Raina MacIntyre1, Joanna Travaglia2 and Chinthaka Balasooriya1

Abstract
Background: To identify the: extent to which medical students in China experience burnout; factors contributing
to this; potential solutions to reduce and prevent burnout in this group; and the extent to which the experiences of
Chinese students reflect the international literature.
Methods: Systematic review and narrative synthesis. Key words, synonyms and subject headings were used to search
five electronic databases in addition to manual searching of relevant journals. Titles and abstracts of publications
between 1st January 1989-31st July 2016 were screened by two reviewers and checked by a third. Full text articles
were screened against the eligibility criteria. Data on design, methods and key findings were extracted and synthesised.
Results: Thirty-three studies were eligible and included in the review. Greater levels of burnout were generally identified
in males, more senior medical students, and those who already experienced poorer psychological functioning. Few
studies explored social or contextual factors influencing burnout, but those that did suggest that factors such as the
degree of social support or the living environment surrounding a student may be a determinant of burnout.
Conclusions: Greater understanding of the social and contextual determinants of burnout amongst medical students in
China is essential towards identifying solutions to reduce and prevent burnout in this group.
Keywords: Medical education, Burnout, Emotional exhaustion, Depersonalisation

Background strategies to prevent and reduce burnout amongst medical

Burnout amongst health professionals is characterised by students are evidenced in literature, but these largely
“various degrees of emotional exhaustion, depersonalization report data solely from students in English-speaking
and a low sense of personal accomplishment” [1]. Although countries.
the detrimental consequences of burnout on clinician well- Strategies at individual, and structural or organisa-
being and patient care are widely documented, burnout tional strategies have all reported clinically meaningful
continues to be endemic in the health system [2–9]. reductions in burnout amongst doctors [19]. Such strat-
Symptoms of burnout are prevalent from the outset of egies include the: promotion of healthier lifestyle choices
medical training, with multi-institutional studies indicat- and social activities in medical training; provision of
ing that at least 50% of medical students may meet burn- psychosocial support; web-based interventions; guidance
out criteria at some point during their studies [6–18]. to support positive attribution styles during the teaching
Burnout in medical school has potential to negatively process; and elective courses for learning relaxation
impact on students’ academic development and overall techniques [20–24]. In the workplace, contextual factors
well-being, with burnout identified as a significant inde- such as working hours, social support and relationships
pendent predictor of suicide ideation and dropping out of with co-workers have been increasingly recognised as
medical school [11]. A number of potential solutions and key determinants of burnout and therefore targets for
intervention [25]. Yet a recent systematic review
* Correspondence: [email protected] highlighted that knowledge regarding the interventions
1
School of Public Health and Community Medicine, UNSW Sydney, Australia
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Chunming et al. BMC Medical Education (2017) 17:217 Page 2 of 11

that are most effective for specific populations of published from January 1989–July 2016; subjects were
medical students is lacking [19]. medical students of Chinese origin studying in China;
China has the largest number of medical practitioners any study design (including quantitative, qualitative and
in the world, and these practitioners service the world’s mixed-methods research); any study which validated or
biggest population of 1,400,000,000, yet studies that re- purpose-developed assessment of burnout or its con-
port the experiences of medical students in China are structs of emotional exhaustion, depersonalisation or
under-represented in the English language literature personal accomplishment. In studies that included other
[26]. As such, there is a dearth of knowledge about the professions in the sample, only data relating to medical
contextual factors that influence burnout in Chinese students were extracted for the present review.
medical students. It is important to explore this area in Articles were excluded if they did not meet the above
order to understand not only the scale of the problem of criteria. Literature assessing hypothetical vignettes or
burnout in Chinese medical students but also to develop scenarios rather than actual experience was excluded, in
possible evidenced-based solutions. addition to studies that focused on general well-being or
To address this gap, a systematic review of studies of psychological well-being but not specifically burnout.
burnout amongst medical students in China in both Articles that focus on medical teachers, trainees, resi-
mainstream and Chinese language research databases, dents, nurses and nurse students were excluded.
was undertaken. The review had four aims. These were
to identify: 1) the extent to which medical students in Study selection and data extraction
China are experiencing burnout; 2) the demographic, so- Two reviewers independently screened the titles and ab-
cial and psychological factors contributing to this, 3) po- stracts (WC; CB). Copies of full articles were obtained
tential solutions to reduce and prevent burnout in China for those that were potentially relevant. Inclusion criteria
and; 4) the extent to which experiences in China reflect were then independently applied to the articles by the
the international literature. two reviewers. Disagreements were resolved by consen-
sus or consultation with a third reviewer. The following
Methods data were extracted: author(s), publication year, sample,
The Preferred Reporting Items for Systematic Reviews setting, design, primary focus and main findings.
and Meta-Analyses (PRISMA) statement is an evidence-
based approach for reporting in systematic reviews and Data synthesis
meta-analyses. The PRISMA statement was used to Findings were analysed using a narrative synthesis in
guide the reporting of this systematic review [27]. stages based on the study objectives [28]. A narrative ap-
A range of text words, synonyms and subject headings proach was utilised to synthesize the findings as given
were developed for the three major concepts in this re- the heterogeneity of the outcome measures used, whilst
view of 1) burnout, 2) the associated constructs of emo- many studies used variants of the same measure, these
tional exhaustion, depersonalisation and personal were not consistently used in every study and therefore
accomplishment, and 3) medical education settings in a narrative synthesis was appropriate on this occasion. A
China. These phrases were combined with AND and quantitative approach was not considered appropriate as
used to undertake a systematic search of five electronic the measures were not directly comparable [28]. Initial
databases from January 1989 to July 2016. The date descriptions of the eligible studies and results were tabu-
range was selected to identify sufficient relevant litera- lated (presented in Table 1). Patterns in the data were
ture within a relatively recent timeframe given the chan- explored to identify consistent findings in relation to the
ging context of medical education. Databases searched study objectives. Interrogation of the findings explored
were: MEDLINE, China Academic Journals Full-text relationships between study characteristics and their
Database, Chinese Scientific Journals Database,Wanfang findings; the findings of different studies; and the influ-
Data Resource System. Hand searching of relevant jour- ence of the use of different outcome measures, methods
nals (e.g. Chinese Journal of Medical Education Research and settings on the resulting data.
and Chna Higher Medical Education) and reference lists
of the included papers ensured that relevant published Data appraisal
material was captured. Results were merged using All the papers were evaluated using medical education
reference-management software (Endnote) and dupli- research study quality instrument (MERSQI) [29]. The
cates removed. possible score of MERSQI range 5–18, including study
Several limitations were applied. Only studies with the design (1–2), sampling (1–3), type of data (1–3), validity
following. of evaluation instruments’ scores (0–3), data analysis (1–
characteristics were included: available in English or 3), outcome (1–3). Two reviewers individually assessed
Chinese languages that reported original primary data all publications; disagreements were resolved through
Table 1 Summary of included studies (n = 33)
Lead author Year Participants Outcome measure Items Primary aim Key findings
Chen [39] 2012 492 postgraduate medical MBI-GS 15 • To determine burnout levels and related • 38.4% students had moderate or high levels of burnout.
students factors. • There was a correlation between burnout level on the
dimension of EX and age, marriage status, course
(PHD/Master), working hours, coping styles, anxiety.
• There was a correlation between burnout level on the
dimension of CY and age, type of course, coping styles,
anxiety.
• There was a correlation between burnout level on the
dimension of PE reduction and gender, coping styles and
anxiety.
Chunming et al. BMC Medical Education

Chen [44] 2011 471 undergraduate LRS 20 • To determine burnout levels and related • 30.6% students had above moderate levels of burnout.
medical students factors. • Male students suffered more burnout on the dimension
of EX.
• There was a significant correlation between burnout and
student-origin on the dimension of EX and CY. Students
from cities suffered more burnout.
Shen [40] 2012 111 postgraduate medical LRS 20 • To determine burnout levels and • The level of burnout among postgraduate
(2017) 17:217

students correlation with the sense of professional medical students was average (not serious).
commitment. • There was a correlation between overall burnout level
and the sense of continuing commitment.
Di [37] 2014 635 undergraduate medical LRS 20 • To determine burnout levels and related • 41.7% students had above moderate levels of burnout.
students factors. • Male students suffered more burnout than females on
the dimensions of EX and CY.
• Social support and professional commitment were
negatively correlated to burnout.
Fan [52] 2015 277 undergraduate medical MBI-SS Not stated • To determine the correlation between • There was no significant correlation between burnout
students burnout levels and occupational motivation. level and occupational motivation.
Fu [61] 2012 131 undergraduate medical LRS 20 • To test the difference between burnout • Non-medical students had more serious burnout than
students; 119 non-medical levels in medical students and non-medical medical students.
students students.
Hu [49] 2014 866 undergraduate medical Li et al. 2011 Burnout Scale Not stated • To determine burnout levels and related • There was significant difference of burnout level on the
students factors. dimension of EX by different grades.
Jiang [38] 2008 42 non’211′ university MBI-GS 15 • To determine burnout levels, related • Burnout level of students from non’211′ university are
students; 38 ‘211′ university factors and differences between students higher than ‘211′ on the dimension of EX and CY.
students from ‘211’ and non ‘211’ universities. • There is negative correlation between burnout and
organizational justice
Jin [43] 2010 77 undergraduate and MBI-GS 15 • To determine burnout levels and There was no significant correlation between burnout and
postgraduate medical correlation with psychological problems psychological problems and symptoms of psychopathology.
students and symptoms of psychopathology.
Li [62] 2015 1220 postgraduate medical MBI-HSS 22 • To test burnout levels. • The burnout level on the dimensions of CY and PE
students reduction were more serious comparing to the MBI-
HSS norm score
Li [63] 2015 224 postgraduate medical MBI (version not stated) Not stated • To determine burnout levels and related • Students’ level of burnout was moderate.
students factors.
Page 3 of 11
Table 1 Summary of included studies (n = 33) (Continued)
Lead author Year Participants Outcome measure Items Primary aim Key findings
• There was a significant correlation between burnout
level and gender, marital status, drinking, smoking,
student-origin.
Li [42] 2009 120 postgraduate medical MBI-GS 22 • To determine burnout levels and related • Students scored highly on the burnout dimensions of EX
students; 102 interns factors. (39%) and PE reduction (52%) but less so on the dimension
of CY (21%).
• There was no significant difference between medical
students and physicians on burnout levels.
• Social support was associated with burnout levels on the
dimension of EX and CY.
• Medical students reported a lack of social support
Chunming et al. BMC Medical Education

compared to physicians.
Li H [55] 2011 155 undergraduate medical MBI 22 • To determine burnout levels and related • There were significant correlations between burnout and
students factors. the age and gender. The older the students the more
serious burnout level on the dimension of CY. Male
students suffered more than female students on the
burnout dimension of CY.
(2017) 17:217

Ling L [23] 2014 200 undergraduate medical LRS 20 • To explore burnout levels and their • There was a significant correlation between burnout level
students correlation with parents’ upbringing style. and parents’ upbringing style.
Li L [48] 2013 679 undergraduate medical LRS 20 • To determine burnout levels and related • Self-efficacy and attributional style were negatively
students factors. correlated to burnout
• Scholarship and grade were predictors of students’
burnout level.
Li YZ [64] 2014 137 western medicine LRS 20 • To determine burnout levels and related • 25.8% students had above moderate levels of burnout.
undergraduate medical factors. • Medical students learning traditional Chinese medicine
students; 123 traditional • To compare burnout levels between suffered more burnout than medical students learning
Chinese medicine medical students learning western western medicine on the dimensions of CY and PE
undergraduate students medicine and medical students learning reduction
traditional Chinese medicine. • There was significant difference in burnout level on the
dimension of CY by grade among medical students
learning traditional Chinese medicine. Grade two suffered
the most burnout on the dimension of CY.
Liao [36] 2011 627 undergraduate medical Scale based on LRS 24 • To determine burnout levels and related • 52.1% students reported above moderate level of
students factors. burnout
• There was a significant correlation between burnout and
student grade on the dimension of EX. Students from
higher grade suffered burnout more commonly.
• There was a significant correlation between burnout and
student-origin on the dimension of PE reduction. Students
from cities suffered more burnout.
Lu [34] 2012 80 undergraduate medical MBI Not stated • To determine burnout levels. • 41% students are above moderate level of burnout.
students
Song [54] 2015 144 undergraduate medical MBI-GS 15 • To determine the correlation between • There was a significant negative correlation between
students burnout levels and accomplishment burnout and accomplishment motivation on the
motivation. dimensions of seeking success motivation.
Page 4 of 11
Table 1 Summary of included studies (n = 33) (Continued)
Lead author Year Participants Outcome measure Items Primary aim Key findings
• There is significant correlation between burnout and
accomplishment motivation on the dimensions of
avoiding failure motivation
Song [53] 2013 378 undergraduate medical Ni et al. 2009 Burnout Scale 14 • To explore burnout levels and their • Study motivation and psychological capital were
students correlation with study motivation and negatively correlated to burnout.
psychological capital
Sun [56] 2013 458 undergraduate medical MBI Not stated • To explore burnout levels and their • Social support and self-efficacy were negatively correlated
students correlation with social support and to burnout.
self-efficacy
Wang [46] 2011 312 undergraduate medical Ni et al. 2009 Burnout Scale 14 • To determine burnout levels and related • The level of burnout among medical students is above
Chunming et al. BMC Medical Education

students factors. average (serious).

• There were significant correlations between burnout and
gender and burnout and grade. Male students suffered
more than female students on the burnout dimension
of CY, but less on the burnout dimension of PE reduction.
Grade 2 and 3 students suffered more than grade 1.
(2017) 17:217

Wei [51] 2014 748 undergraduate medical LRS 20 • To explore burnout levels and their • There was a significant correlation between burnout level
students correlation with study pressure. and study pressure.
Wu [50] 2012 388 undergraduate medical LRS 20 • To determine burnout levels, related • Students’ level of burnout was reported as moderate.
students factors and correlation with the sense of • There was a significant negative correlation between
professional commitment. burnout and scores of exams.
• There was a correlation between burnout level and the
sense of professional commitment on all the dimensions
including affective commitment, normative commitment,
continuing commitment and ideal commitment.
Xiao [45] 2013 442 undergraduate medical LRS 20 • To test the correlation between burnout • Overall burnout was higher in males except in PE
students and emotional intelligence. reduction dimension.
• There was a significant negative correlation between
burnout and emotional intelligence.
Xu[35] 2009 610 undergraduate medical LRS 20 • To determine burnout levels and • 39.5% students were suffering burnout, especially on the
students organizational, social and individual factors dimension of CY.
related to this. • Male students and more senior students suffered more
burnout than junior or female counterparts.
• Social support and learning environment were significant
correlated with burnout.
Yang[31] 2013 952 undergraduate medical LRS 20 • To explore burnout levels and their • The burnout levels of medical students on the dimension
students; 299 undergraduate correlation with professional commitment of CY and PE reduction were less serious than nurse
nursing students and time management disposition. students.
• Professional commitment was negatively correlated to
burnout.
• Professional commitment was correlated to and time
management disposition.
Yang[30] 2011 576 undergraduate medical LRS 20 • To determine burnout levels and related • The level of burnout among medical students was
students factors and evaluate the effectiveness of moderate and influenced by grade, academic
performance, student-origin, family parenting pattern.
Page 5 of 11
Table 1 Summary of included studies (n = 33) (Continued)
Lead author Year Participants Outcome measure Items Primary aim Key findings
group coaching intervention to deal with • The higher the pressure, the more serious the burnout.
burnout among medical students. Problem-focused coping styles were identified as
beneficial to reduce burnout. Emotion-focused coping
styles were identified as detrimental.
• Group Intervention reduced burnout effectively by
enhancing coping styles.
Zhang[47] 2013 323 undergraduate medical LRS 20 • To explore the correlation between • There was a significant negative correlation between
Students burnout and the dormitory environment. burnout on the dimension of EX and dormitory
environment on the dimension of social environment
and learning environment.
• There was a significant negative correlation between
Chunming et al. BMC Medical Education

burnout (dimension of CY) and dormitory environment

(dimension of social environment and learning
environment).
Zhang[57] 2011 642 undergraduate medical MBI-HSS 22 • To determine burnout levels and related • Burnout levels were higher amongst medical students
students; 628 non-medical factors. than non-medical students, and higher than physicians
students; 132 physicians on the dimension of PE reduction, but lower than
(2017) 17:217

physicians on the dimensions of EX and CY.

• There was a significant correlation between burnout and
psychological problems and symptoms of
psychopathology.
Zheng[41] 2015 545 postgraduate medical LRS 20 • To determine burnout levels and related • There was a significant difference of burnout level on the
students factors. dimension of EX by different grades. Grade three students
were the most burned out.
• Male students suffered more burnout than female
students on the dimension of EX.
Zhu HC[32] 2012 87 postgraduate medical MBI-GS Not stated • To determine burnout levels and • 71.1% students are above moderate level of burnout.
students correlation with psychological problems • Male students scored higher on the dimension of EX.
and symptoms of psychopathology and • There is significant correlation between burnout and
the other factors. psychological problems and symptoms of
psychopathology.
Zhu Y[33] 2012 184 undergraduate or LRS 20 • To determine burnout levels and • 37.5% students are above moderate level of burnout.
postgraduate medical correlation with exam performance. • Male students suffer more overall burnout than females.
students • There was a significant negative correlation between
burnout and scores of exams.
Page 6 of 11
Chunming et al. BMC Medical Education (2017) 17:217 Page 7 of 11

discussion. Due to the limited number of eligible publi- compare; 10 studies recruited students from more
cations, we did not exclude studies based on the quality than two institutions. There were 25 studies analysing
assessment; quality assessment data was used simply to the present situation, seven studies were retrospective
portray the strength of the available evidence. control studies and only one prospective cohort study
(see Table 1). There was no randomized controlled
Results experiment study design among the articles. Seven
Search results were non-randomized two group studies while one
Using the search strategy described above, 380 refer- was a single group pre and post-test design. The re-
ences were retrieved, including 6 articles from mainder were single group cross-sectional or single
MEDLINE, 157 articles from the China Academic group post-test only.
Journals Full-text Database, 99 articles from the
Chinese Science Citation Database and 118 articles Study quality
from Wanfang Data Resource System. Thirty-three Among the the 33 included studies, the MERSQI
studies were included (Fig. 1). score range was 8–13. The mean total MERSQI
score was 11.3. Response rate of all the studies were
Characteristics of included studies over 75%. Data analysis of all the articles included
The main characteristics of the included studies are were appropriate for study design and type of data.
listed in Table 1. The range of sample size was between However, the outcome of the articles are mostly sat-
77 and 1402. There was a total of 14,774 participants isfaction, attitudes, perceptions, opinions and general
across all of the studies. The year of the studies included facts according to MERSQI. Only two articles devel-
were from 2008 to 2015. Among 33 studies, seven stud- oped knowledge or skills as outcome based on the
ies divided participants into two or three groups to study [30, 31].

Fig. 1 Flow diagram of the search and selection process

Chunming et al. BMC Medical Education (2017) 17:217 Page 8 of 11

Review findings A statistically significant difference was identified in

Included studies reported high levels of burnout one study in the overall burnout scores of medical
amongst medical students in China, with over 40% of students from different areas (village, town and city);
students in most studies identified as having more than students who came from a village had higher learning
moderate levels of burnout [32–37].Among the 33 burnout scores than students who came from a city or
studies included, only five studies solely targeted township [30]. An additional study reported that whilst
graduate medical students, with three further studies there was no significant difference in overall burnout
that targeted graduate medical students in addition to scores of medical students from rural or urban settings,
interns and undergraduate medical students [33, 38–43]. medical students from rural areas had a significantly
The remaining 25 studies targeted undergraduate med- lower score than those from cities in the dimension of
ical students. personal accomplishment [41]. Another two studies re-
ported no significant difference in overall burnout scores
i. Demographic factors or any dimension of burnout between those in different
areas. [33, 45]
Gender, age and whether the student was from an
urban or rural setting were all identified as significant ii. Social factors
predictors in some studies, but findings were not con-
sistent across the included studies. A total of eight A total of three studies explored the association be-
studies reported gender as a significant predictor of tween social support and burnout using the Social Sup-
burnout or its at least one of its constructs, with males port Rate Scale (SSRS) [35, 39, 42]. Two of these studies
experiencing a greater degree of suffering than females found that the emotional exhaustion and
[33, 35, 37, 41, 42, 44–47]. Of the studies identified, two depersonalization dimensions of burnout among medical
found that scores for emotional exhaustion in males students were significantly negatively correlated with so-
were significantly higher than in females [41, 42]. An- cial subjective support and the utilisation level of social
other four studies found that males’ scores for support [39, 42]. The third study found that all the three
depersonalization were also significantly higher than in dimensions of burnout were significantly negatively
females [35, 44, 45, 47]. In contrast, Yang et al. (2011), correlated with social subjective support such as family,
reported significantly lower scores on personal accom- friends and organisation [35]. Social support and self-
plishment in males than in females and two further efficacy were identified as negatively associated with
studies found no significant difference in the total burn- burnout in two further studies [47, 56]. One of these ex-
out score between males and females [30, 44, 48]. plored social support in terms of the interpersonal
Overall burnout scores among different grades of relationships and learning atmosphere in dormitories in
medical students varied significantly in six studies which medical students lived [47]. The results showed
[30, 36, 45, 46, 48, 49]. All identified that more senior that interpersonal relationships and learning atmosphere
students suffered greater burnout, with third and were negatively correlated with dimensions of burnout
fourth year students reporting significantly higher scores (exhaustion and depersonalisation), which meant that
than first and second year students [30, 36, 45, 46, 48]. the better interpersonal relationships within the dormi-
Only one study did not report any significant differences tories was able to reduce the burnout rate.
between overall burnout scores between different grades
of students [47]. Related to this, four studies reported a iii. Psychological factors
positive correlation between burnout and the students’
sense of continuing commitment to the medical Of the studies identified, three reported associations
profession or study pressure experienced [31, 40, 50, 51]. between burnout and other psychological constructs,
A significant negative correlation between students indicating that those experiencing poorer mental
motivation to accomplish and burnout was reported in health overall were also more likely to suffer burnout
two further studies, although a third found no such [30, 32, 57]. Zhang et al. (2011) reported a significant
association [52–54]. positive correlation between the dimensions of ex-
The extent of emotional exhaustion and depersonalization haustion and depersonalization and a student’s general
among medical students significantly increased with age in psychological condition (using the SCL-90 symptoms
one study [55]. Whilst a second study identified that the self-evaluation scale) [57]. There was a significant negative
level of emotional exhaustion and depersonalisation correlation between the burnout dimension of personal
significantly increased with age, no significant difference in achievement and a student’s psychological condition. Zhu
the overall burnout score was identified between different et al. (2012) found that increased emotional exhaustion
age groups [39]. and a low sense of personal achievement were significantly
Chunming et al. BMC Medical Education (2017) 17:217 Page 9 of 11

positively associated with a student’s psychological limited. Secondly, even though demographic studies dom-
condition (SCL-90 symptoms self-evaluation scale) [32]. inate, comparatively little is known about burnout in
In the third study, overall burnout and each of its con- graduate medical students who have a markedly different
structs were independently positively associated with demographic profile from their undergraduate counter-
higher stress scores (r = 0.184~0.349) [30]. Overall parts [58]. Lastly, as research into interventions to prevent
burnout scores were negatively correlated with coping burnout is limited in China, there may be value assessing
styles that focused on problem solving and asking for international interventions identified as effective within
help(r = −0.383~ − 0.255) but positively correlated with Chinese settings [19].
coping styles that included self-blame, fantasy, retreat and
rationalisation (r = 0.234~0.421) [30]. Limitations
Limitations apply to this study both in terms of the in-
Discussion cluded studies and the review methods used. Non-
Of the 33 included studies on burnout published in published and non-empirical work were not included
Chinese, most focused on demographic factors. More and as such may have led to the omission of relevant
specifically, being male, experiencing poorer psycho- perspectives [59]. Bibliographic databases vary in their
logical functioning and being a more senior medical levels of specificity and sensitivity, impacting the number
student were found to correlate with increased burnout. of articles returned and those that are considered
While the demographic factors were well substain- relevant to the search terms [60]. Several databases in
tiated substantiated, our review shows a lack of research addition to manual searching were used to broaden
into other contributing factors. This is despite growing coverage but relevant material may have been omitted.
evidence to highlight the valuable role of contextual fac- With the limitation number of the included articles, all
tors in interventions to reduce burnout [19]. the articles scored by MERSQI ranging from eight to13
The few studies in this review that explored contextual were accepted to maximize the information. However, it
or social factors indicate these are important in the might affect the quality of the conclusion.
Chinese context. Findings that show both lack of social
support (as a contributing factor to burnout) and a
supportive environment in living quarters (as a mediat- Conclusions
ing factor), affect rates of burnout flag the potential im- The review findings highlight recognition of the problem
portance of context in both prevention and remediation of burnout amongst medical students in China, and that
strategies [35, 38, 39, 42]. Additional evidence regarding medical students are at risk of burnout. The evidence
the contextual and social factors that promote or protect available is currently limited which is a barrier to
medical students from burnout is critical in order to de- developing effective, context-specific interventions.
velop contextually relevant and effective prevention Additional studies that explore the contextual and social
strategies for this group. factors affecting burnout rates, the experiences of
Few studies targeted graduate students (those who burnout in graduate students and that test existing inter-
already have their degree, also referred to as postgradu- ventions identified as effective in other settings in a
ate). Greater exploration of the unique factors affecting Chinese context are needed.
graduate medical students are necessary due to the dif-
Abbreviations
ferent curriculum, the substantial proportion of medical CY: Cynicism; EX: Exhaustion; LRS: Lian rong survey; MBI: Maslach burnout
students in this group and their learning environment inventory; MBI-GS: MBI – general survey; MBI-HSS: MBI – human services
[39, 41]. The average age of enrollment for graduate survey; MBI-SS: MBI – student survey; MERSQI: Medical education research
study quality instrument; PE: Professional efficacy; PSMS: Postgraduate
medical students is generally higher then undergraduate student mentor scheme; SCI: Science citation index CY; SCL-90: Symptom
students - this population may therefore encounter dif- checklist-90; SPRF: Survey with the possible related factors
ferent contextual and social factors and pressures that
influence their experience of burnout. Warranting Acknowledgements
further study of this specific group. None to note.

Funding
Implications This project was funded by Shanghai Jiaotong University School of Medicine
Three implications emerge from our review. The literature Science and Technology Fund Project (14XJ10061). The additional funding
reviewed demonstrates that burnout is a challenge for source of the following is to be noted as follows: 2015 SMC Outstanding
Young Teachers of ShanghaiJiaotong University.
medical students in China, but there is a lack of studies
into factors beyond demographic variables that might
Availability of data and materials
predict increased burnout. This in turn means that the Data sharing is not applicable to this article as no datasets were generated
scope for evidence-based intervention development is or analysed during the current study.
Chunming et al. BMC Medical Education (2017) 17:217 Page 10 of 11

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and for drafting the initial manuscript; RH and CB made substantial revisions 14, 2005]. J Gen Intern Med. 2005;20(S1):149.
to the manuscript and supported WC in its development including the 17. Paro HB, Silveira PS, Perotta B, et al. Empathy among medical students: is there
search process; RM and JT were responsible for conceptualising the study, a relation with quality of life and burnout? PLoS One. 2014;9(4):E94133.
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