The Predictive Value of Burnout and Impostor Syndrome on Medical Students’ Self-Esteem and Academic Performance: A Cross-Sectional Study

Abstract

Stress exposure can take a toll on the adjustment of young individuals, including students. The aim of this study was to investigate the impact of burnout and impostor syndrome (IS) on self-esteem and academic performance in medical students. The participants were 331 undergraduate medical students (102 men, 229 women; 89.7% native, 12,1% international; mean age = 21.18, SD = 2.338). The study instruments included the Copenhagen Burnout Inventory for Students (CBI-S), Clance Impostor Phenomenon Scale (CIPS), and Rosenberg’s Self-Esteem Scale, while academic performance (AP) was reported as received GPA (objective AP) and expected GPA (subjective AP). The statistical analysis comprised independent t-tests, MANOVA, ANOVA, and correlational and mediational analyses. The results showed that native students had lower self-esteem and higher scores of personal burnout and IS. Irrespective of cultural differences, women scored higher than men in IS and in personal burnout, while men had higher self-esteem than women. Burnout and IS were correlated with a decrease in self-esteem (adj. R² = 0.531) in the overall sample, whereas in native students, IS was correlated with a difference between subjective and objective self-assessments of AP (adj. R² = 0.027). Burnout and impostor syndrome, despite not directly impacting academic performance, may significantly influence self-esteem, making them a target for preventive or interventional measures.

1. Introduction

1.1. Academic Burnout Among Medical Students

Academic burnout as a whole, but also in its individual components—emotional exhaustion, depersonalization, and low professional accomplishment—has a high prevalence among undergraduate students [1,2,3]. In particular, the medical academic environment is particularly favorable to the development of burnout symptoms because of factors such as the overloaded study curriculum, the high competitivity, the disproportionate expectations about success, or the everyday confrontation with emotional and physical suffering [2,4,5]. High levels of burnout (up to 88%) are described in both preclinical and clinical years [5,6,7], with an increase in the latter, suggesting a cumulative mechanism [8,9].

Burnout can have redoubtable consequences, both in the short- and long-term [10,11]. These are represented especially by depressive and anxiety disorders [5,12], a general decrease in overall well-being [13,14], and even suicidal ideation [14]. The occurrence of burnout during academic studies can also impact the quality of care that medical students are able to provide to their patients, via a detached attitude toward patients and feelings of academic incompetence and reduced performance [15,16]. These phenomena are amplified by their frequent exposure to sickness, suffering, and death [17]. Medical universities have implemented awareness programs regarding burnout and prevention strategies to maintain the students’ well-being and to indirectly provide better healthcare to their patients [18,19].

1.2. Academic Performance in Medical Schools

In medical schools, academic performance is considered paramount for building durable professional success. In this respect, the grades obtained in medical school do not reflect only the acquisition of specific knowledge and skills [20] but are often seen as an indicator of a long-time professional commitment and an early indicator of responsibility. One of the most common ways of expressing academic performance is General Point Average (GPA), which reflects cumulative performance over time and has been reported to have strong relationships with burnout [21]. Despite the fact that academic performance can be influenced by factors that are often out of the control of the medical student, such as the learning environment or perceived social support [22,23], burnout is seen in many studies as one of the main contributors to poor academic performance [24], via low motivation and attention, negative outlook on academia, feelings of professional inadequacy, absenteeism, and lack of self-trust [21,25,26]. A meta-analysis [21] showed that academic performance can be negatively influenced by total burnout (r_c⁺ = −0.24), but also by each of its three components, with lack of professional effectiveness displaying the highest predictive value (r_c⁺ = −0.39). The inverse association between these variables has been also documented: low academic performance may act as a significant independent predictor of a higher burnout risk [27,28].

1.3. Impostor Syndrome (IS) and Its Impact on Medical Students

Impostor syndrome (IS) is a well-documented phenomenon in the healthcare profession and in the medical academic environment [29]. IS is not a disease or disorder in the common sense, but rather the manifestation of a set of associated emotions, attitudes, and behaviors, causing the individual to have chronic self-doubt and the lingering fear of being discovered as an intellectual fraud, despite the existing proof of their aptitudes [30]. In medical academic environments, approximately 30–60% of medical students may experience IS during their studies [31,32,33,34,35,36]. Its incidence reaches a peak during the final year before graduation [37], possibly in relation to the upcoming challenges derived from going from professional formation to the practice of the profession on an everyday basis. Most frequently, students with IS do not recognize this condition and persist in comparing their achievements in a degradative manner to those of others. They may display low self-esteem, a chronic lack of trust in themselves and their abilities, and perfectionism [38]. Under-represented groups (women, ethnical minorities, disabled individuals), people whose parents have a successful career, those who obtained success in a short period of time or in an unusual way, and the first generation of professionals, students, or graduates tend to be affected more frequently [39].

Academic performance can be influenced by the presence of IS. High personal expectations and perfectionism in the medical environment [33,34], on the one hand, and doubts regarding their own results and beliefs, on the other hand, may trigger students with IS to perceive they have lower subjective academic performance [40].

The negative impact of IS on academic performance is seen in learning environments that value hierarchy and expertise [41], which are considered to be reflected by objective academic performance (i.e., GPA from academic records). Studies on medical students and residents have consistently described a solid relationship between levels of burnout and IS. In both cases, a negative correlation was observed with career satisfaction and perceived professional success [42].

1.4. The Role of Self-Esteem in Medical Students’ Professional Achievements

A psychological variable that is considered to be paramount for healthcare professionals is self-esteem, defined as “the subjective general evaluation an individual has over its own worth, self-trust and self-respect” [43]. People with a sound level of self-esteem are confident in their own abilities to solve problems, without being discouraged by difficulties and failures [44]. In particular, students with high self-esteem experience more motivation, happiness, optimism, empathy, and a better ability to face difficult or unexpected challenges [45]. Although medical students generally have good self-esteem [46], some studies have found low self-esteem in approximately 20–23% of students [35,47]. Students with low self-esteem have higher levels of burnout, and they use avoidant coping strategies, which are unable to help them to overcome encountered difficulties, including academic ones [48].

Burnout can influence people to work at suboptimal levels, which in turn affects self-esteem, thus creating a vicious circle [49]. While it appears clear that self-esteem is negatively correlated with burnout, including its sub-dimensions [47,50,51], the direction of causality is debatable.

In students suffering from IS, self-esteem can be significantly lower. They cannot internalize feelings of competence, accomplishment, or skills, and they tend to perceive themselves as less competent and less intelligent than how their peers perceive them [52,53,54].

Self-esteem in medical students has an important predictive value. Students with higher self-esteem not only have a higher GPA but are able to display a higher clinical performance as physicians (e.g., better care provided to patients, and positive inner beliefs in their own abilities) [55,56].

1.5. Gender and Cultural Influences on Burnout, Self-Esteem, and Impostor Syndrome

All the abovementioned variables (burnout, self-esteem, and IS) are highly susceptible to demographic and cultural influences. Still, in the current literature, these relationships are insufficiently explored and/or challenged. For example, while many studies have identified female students as being more prone to burnout compared to male students [5,57,58], other data suggest the opposite [59] or no differences in this respect [60]. Despite IS being more common in women [34,61,62], the perception of IS can be biased by societal preconceptions and expectations [63]. Several studies found relevant social and racial differences, but they focused mostly on the population groups in each country [57]. A meta-analysis [42] showed that there are mixed results regarding the relationship between burnout, IS, and socio-cultural factors (such as race and ethnicity) and that there may be various mediators (such as self-esteem, racial discrimination, racial identity, feelings of belonging to an ethnic group) potentially influencing this relationship.

The goal of a well-grounded medical education is to produce physicians with high professional skills but also with a reasonable level of self-esteem, which would encourage the use of these aptitudes in practice [64]. Variables such as burnout and IS could undermine academic performance and durably affect self-esteem. Exploring the comparative impact of burnout and IS on self-esteem and academic performance from an individual and cultural perspective can offer useful insights into the causes of low academic performance and personal incompetence perceived by many medical students.

The present study aims to investigate the effects of burnout and IS on self-esteem and academic performance among medical students.

Our objectives were to assess the prevalence and impact of burnout and impostor syndrome on self-esteem, to examine how burnout and impostor syndrome influence academic performance, and to explore the mediating role of self-esteem in the relationship between burnout, impostor syndrome, and academic performance. In this respect, we developed the following four hypotheses:

Hypothesis 1: 

Burnout and imposter syndrome negatively predict self-esteem and academic performance in medical students.

Hypothesis 2: 

Burnout and impostor syndrome are positive predictors of the differences between subjective and objective evaluations of academic performance.

Hypothesis 3: 

Gender can have a significant role in explaining differences in burnout, impostor syndrome, and self-esteem.

Hypothesis 4: 

The effects of burnout and impostor syndrome on self-esteem and academic performance may vary based on the cultural background.

2. Materials and Methods

2.1. Study Design and Procedure

The design of this study was transversal. Data collection was realized between November 2023 and May 2024.

The study protocol consisted of a cross-sectional evaluation of academic burnout, impostor syndrome, self-esteem, and academic performance.

Information about this study and its objectives was posted on social media groups of the university. After expressing interest in the study theme, a convenience sample of self-selected participants was established. After applying the inclusion and exclusion criteria, the final study sample was reached.

Before participating in this research, the students were provided with information about this study and were asked if they wanted to participate in this study or not. Before answering, all the students completed an informed consent form. This study was run in accordance with the World Medical Association Declaration of Helsinki and was approved by the CDUMP Ethics Committee (no. 36367/29.11.2023).

All questions were administered online and distributed through the social media groups of the university. Three researchers (ANC, AD, IRSB) were available by email in case there were questions related to the process of filling out the questionnaires. All responses were processed anonymously, and a numerical code was assigned to each participant. The collected data were accessible exclusively to the study researchers (ANC, AD, IRSB, LVD, AIM, OPV). Regular didactic staff had no access to the distribution, collection, or interpretation of questionnaires.

The interpretation of the questionnaires was performed independently by three researchers (ANC, IRSB, LVD) and cross-checked for congruence afterward. The final results were included in an SPSS 21 (SPSS Inc.^®, Chicago, IL, USA) database.

2.2. Participants

The participants were undergraduate students enrolled in the “Carol Davila” University of Medicine and Pharmacy Bucharest, Romania (CDUMP). This university is the largest medical school in Romania, which hosts both national and international students (approximately 6000 national students and 1500 international students), thereby offering a representative selection sample.

The inclusion criteria were as follows: (a) age over 19 years old; (b) having the status of undergraduate students in the abovementioned institution; (c) giving informed consent to participate in this study; and (d) completing all the study instruments.

The exclusion criteria were represented by current self-reported somatic or psychiatric morbidity and lack of completion of one or more of the study instruments.

The minimum sample size to ensure statistical relevance (n = 274) was calculated according to current guidelines [65] and aiming for a confidence interval of 90% and an error margin of ±5%.

From the total of 340 CDUMP students who agreed to participate in the time frame designated, 9 students were eliminated because they did not meet the inclusion criteria and/or met the exclusion criteria. Finally, 331 students were enrolled in this study. The students came from a Romanian-speaking group (“native students”), 291 (87.9%), and from an English-speaking group (“international students”), 40 (12.1%).

The sample included 102 (30.2%) men and 229 (69.2%) women. Gender-wise, this ratio was representative of the Faculty of Medicine since it was not significantly different from the distribution by gender of all students in the faculty.

The mean age was 21.18 (SD = 2.338).

In terms of study cycle, 237 (71.6%) students were pursuing the preclinical track and 84 (28.4%) the clinical track.

2.3. Instruments

(1)

The Copenhagen Burnout Inventory for Students CBI-S [66] includes 25 items (answer options: “always/to a very large extent”, “often/in to a large extent”, “sometimes/somewhat”, “rarely/to a small extent”, “never/almost never”). The CBI-S was elaborated from the Copenhagen Burnout Inventory (CBI) [67] and adequately calibrated for the student population. The questionnaire investigates four dimensions of burnout, according to its source: “personal burnout”, “study-related burnout”, “colleague-related burnout”, and “teacher-related burnout”. The scale has very good psychometric properties (Cronbach’s coefficient = 0.957 [67]), being largely used in research papers from this area. In this paper, its use allowed for a finer analysis of the relationship between the source of burnout and the dependent variables.

(2)

The Clance Impostor Phenomenon Scale (CIPS) [30] is a psychometric tool assessing the perception of individuals as being successful by external standards but incompetent in terms of self-evaluation. The scale includes 20 items. The response options range on a Likert scale from 1 to 5, where 1 = “does not suit me at all” and 5 = “suits me to a great extent”. The higher the score, the more intensely the person experiences feelings of being an impostor. CIPS states 4 categories of results, according to the obtained points: lower than 40 (“a few impostor characteristics”), 41–60 (“moderate experiences of being an impostor”), 61- 80 (“frequent feelings of being an impostor”), and above 81 (“intense experiences of being an impostor”). The questionnaire has a satisfactory internal consistency, with Cronbach’s alpha varying between 0.85 and 0.96 [68].

(3)

The Rosenberg’s Self-Esteem Scale [69] is a widely used self-report instrument for assessing individual self-esteem. It includes 10 items, with the answer options ranging from 0 = “strong disagreement” to 3 = “strong agreement”. The scale presents good psychometric properties (Cronbach’s alpha = 0.77–0.88) [70].

The participants also provided information about their age at the time of the testing, gender, study year, objective academic performance (measured by annual GPA or entrance exam grade, in the case of 1st-year students), and subjective perception about it (the GPA they thought they deserved; in the descriptive analysis, this was included by three distinct levels—“deserved better”, “deserved the same”, “deserved worse”).

2.4. Data Analysis

Descriptive analyses (including mean, standard deviation, lowest/highest values, and standard error of the mean) were used to depict socio-demographic characteristics and the variables’ scores.

The statistical analysis used for testing Hypothesis 1 included the following:

(a)

A correlation analysis between dependent (self-esteem, subjective and objective performance) and independent (burnout and IS) variables, using Pearson’s correlation coefficient, followed by the testing of the coefficient, using a t-test;

(b)

MANOVA for examining simultaneously multiple dependent variables (self-esteem, subjective and objective performance) in relation to burnout and IS;

(c)

ANOVA for examining group differences, understanding the relationship between the objective and subjective evaluations of academic performance vs. independent variables (burnout and IS);

(d)

A mediation analysis to examine whether self-esteem mediates the relationship between burnout and IS (independent variables) on academic performance (dependent variable).

To test Hypotheses 2 and 3, we used t-tests. They aimed to compare group differences in men vs. women and native vs. international students. We also analyzed gender and native/international status as moderators for the relationship between burnout and IS (independent variables) on academic performance (dependent variable).

3. Results

3.1. Descriptive Analysis

A list of the students’ socio-demographic characteristics is depicted in

Table 1. Socio-demographic characteristics.

		Mean	SD *	Min.	Max.	SEM †
Age		21.18	2.338	18	39	0.128
		N	%
Gender	Male	102	30.8
	Female	269	69.2
Study group	Romanian (native)	291	87.9
	English (international)	40	12.1
Study year	First	49	14.8
	Second	188	56.8
	Preclinical (Total)	237	71.6
	Third	12	3.6
	Fourth	19	5.7
	Fifth	27	8.2
	Sixth	36	10.9
	Clinical (Total)	94	28.4

* SD = standard deviation; ^† SEM = standard error of the mean; italics stand for subtotals.

.

The synthesis of the variables’ scores is included in

Table 2. Variables’ scores.

		Mean	SD *	Min.	Max.	SEM †
Burnout	Personal	60.85	16.941	4	100	0.931
	Study-related	58.09	17.142	7	100	0.942
	Colleague-related	32.99	22.140	0	100	1.217
	Teacher-related	39.90	23.651	0	100	1.300
	Total	48.37	14.335	3	85	0.788
Self-esteem		17.80	5.766	0	30	0.317
Impostor syndrome	Total score	64.77	16.246	23	97	0.893
	By points:	N	%
	≤40	26	7.854
	41–60	100	30.211
	61–80	148	44.712
	≥81	57	17.220
		Mean	SD *	Min.	Max.	SEM †
Academic performance	Objective **	8.541	1.082	4	10	0.059
	Subjective ***	8.619	1.130	0	10	0.062
	Subjective (by categories):	N	%
	“I deserved better”	81	24.471
	“I deserved the same”	224	67.673
	“I deserved worse”	26	7.854

* SD = standard deviation; ^† SEM = standard error of the mean; ** obtained GPA (General Point Average); *** deserved GPA.

.

3.2. Statistical Analysis

3.2.1. Burnout and Impostor Syndrome Negatively Predict Self-Esteem and Academic Performance (Hypothesis 1)

First, we assessed the relationship between the tested variables through a correlational analysis. This showed a significant negative correlation between self-esteem and burnout (r = −0.43, p < 0.001), on the one hand, and another negative correlation between self-esteem and impostor syndrome (r = −0.71, p < 0.001), on the other hand. The independent variables (burnout and IS) did not directly correlate with performance, which directed us to consider the multivariate relationships that correlation analysis cannot capture.

We conducted a multivariate analysis of variance (

Table 3. Effects of burnout and impostor syndrome on self-esteem and academic performance (whole sample) (MANOVA).

Source	Dependent Variables		F	p	Partial Eta2	Adjusted R2
Corrected model	Self-esteem		75.124	0.001	0.538	0.531
	Academic performance	Obj. *	1.925	0.090	0.029	0.014
		Subj. **	1.513	0.185	0.023	0.008
Burnout (total score)	Self-esteem		21.584	0.001	0.062
	Academic performance	Obj. *	2.295	0.131	0.007
		Subj. **	0.599	0.440	0.002
Impostor syndrome	Self-esteem		210.043	0.001	0.394
	Academic performance	Obj. *	1.809	0.180	0.006
		Subj. **	0.345	0.557	0.001
Gender	Self-esteem		1.483	0.224	0.005
	Academic performance	Obj. *	0.336	0.563	0.001
		Subj. **	0.149	0.699	0.001
Study cycle	Self-esteem		0.447	0.504	0.001
	Academic performance	Obj. *	1.332	0.249	0.004
		Subj. **	0.835	0.362	0.003
Gender x study cycle	Self-esteem		0.600	0.439	0.002
	Academic performance	Obj. *	2.388	0.123	0.007
		Subj. **	2.033	0.155	0.006

* Obj. = objective performance (obtained GPA); ** Subj. = subjective performance (deserved GPA).

), to capture the relationship between burnout and impostor syndrome (as independent variables) and self-esteem, subjective academic performance, and objective academic performance (as dependent variables).

The analysis indicated that self-esteem had a significant relationship with both burnout (F = 21.584, p < 0.001) and impostor syndrome scores (F = 210.043, p < 0.001). For self-esteem, the model explained approximately 53.1% of the variance, while for academic performance, the model had a weak explanatory power of only 1.4% for objective academic performance and 0.8% for subjective academic performance.

No substantial relationship was identified for gender, study cycle, or their interaction.

The mediation analysis did not reveal a statistically significant effect of burnout (B = −0.02, p < 0.841) or IS (B = −0.02, p < 1.00) on subjectively assessed academic performance through self-esteem. Oppositely, it revealed a significant indirect effect of burnout on objective performance through self-esteem (B = 0.22, p < 0.034). The indirect effect of IS on objective performance through self-esteem was not significant (B = 0.32, p < 0.085).

3.2.2. Burnout and Impostor Syndrome as Predictors of the Differences Between Subjective and Objective Evaluations of Academic Performance (Hypothesis 2)

These data are depicted in

Table 4. Effects of burnout and impostor syndrome on the difference between subjective and objective evaluations of academic performance (whole sample) (ANOVA).

Source	Dependent Variable	F	p	Partial Eta2	Adjusted R2
Corrected model	Difference in objective–subjective evaluation of academic performance	2.850	0.016	0.042	0.027
Burnout (total score)		1.643	0.201	0.005
Impostor syndrome		12.861	0.001	0.038
Gender		0.100	0.752	0.001
Study cycle		0.125	0.723	0.001
Gender x study cycle		0.007	0.932	0.001

.

The model explains a very low amount of variance (2.7%). The highest contribution to the difference between objective and subjective evaluations of academic performance is brought by the presence of impostor syndrome.

3.2.3. The Effects of Burnout and IS on Self-Esteem and Academic Performance May Vary, Based on Gender (Hypothesis 3)

The data on gender differences are synthesized in

Table 5. Gender differences (whole sample).

Characteristics	Men	Women	Statistics
	Mean (Standard Deviation)	Mean (Standard Deviation)	t	df	p
Personal burnout	53.80 (17.987)	63.99 (15.489)	−4.962 º	170.493 º	0.001 º
Study-related burnout	52.94 (18.372)	60.39 (16.082)	−3.534 º	172.786 º	0.001 º
Colleague-related burnout	33.66 (24.364)	32.70 (21.123)	0.346 º	171.438 º	0.730 º
Teacher-related burnout	41.09 (24.924)	39.37 (23.099)	0.611 †	329 †	0.542 †
Total burnout	45.68 (14.916)	49.56 (13.936)	−2.292 †	329 †	0.023 †
Impostor syndrome	59.00 (15.653)	67.34 (15.871)	−4.436 †	329 †	0.001 †
Self-esteem	19.86 (5.256)	16.89 (5.756)	4.459 †	329 †	0.001 †
Academic performance (obj. *)	8.54 (0.972)	8.54 (1.129)	0.028 †	328 †	0.978 †
Academic performance (subj. **)	8.67 (0.892)	8.594 (1.223)	0.605 †	328 †	0.546 †

* Obj. = objective performance (obtained GPA); ** Subj. = subjective performance (deserved GPA). ^† Equal variances assumed (Levene’s test); º equal variances not assumed (Levene’s test).

.

Women obtained significantly higher scores than men in IS and in personal, study-related, and total burnout. Oppositely, men were significantly higher in self-esteem. No significant differences were met in terms of colleague-related burnout, teacher-related burnout, or in what concerned subjective and objective evaluations of academic performance.

A moderation analysis was conducted to examine whether gender moderates the relationship between burnout (independent variable) and self-esteem (dependent variable). The analysis revealed a significant interaction effect between burnout and gender on self-esteem (B = 0.12, p < 0.005).

Further, a moderation analysis was conducted to examine whether gender moderates the relationship between IS (independent variable) and self-esteem (dependent variable), with no significant results (B = 0.04, p < 0.178).

Additional analyses regarding a moderation effect of gender on the impact of burnout and IS (as independent variables) on academic performance (dependent variable) showed no significant results.

3.2.4. Cultural Differences

The effects of burnout and impostor syndrome on self-esteem and academic performance could vary based on the cultural background (Hypothesis 4).

To capture the importance of cultural differences for the relationships between the study variables, we replicated the analyses described in Section 3.2.1, Section 3.2.2 and Section 3.2.3 separately on native and international students.

Additionally, we realized an analysis of the culturally mediated differences in what concerned all the study variables (

Table 6. Differences in the study variables (native vs. international students).

Characteristics	Native Students	International Students	Statistics
	Mean (Standard Deviation)	Mean (Standard Deviation)	t	df	p
Personal burnout	61.74 (16.536)	54.38 (18.610)	2.601 †	329 †	0.010 †
Study-related burnout	58.89 (16.383)	52.32 (21.253)	1.878 º	45.591 º	0.067 º
Colleague-related burnout	32.37 (21.470)	37.50 (26.386)	−1.176 º	46.370 º	−0.245 º
Teacher-related burnout	39.25 (23.802)	44.69 (22.229)	−1.366 †	329 †	0.173 †
Total burnout	48.49 (14.237)	47.43 (15.184)	0.442 †	329 †	0.659 †
Impostor syndrome	65.62 (16.328)	58.60 (14.361)	2.585 †	329 †	0.010 †
Self-esteem	17.51 (5.717)	19.95 (5.733)	−2.532 †	329 †	0.012 †
Academic performance (obj. *)	8.61 (1.079)	7.96 (0.928)	3.604 †	328 †	0.001 †
Academic performance (subj. **)	8.68 (1.096)	8.14 (1.276)	2.837 †	328 †	0.005 †

* Obj. = objective performance (obtained GPA); ** Subj. = subjective performance (deserved GPA). ^† Equal variances assumed (Levene’s test); º equal variances not assumed (Levene’s test).

).

Burnout and Impostor Syndrome as Predictors of Self-Esteem and Academic Performance (Native vs. International Students)

For both native and international students, the model describing self-esteem exhibited an adjusted R-squared value of 0.523, signifying that more than 50% of the variance in self-esteem was attributable to burnout, impostor syndrome, gender, and study cycle. Oppositely, the adjusted R-squared values for academic performance were minimal (0.013 and 0.028, respectively), indicating that the abovementioned variables do not significantly predict academic success.

A moderation analysis was conducted to examine whether native/international student status moderates the impact of burnout and IS (independent variables) on self-esteem (dependent variable), with no significant results.

An additional moderation analysis was conducted to examine whether native/international student status moderates the impact of burnout (independent variable) on academic performance (dependent variable). The result was significant only in terms of subjective academic performance (B = −1.54, p < 0.013), but it did not reach statistical significance on objective academic performance.

When a similar analysis was run for the moderating effect of student status on the impact of IS (independent variable) on academic performance, the result was only marginally significant for both kinds of academic performance, including objective (B = 1.18, p < 0.066) and subjective (B = −1.07, p < 0.096).

Burnout and Impostor Syndrome as Predictors of the Differences Between Subjective and Objective Evaluations of Academic Performance (Native vs. International Students)

The model explained a low amount of variance (5.3%). The contribution to the difference between objective and subjective evaluations of academic performance was met exclusively in Romanian students and was correlated to the presence of burnout and impostor syndrome.

Gender Differences (Native vs. International Students)

Gender differences were more prominent in the native students and comprised higher scores of impostor syndrome, personal burnout, and study-related burnout, while self-esteem was significantly higher in men. In the international students, women scored higher only in personal burnout, while men were significantly higher in self-esteem.

Differences in Study Variables (Native vs. International Students)

These results are synthesized in Table 6.

The independent samples t-test indicated substantial differences between the native and international students across multiple scales. Personal burnout, impostor syndrome, and both objectively and subjectively evaluated academic performance were all significantly higher in the first group, while self-esteem was significantly higher in the second group. No significant differences were noted in terms of colleague-related burnout, teacher-related burnout, or total burnout.

4. Discussion

This study aimed to investigate burnout, impostor syndrome, self-esteem, and academic performance among medical students and the predictive effect of the first two variables on the second two. Additionally, this study explored the importance of gender and cultural differences in this matter.

4.1. Descriptive Data

The medical students enrolled in this study showed a high level of total burnout, especially personal and study-related burnout. Both are specific aspects of the medical academic field and may reflect the important cumulative impact of overloaded curriculum, high competitivity, and exposure to human suffering [1,2,3,4,5].

Self-esteem scores were within the normal range (i.e., between 15 and 25 points), as reported by similar studies run on medical students [46,70]. However, the students in this study had an average self-esteem at the lower limit of the normal (17,80).

Almost 45% of the respondents frequently felt like an impostor, while 17% had intense impostor experiences. This can be due (at least in part) to the intense pressure medical students perceive throughout their academic training. Further, this suggests a possible effectiveness of organizational interventions targeting IS (e.g., mentoring, academic support, individual and group counseling) [47].

The respondents in our study showed high academic performance (GPA mean = 8.541). Although the subjective appreciation of the performance was slightly higher, two-thirds of the students considered that their obtained GPA truly reflects their performance.

4.2. Correlations Between Study Variables

Our results illustrate a significant statistical relationship between self-esteem and both burnout and IS, also confirmed by the correlational analysis.

Self-esteem was decreased in the presence of burnout. This is supported by models such as The Cognitive-Affective Stress Model [71], which asserts that burnout (frequently connected to a high amount of perceived stress in medical environments [72,73,74]) may negatively impact self-esteem. Oppositely, if preserved, self-esteem can serve as a protective mechanism against burnout, as it may assist students in better management of daily stressors [75].

In turn, the negative relationship between self-esteem and IS can be corroborated with the existing literature, pointing out that IS may result in anxiety, despair, and fear of failure, which could all diminish self-esteem [17,76]. As a whole, this study highlights the significant impact of IS on self-esteem among medical students and the necessity of targeting IS to enhance students’ self-worth.

4.3. Predictors of Academic Performance

Unlike other studies [28] that identified a clear correlation between high burnout and low GPA, our study found a weak influence of burnout and impostor syndrome on subjective academic performance. This can be explained by other factors (e.g., personality type) that were not considered in this study.

Still, we found through mediation analysis that burnout moderately impacts objective academic performance via its negative effect on self-esteem. This suggests that lower self-esteem stemming from burnout can contribute to changes in objective academic performance.

When further analyzing the difference between objective and subjective evaluations of academic performance, a distinct predictor was identified, namely, IS. The students experiencing IS were prone to underestimate their academic achievements and to exaggerate their failures, resulting in heightened stress. This is consistent with research indicating that IS can diminish self-evaluation of academic achievements [77] and predispose those affected to increased anxiety, self-doubt, and fear of failure [30].

4.4. Gender Differences

Women displayed higher levels of personal, study-related, and total burnout, significantly higher levels of IS, and lower self-esteem compared to men. A mixed effect of gender and burnout was identified as predictive of low self-esteem in these respondents. This can be due to the stronger impact of exhaustion, combined with internal and external criticism, in women. Several other studies [78,79,80] equally argue in favor of a higher predisposition of women (including those in academic environments) to compare themselves to others and/or to give importance to the opinion of others.

4.5. Cultural Differences

For both native and international students, burnout and impostor syndrome largely influenced self-esteem. The effect on academic performance was limited to subjective performance, significantly lower in international students affected by burnout. Although prior studies found that there is a negative association between IS and subjective academic performance [40,81], a review showed that their relationship is rather inconsistent [42]. A possible explanation is that there may be individual factors that make the internalization of performances and feelings of IS not systematically aligned with students’ actual performance [76].

Concerning the difference between objective and subjective performance, the influence of burnout and IS on academic performance was found only in native students. Also, native students achieved superior scores in both objectively and subjectively assessed academic performance. This finding may suggest that native students possess more knowledge of the educational system, better access to resources, and a superior integration in support networks that promote academic performance [82]. Cultural background may also influence perceptions of academic achievement, as native students may possess distinct benchmarks for success, in contrast to their overseas peers.

Gender differences were more pronounced among native students, with women exhibiting elevated levels of IS, and personal and study-related burnout, whereas men demonstrated significantly higher self-esteem. Among international students, women exhibited superior scores solely in personal burnout, but men demonstrated considerably elevated levels of self-esteem.

Differences in IS may also be due to cultural differences regarding gender. Society can influence the way in which a person relates to their success, in relation to gender identity [83,84]. Consequently, in some societies, there may be an increased inclination towards IS, especially in women. However, according to a scoping review, cross-cultural assessments of IS, including differences in gender perceptions and roles, are still scarcely explored [85].

We did not note differences in total burnout between native and international students. However, the independent samples t-test revealed significant disparities between native and international students on several dimensions. Personal burnout, study-related burnout, IS, and both objectively and subjectively assessed academic performance were markedly elevated in the first group, whereas self-esteem was much greater in the second group.

Higher scores of study-related burnout in native students can be explained by the fact that Romanian students need to typically face a large curriculum and high competitivity (e.g., their tax-free status can be revoked if their GPA is low; this being an additional pressure). In turn, international students seem to be stressed by a series of significant variables besides studying (e.g., their poor adjustment to a new academic environment or their inability to cope with a totally different cultural background).

Romanian students had higher levels of IS and lower levels of self-esteem compared to international ones, although their objective and subjective academic performance was significantly better. Students’ experiences of IS could have been influenced, besides personal characteristics [86,87] and socio-cultural background [83], by specific aspects related to the academic environment (e.g., educational requirements, grading systems, or the different emphasis placed on grades, compared to the practical skills acquired in the learning process) [34].

The abovementioned data could be also analyzed in light of societal differences. Research indicates that many Eastern European societies, including Romania, frequently place a significant societal focus on academic achievement [88], potentially explaining the higher grades. This pressure may also lead to increased fatigue and IS, as students struggle to fulfill elevated expectations [83]. This kind of collectivistic society often prioritizes the significance of others’ perceptions, potentially intensifying IS and exhaustion [89].

In light of these findings, educational institutions ought to implement tailored interventions to assist both native and international students. Programs focused on stress management, mentorship, and community development could assist native students in mitigating personal burnout and feelings of IS [90,91]. In contrast, international students may gain from measures that improve their integration into the academic community.

4.6. Limitations and Further Research

The results in our sample have limited generalizability to all students, given the size of the sample, the self-selection of the participants, the skewed gender ratio (with a significantly higher number of female participants), and a greater participation of students from the preclinical years. The results could have had higher representativity if the collection of data had been extended nationwide. Another limitation is brought by the size of the sample of international students and its representativeness (the socio-cultural background and the specifics of the academic environment are very diverse). Data were collected online (bringing potential limitations to respondents) and were largely self-reported. This aspect could have influenced the self-selection of the participants (being under the protection of anonymity, there is no indication of the base level of the participants’ self-esteem).

Unmeasured factors in this study, including external support, study habits, or personal motivation, may more effectively elucidate discrepancies in academic achievements. Future studies should investigate additional factors that might mediate the association between psychological characteristics and academic outcomes, including resilience and social support systems.

5. Conclusions

Burnout and IS are frequently experienced by medical students. It is worth identifying if they could impact self-esteem and academic performance, as both these characteristics are paramount in medical training. Our study highlighted that burnout and IS may act as predictors of self-esteem in medical students, regardless of the environment of origin, cultural background, and particularities of the academic system. Although our study showed that these two variables do not directly affect academic achievement, their significant impact on self-esteem emphasizes the necessity of mental screening and continuous psychological support in medical academic settings. The small effects of gender and position in the study track indicate that initiatives should address the entire student population, rather than particular subgroups. Their implementation can have an extended positive impact on current medical students, and later on, in their future professional careers.