Yusoff et al.

BMC Medical Education (2021) 21:293

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RESEARCH Open Access

The roles of emotional intelligence,

neuroticism, and academic stress on the
relationship between psychological distress
and burnout in medical students
Muhamad Saiful Bahri Yusoff1*, Siti Nurma Hanim Hadie2 and Mohd Azhar Mohd Yasin3

Abstract
Background: Stress and burnout commonly threaten the mental health of medical students in Malaysia and
elsewhere. This study aimed to explore the interrelations of psychological distress, emotional intelligence,
personality traits, academic stress, and burnout among medical students.
Methods: A cross-sectional study was conducted with 241 medical students. Validated questionnaires were
administered to measure burnout, psychological distress, emotional intelligence, personality traits, and academic
stress, respectively. A structural equation modelling analysis was performed by AMOS.
Results: The results suggested a structural model with good fit indices, in which psychological distress and
academic stress were noted to have direct and indirect effects on burnout. The burnout levels significantly
increased with the rise of psychological distress and academic stress. Neuroticism was only found to have
significant indirect effects on burnout, whereby burnout increased when neuroticism increased. Emotional
intelligence had a significant direct effect on lowering burnout with the incremental increase of emotional
intelligence, but it was significantly reduced by psychological distress and neuroticism.
Conclusion: This study showed significant effects that psychological distress, emotional intelligence,
academic stress, and neuroticism have on burnout. Academic stress and neuroticism significantly increased
psychological distress, leading to an increased burnout level, while emotional intelligence had a significant
direct effect on reducing burnout; however, this relationship was compromised by psychological distress
and neuroticism, leading to increased burnout. Several practical recommendations for medical educators,
medical students, and medical schools are discussed.
Keywords: Burnout, Psychological distress, Emotional intelligence, Neuroticism, Academic stress

* Correspondence: [email protected]
1
Department of Medical Education, School of Medical Sciences, Universiti
Sains Malaysia, Kota Bharu, Kelantan, Malaysia
Full list of author information is available at the end of the article

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Yusoff et al. BMC Medical Education (2021) 21:293 Page 2 of 10

Introduction emotional instability, distress, moodiness, irritability,

Psychological distress is an unpleasant emotional state poor coping ability, and sadness [22, 23]. Likewise, in
experienced by individuals in response to demands that the medical context, personality traits are associated
cause mental disturbances [1]. Psychological distress is a with several important areas, which include the ap-
multi-facet construct that correlates with poor mental proach to work, mental health, career success, learning
health and function [2, 3]. Literature has shown psycho- approach, and academic performance of medical stu-
logical distress is more prevalent in medical students dents and professionals [24, 25]. A longitudinal study re-
than in the public [4, 5]. However, before the medical ported that neuroticism was the strongest factor of
training start, medical students have shown a similar psychological distress for medical students during stress-
level of psychological health as compared to the public ful periods, such as the final examination [26]. Besides, a
[5–8]. In comparison to undergraduate students across study had also shown that burnout was strongly linked
15 courses, the students enrolled in medicine and health to neuroticism and it explained more variance in burn-
science courses showed the highest psychological dis- out than work stress [27]. These facts suggest individuals
tress scores [9]. These facts suggest medical training is with high neuroticism are more vulnerable to developing
challenging and demanding for young medical students psychological distress and burnout. The significance of
[10]. Given its prevalence and the serious nature of the personality traits may have been underestimated in
consequences, understanding the underlying factors con- burnout research among medical students, hence this
tributing to psychological distress is imperative for ne- study was an attempt to close this research gap.
cessary intervention. Moreover, there is considerable evidence showing that
Mental health implies a state of wellbeing enabling in- emotional intelligence (EI) is a determinant of success in
dividuals to realise their abilities, cope with the normal a variety of occupational settings [28–30]. EI refers to
stresses of life, work productively, and contribute to the ability to perceive, express, understand, motivate,
their communities [11]. Unfortunately, some compo- control, and regulate emotion [30–33]. A recent system-
nents of training have unintended and detrimental im- atic review on EI in medicine revealed that a higher EI
pacts on students’ mental health. A high proportion of positively contributed to important outcomes in the
students experience high academic-related stress [12– competence of future doctors [29], and EI prior to med-
15]. The negative factors contributing to psychological ical training predicted psychological health and academic
distress among medical students are related to academic performance during medical training [26]. For example,
stress, such as course activities, course load, examina- a cross-sectional study found emotional intelligence
tions, teaching and learning hassles, placement hassles, negatively correlated with depression and anxiety levels
and high workload [14, 16]. Empirical evidence demon- [34], and a longitudinal study found that self-appraisal
strates that psychological distress was positively corre- emotion was the only EI dimension related to burnout
lated with burnout [3], which certainly affects one year later [35]. These facts suggest that EI plays a
performance and mental health [17]. Burnout can be significant role in several areas that are related to the
conceptualised as a syndrome of emotional exhaustion, psychological health of future doctors.
depersonalization, and a low sense of personal accom- Considering all facts related to the effects that personal-
plishment [18] that eventually leads to detrimental con- ity, EI, and academic life might have on psychological dis-
sequences to mental health and psychological function tress and burnout, this study attempted to provide a best
[17, 19]. The prevalence of burnout among medical stu- fit structural model for the interrelations of burnout with
dents during medical training is high at approximately psychological distress, academic stress, personality, and EI.
43.3% [19], in which 35–45% of medical students had This study hypothesized that (a) psychological distress is a
high emotional exhaustion, 26–38% experienced high predisposing or contributing factor to burnout; (b) aca-
depersonalization, and 45–56% had symptoms suggestive demic and psychological stress on the same side or in the
of burnout [17]. These facts demonstrate academic stress same role lead to burnout; and (c) neuroticism and emo-
contributes to psychological distress and burnout, which tional intelligence are predictors or mediators of the link
may contribute to personal and professional conse- between psychological distress and burnout.
quences, for instance, increased rate of medical error,
malpractice suits, and increased likelihood of physician Method
suicide [19–21]. A cross-sectional study was conducted, and a purposive
Literature shows that medical students with a specific sampling method was applied with 300 second-year
personality, especially neuroticism traits, were more vul- medical students in the academic session of 2016 and
nerable to developing psychological distress and burnout 2017. The acceptable sample size for structural equation
[19]. Neuroticism is generally characterised by a ten- modelling is 200 to 300 samples [36]. The data collec-
dency to experience negative feelings and is linked with tion was carried out immediately after the final
Yusoff et al. BMC Medical Education (2021) 21:293 Page 3 of 10

preclinical examination. Informed consent was obtained, 0.83 and a good construct [51, 52, 54], indicating an ac-
and participation in this study was voluntary that would ceptable to high level of internal consistency and
not affect participants’ academic progression. consistency across time intervals and occasions.
The medical students studied a five-year medical pro- The 20-item Medical Student Stressors Questionnaire
gram based on the SPICES (i.e., student-oriented, (MSSQ-20) measures academic stress [55, 56]. The MSSQ-
problem-based, integrated, community-oriented, elec- 20 has six domains, including academic, interpersonal,
tives, self-learning, and systematic learning) curriculum teaching and learning, social, drive/desire, and group activ-
model. The medical program was organized into the ity. It is a self-reported self-scoring instrument that requires
pre-clinical phase (first and second year) and the clinical medical students to rate the intensity of stress caused by
phase (third, fourth, and fifth year). Medical students in each source. The internal consistency (Cronbach’s alpha)
the pre-clinical phase learn the basic and applied know- for the MSSQ-20 was more than 0.8 and ranged from 0.55
ledge related to the normal human being and early clin- to 0.97 for each MSSQ construct [56]. The MSSQ-20 has
ical exposure to common pathological conditions. stable internal consistency over multiple measurements
Medical students in the clinical phase learn clinical sci- across different time intervals [57].
ences and skills in a workplace setting. A descriptive analysis of the demographic data was
Burnout was measured by the Copenhagen Burnout performed using the Statistical Package for Social Sci-
Inventory (CBI) consists of 19 items. It is the newest and ences (SPSS) version 20. Structural equation modelling
public domain tool developed to assess the core features (SEM) was performed on the samples with complete re-
of burnout (fatigue and exhaustion) concerning personal sponses to all five inventories to examine the interrela-
life (personal burnout), work (work-related burnout), tions between observable variables in the proposed
and service to clients (client-related burnout) [37–39]. model (Fig. 1). CFA and SEM were performed using the
The CBI was validated in the medical student population Analysis of Moment Structure (AMOS) software. The la-
[40], which has three domains; personal, work-related, tent constructs and the proposed model were considered
and client-related burnout [38, 40]. The internal struc- fit if all the goodness of fit indices achieved the minimal
ture reliability of the CBI was good with Cronbach’s requirement [36], as stated in Table 1.
alpha ranging from 0.83 to 0.87 [40]. Reversed scoring
was applied in positively worded items, and high scores Results
indicated high levels of burnout. Out of 300, 241 second-year medical students [n (%)2016
Psychological distress was measured using the 21-item batch = 141 (58.5%); n (%)2017 batch = 100 (41.5%)]
Depression Anxiety Stress Scale (DASS-21). Researchers responded completely to the five inventories. The major-
have used the DASS-21 to measure symptoms of depres- ity of respondents were 63.5% female (n = 153) and
sion, anxiety, and stress as well as overall psychological 49.4% non-Malay (n = 122), and the mean age was about
distress, in which a high score indicates poor psycho- 21 years (M = 21.8).
logical health [41–45]. Its validity and reliability among The goodness of fit indices for the psychological
student samples have been well established in previous distress-burnout relationship and the mediating effects of
studies [42, 44–46]. The internal consistency coefficients academic stress, neuroticism, and emotional intelligence
of depression, anxiety, and stress scales ranged between are summarised in Table 2. The direct, indirect, and total
0.81 and 0.97 [46]. effects of the model paths are shown in Tables 3 and 4.
EI was measured using the 17-item USM Emotional
Quotient Inventory (USMEQ-17), which is a valid and Psychological distress is a predisposing and contributing
reliable tool for measuring EI in medical student samples factor to burnout
as it demonstrated high internal consistency (Cronbach’s The psychological distress-burnout relationship achieved
alpha was greater than 0.7) and good construct validity model fit (Fig. 1, Table 2: Model 1). The relationship be-
[47–50]. The assessment consists of personal compe- tween psychological distress and burnout was significant
tence and social competence, both domains represented (β = 0.494, B = 0.228, SE = 0.035, p-value < 0.001). When
by global EI are together the ability to perceive, express, psychological distress went up by 1 unit or standard de-
understand, motivate, control, and regulate emotion. viation (SD), burnout went up by 0.228 units or 0.494
The 15-item USM Personality Traits Inventory SDs. Of importance, psychological distress significantly
(USMaP-15) measures the five-factor personality traits, contributed to the burnout level of medical students.
which are openness, conscientiousness, extroversion,
agreeableness, and neuroticism [51–53]. It is a valid and Academic and psychological stress on the same side and
reliable tool to measure personality traits in medical stu- in the same role lead to burnout
dent samples as it demonstrated a stable internal The psychological distress significantly increased burn-
consistency (Cronbach’s alpha) that ranged from 0.63– out levels and decreased EI (Table 3, Fig. 2) When
Yusoff et al. BMC Medical Education (2021) 21:293 Page 4 of 10

Fig. 1 Structural equation modelling (standardised estimates) of the psychological distress-burnout relationship. (e = error; the decimal value
estimates contribution of an item to the construct’s variance)

psychological distress increased by 1 unit or SD, burnout neuroticism increased, academic stress and psychological
increased by 0.160 units or 0.344 SDs. Significantly, the distress also increased.
effects of psychological distress on burnout were re-
duced after including EI, academic stress, and neuroti-
cism into the SEM, as compared to Model 1 (Fig. 1). EI Neuroticism and emotional intelligence are predictors or
significantly reduced the burnout level, when EI in- mediators of the link between psychological distress and
creased, burnout decreased. Furthermore, academic burnout
stress significantly increased psychological distress and The results showed a significant direct effect of psycho-
burnout levels. Thus, when academic stress increased, logical distress on burnout (Table 4). However, the effect
psychological distress and burnout increased. Addition- of psychological distress on burnout was significantly
ally, neuroticism significantly increased academic stress mediated by EI (Fig. 2). Additionally, psychological dis-
and psychological distress and decreased EI. When tress significantly decreased EI, but EI directly decreased

Table 1 The goodness of fit indices used to signify model fitness

Name of category Name of index Level of acceptance
Absolute fita Root mean square of error approximation (RMSEA) less than 0.08
Goodness of fit index (GFI) more than 0.9
Incremental fitb Comparative fit index (CFI) more than 0.9
Tucker-Lewis index (TLI) more than 0.9
Normed fit index (NFI) more than 0.9
c
Parsimonious fit Chi-square/degree of freedom (Chisq/df) less than 5
Note.aAbsolute fit: Measures overall goodness of fit for both the structural and measurement models collectively. This type of measure does not make any
comparison to a specified null model (incremental fit measure) or adjust for the number of parameters in the estimated model (parsimonious fit measure).
b
Incremental fit: Measures goodness of fit that compares the current model to a specified “null” (independence) model to determine the degree of improvement
over the null model. cParsimonious fit: Measures goodness of fit representing the degree of model fit per estimated coefficient. This measure attempts to correct
for any “overfitting” of the model and evaluates the parsimony of the model compared to the goodness of fit
Yusoff et al. BMC Medical Education (2021) 21:293 Page 5 of 10

Table 2 The goodness of fit indices for supporting the best fit model
Model χ2 p- The goodness of fit indices
statistics value
χ2/df RMSEA GFI CFI NFI TLI
(df)
1. Model 1 (Fig. 1) 17.48 (8) 0.025 2.186 0.070 0.976 0.989 0.980 0.980
2. Model 2 (Fig. 2) 62.78 (29) < 0.001 2.165 0.070 0.951 0.973 0.952 0.958
Note. χ 2/df Chi-square/degree of freedom, RMSEA root mean square of error approximation, GFI goodness of fit index, CFI comparative fit index, NFI normed fit
index, TLI Tucker–Lewis index

burnout levels (Tables 3 and 4. In other words, emo- predominantly has a direct effect on escalating the burn-
tional intelligence was a protective factor for burnout. out level of medical students. Second, academic stress
Additionally, a significant effect was shown with aca- has direct and indirect effects (mainly mediated through
demic stress and neuroticism in the relationship between psychological distress) on increasing the burnout level of
psychological distress and burnout (Fig. 2; Tables 3 and medical students during stressful events. Third, neuroti-
4). Both academic stress and neuroticism increased psy- cism predominantly has an indirect effect, mediated
chological distress, thereby contributing to the increased through psychological distress and academic stress, on
burnout level. Academic stress showed both direct and increasing medical students’ burnout levels during
indirect effects on burnout; although, neuroticism only stressful periods. Fourth, EI mainly demonstrates a dir-
showed an indirect effect on burnout. In other words, ect effect on reducing the burnout level of medical stu-
academic stress was a predictor of the relationship be- dents during stressful events. Lastly, EI was significantly
tween psychological distress and burnout; however, compromised by the increase of psychological distress
neuroticism was a predisposing contributing factor to and neuroticism, leading to burnout.
burnout. First, psychological distress predominantly had direct
The results also identified that EI was significantly re- effects on escalating the burnout level of medical stu-
duced by psychological distress and neuroticism, indicat- dents. It had the greatest direct standardised effect in
ing both were negative predictors of EI, which suggests positively predicting burnout – making it the strongest
that psychological distress and neuroticism increased predictor of burnout in medical students. This finding
burnout levels by reducing EI levels. These results indi- corresponds to previous studies that showed a significant
cated the significant effects and paths that psychological positive correlation between psychological distress and
distress, emotional intelligence, academic stress, and burnout [3], a significant negative correlation between
neuroticism have on burnout. Academic stress and neur- psychological wellbeing and burnout [58], a significant
oticism significantly increase psychological distress, lead- positive correlation between burnout and depression
ing to the escalation of burnout levels, while EI has a [59–63], a significant correlation between anxiety and
significant effect on reducing burnout; however, this is burnout [63–65], and the strong association of burnout
negatively affected by psychological distress and neuroti- severity with the prevalence of depression [66]. These in-
cism, leading to increased burnout. dicate that psychological distress is the major predictor
of burnout, highlighting the importance of reducing un-
Discussion necessary psychological pressures (sources of stress that
This study contributes several important findings to the are not needed to be introduced), thus leading to better
current body of knowledge. First, psychological distress psychological health and eventually reducing burnout in
Table 3 The estimates of standardised and unstandardised regression weights of academic stress, neuroticism, and emotional
intelligence on the psychological distress-burnout relationship
Independent variables Dependent variables β B SE p-values
Psychological distress Burnout 0.344 0.160 0.037 < 0.001
Emotional intelligence −0.176 −1.376 0.483 0.004
Academic stress 0.168 0.781 0.309 0.012
Academic stress Psychological distress 0.384 3.846 0.584 < 0.001
Neuroticism 0.390 1.324 0.198 < 0.001
Neuroticism Academic stress 0.202 0.068 0.021 0.001
Psychological distress Emotional intelligence −0.241 −0.014 0.004 < 0.001
Neuroticism −0.394 −0.079 0.016 < 0.001
β = standardised regression weights; B unstandardised regression weights; SE = standard error
Yusoff et al. BMC Medical Education (2021) 21:293 Page 6 of 10

Table 4 The unstandardised and standardised estimates of direct, indirect, and total effects of academic stress, neuroticism, and
emotional intelligence on the psychological distress-burnout relationship
Parameter Independent variable Dependent variable Total (L, U) Direct (L, U) Indirect (L, U)
Unstandardised Psychological distress Burnout 0.179 (0.099, 0.276)** 0.160 (0.073, 0.258)** 0.020 (0.003, 0.055)*
Academic stress 1.470 (0.838, 2.069)** 0.781 (0.027, 1.424)* 0.689 (0.373, 1.114)**
Emotional intelligence −1.376 (−2.854, −0.091)* −1.376 (− 2.854, − 0.091)* –
Neuroticism 0.447 (0.261, 0.652)** – 0.447 (0.261, 0.652)**
Standardised Psychological distress Burnout 0.386 (0.214, 0.557)** 0.344 (0.141, 0.525)** 0.042 (0.009, 0.113)*
Academic stress 0.316 (0.173, 0.429)** 0.168 (0.006, 0.300)* 0.148 (0.085, 0.231)**
Emotional intelligence −0.176 (−0.376, −0.014)* −0.176 (− 0.376, − 0.014)* –
Neuroticism 0.283 (0.184, 0.378)** – 0.283 (0.184, 0.378)**
Note. Bootstrap (1000) with 95% bias-corrected confidence interval: L = lower bound; U = upper bound;
**p-value < 0.01; *p-value < 0.05

medical students [67, 68]. Designing a systematic sup- consistent with previous studies that reported daily has-
port system, for instance, a peer-support system, to sup- sles positively correlated with burnout [63], academic
port medical students experiencing difficulty may stress negatively correlated with personal wellness [69],
improve their psychological distress by helping to reduce perceived stress associated with burnout [70], and aca-
unnecessary psychological pressures [12, 19]. demic stress as the most predictive of burnout [71].
Second, academic stress demonstrated direct and in- These facts suggest that psychological wellbeing is nega-
direct effects (mainly mediated through psychological tively affected by high academic stress due to the de-
distress) on increasing the burnout level of medical stu- mands of medical training [69, 72]. Taib et al. (2020)
dents during stressful events. Academic stress had the explained that “Most budding doctors believe that hard
second greatest total effect on burnout. This finding is work, sweat and dedication would lead to successful

Fig. 2 Structural equation modelling (standardised estimates) for the mediating effects of academic stress, neuroticism, and emotional
intelligence on the psychological distress-burnout relationship. (e = error; the decimal value estimates contribution of an item to the
construct’s variance)
Yusoff et al. BMC Medical Education (2021) 21:293 Page 7 of 10

careers” (p.66). Unfortunately, many trainees experience medical training, thus will minimise the vulnerability of
medical and mental health problems, which have be- students to develop burnout.
come more apparent and overwhelming following the Lastly, EI was significantly compromised by the in-
demands of clinical training. Thus, empathetic and heal- crease of psychological distress and neuroticism, which
ing relationships are vital rather than suspicion and hat- led to burnout. It was evident in the literature that EI
red when dealing with the unwell student [12]. It is correlated positively with psychological wellbeing and in-
possible that lowering superfluous academic stress by re- versely with depression [80], that self-perceived stress
ducing unnecessary syllabus, course load, workload, and was lower in those with higher EI [82], that psycho-
psychological pressures while fostering psychological logical distress showed a negative correlation with EI
support, a healthy learning environment, sufficient learn- scores [83], and that EI demonstrated negative correla-
ing time, and adequate breaks would improve their psy- tions between anxiety, stress, and depression [84]. One
chological well-being and prevent them from developing important fact from these findings is the indirect mech-
burnout [19]. anism through which psychological distress causes burn-
Third, neuroticism predominantly had an indirect ef- out is by lowering the EI of medical students. Similarly,
fect (mediated through psychological distress and aca- personality contributed significantly to EI, especially
demic stress) on increasing medical students’ burnout neuroticism, which demonstrated the largest independ-
levels during stressful periods. Previous studies reported ent negative contribution to the increase of burnout [85]
that certain personality traits can contribute to stress via the same indirect mechanism as psychological dis-
among medical students and reduce their wellbeing [72], tress. This is a significant fact for consideration given
for instance, neuroticism demonstrated a positive correl- that medical students usually have high EI but are still
ation with emotional exhaustion and cynicism and a vulnerable to burnout if they are consistently exposed to
negative correlation with professional efficacy [73], burn- chronic excessive psychological pressure. This is known
out risk was strongly associated with neuroticism [74], as a wear and tear phenomenon due to the depletion of
and neuroticism positively correlated with psychological the emotional reservoir in handling chronic exposure to
distress [19]. These findings recognize neuroticism as a prolonged excessive psychological pressures [86], espe-
negative predictor of psychological wellbeing. One pos- cially in those with high neuroticism.
sible reason is potentially due to the tendency of individ- Based on the SEM, several practical applications can
uals with high neuroticism to experience negative be recommended to medical educators, students, and
feelings and to have the poor coping ability in stressful medical schools. First, medical educators should try their
circumstances [75, 76], making them less suitable for best to avoid introducing psychological pressures that
medical training that is complicated and stressful [77, are not needed to students, especially academic-related
78]. On that basis, medical schools should consider in- stress. For an example, medical educators should convey
cluding neuroticism as a criterion in the recruitment of clear expectations on the academic requirement to stu-
candidates into medical programs because it will influ- dents especially the assessment matters as it is the most
ence the quality of medical graduates [79]. stressful event for medical students [19]. This approach
Fourth, EI demonstrated a direct effect on reducing will minimise the sources of psychological distress and
the burnout level of medical students during stressful burnout, hence, lead to better mental health. Second,
events. This finding is aligned with several studies medical students should do their best to develop a posi-
reporting that EI scores correlate inversely with emo- tive and healthy mindset towards academic matters that
tional exhaustion and depersonalization [80], that EI was will help them to thrive under pressure. One of tech-
strongly predictive of emotional exhaustion and niques that was reported to promote a healthy and posi-
depersonalization [80], and that higher EI scores were tive mindset of medical students towards sources of
significantly correlated with lower burnout [81]. These stress was the DEAL-based practice [19]. The DEAL-
facts indicate that individuals with higher EI will have a based practice is a psychoeducational tool that can help
better psychological state and be less vulnerable to de- medical students to systematically and effectively man-
veloping burnout. Emotionally intelligent persons know age sources of stress, thus lead to the reduction of psy-
how to handle their own and others’ emotions and being chological pressures [68]. Third, medical schools should
able to deal with emotions effectively makes them less introduce programs that help medical students manage
vulnerable to developing burnout. Hence, developing a their stress and develop their EI such as the DEAL-
special program to cultivate medical students’ EI could based practice and mindfulness-based stress reduction
help students to face the demands and challenges of technique as these wellbeing strategies foster resilience
medical training, thus preventing them from developing and prevent burnout [19, 68]. Besides, having a regular
burnout. Medical schools could also possibly include EI assessment of these constructs (burnout, distress, aca-
as a criterion for the recruitment of candidates into demic stress, etc.) would be useful for medical schools
Yusoff et al. BMC Medical Education (2021) 21:293 Page 8 of 10

and students as it could help educators identify medical increased burnout levels, while EI had a significant direct
students at risk and increase the awareness that encour- effect on reducing burnout; however, this was compro-
ages them to engage in self-care practices to avoid the mised by psychological distress and neuroticism leading
need for acute intervention. Lastly, medical schools to increased burnout. This study explained the causal-
maybe should consider regularly assessing neuroticism, effect relationships of burnout, psychological distress,
EI and other constructs upon entry and throughout academic stress, neuroticism, and EI through SEM.
medical training due to certain personality traits (like
Acknowledgements
neuroticism) are relatively stable in middle and older Our deepest gratitude is given to all the respondents for their time,
adulthood; however, medical students are typically youn- cooperation, and patience in completing the questionnaires administered to
ger and still developing. Concerning scores in these them.
areas could be seen not as a disqualifying factor but as a
Code availability
point of prevention or intervention. It is worth highlight- Not applicable.
ing that this study showed candidates with low neuroti-
cism and high EI will be able to handle medical training Authors’ contributions
Yusoff MSB: Substantial contributions to the conception of the work, the
pressures in a better way, hence minimising the prob- acquisition and analysis of data, drafting the work, final approval of the
ability of them developing psychological distress and version to be published, and agreement to be accountable for all aspects of
burnout. the work. Hadie SNH: Substantial contributions to the design of the work,
the analysis and interpretation of data, revising it critically for important
It is worthy to mention this research was conducted at intellectual content, final approval of the version to be published, and
a medical school; therefore, any attempt to generalise agreement to be accountable for all aspects of the work. Mohd Yasin MA:
the results to other settings should be done cautiously. Substantial contributions to the interpretation of data, drafting the work, final
approval of the version to be published, and agreement to be accountable
A multi-centre and longitudinal research should be con- for all aspects of the work.
ducted in the future to validate the proposed model as
distress, burnout, academic stress, EI, and even neuroti- Funding
This study has no funding to be declared.
cism may different at different educational settings and
fluctuate over time. Besides, the sampling technique Availability of data and materials
used was not the ideal method due to the limitation of The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.
the non-probability technique due to sampling bias,
which may cause imprecision of the obtained results. Declarations
Hence, future research should use the probability sam-
pling technique to overcome this limitation. Lastly, it is Ethics approval and consent to participate
This study was approved by the Human Research Ethics Committee of
recommended to perform subanalysis by gender and Universiti Sains Malaysia (Reference Code:USMKK/PPP/JEPeM(212.4[2.5]).
academic years in the future study to examine this Informed consent was obtained from each participant prior to the study. All
model because EI may be different according to the gen- methods were carried out in accordance with relevant guidelines and
regulations.
der, and also, if the subjects were in a different academic
year, they could have a different level of distress and Consent for publication
burnout. Despite these limitations, this research has sev- Participants had given consent to publish the data as long as the anonymity
is maintained.
eral strengths. First, the research variables were mea-
sured by validated research tools, and the obtained Competing interests
results supported the measurement model fit. Second, No conflict of interest to be declared.
the sample size was satisfactory for SEM; thus, the ob-
Author details
tained results are trustworthy for the proposed structural 1
Department of Medical Education, School of Medical Sciences, Universiti
model. Third, the analysis was conducted by standard Sains Malaysia, Kota Bharu, Kelantan, Malaysia. 2Department of Anatomy,
School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan,
and recommended statistical software; therefore, the ob-
Malaysia. 3Deparment of Psychiatry, School of Medical Sciences, Universiti
tained results can be trusted and compared with previ- Sains Malaysia, Kota Bharu, Kelantan, Malaysia.
ous studies. Lastly, as far as the author is aware, this is
Received: 11 January 2021 Accepted: 12 May 2021
the first attempt to describe the causal-effect relation-
ships of burnout, psychological distress, academic stress,
neuroticism, and EI through SEM. References
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