Burnout as a mental health challenge among medical students in pakistan: a qualitative study of its triggers, impacts, and support needs

Abstract

Background

Burnout is a growing global concern among medical students, especially in low-resource settings where academic and personal stressors are heightened. Marked by emotional exhaustion, depersonalization, and reduced performance, it poses serious risks to students’ mental health and future professional roles. This study qualitatively investigates the key contributors, impacts, and support needs related to burnout among medical students in Pakistan.

Methods

A qualitative research design was employed using one focus group discussion (FGD) comprising 12 purposively selected medical students from Rawalpindi and Islamabad who self-reported burnout experiences. Discussions were guided by a semi-structured interview protocol exploring sources of stress, emotional and academic consequences, and perceptions of institutional support. Thematic analysis was conducted using NVivo to identify key patterns and emergent themes.

Results

Six major themes emerged as key contributors to burnout: overwhelming academic pressure, extended clinical hours, emotional distress from patient care, inadequate institutional and mental health support, personal and cultural stressors, and uncertainty about future career prospects. Students reported emotional and psychological consequences, including isolation, emotional numbness, reduced motivation, and doubts about their professional future. Importantly, participants expressed the need for accessible, stigma-free mental health services, stronger faculty mentorship, peer support mechanisms, and reforms in academic workload to support well-being.

Conclusion

Burnout among Pakistani medical students is driven by multifactorial stressors that are both systemic and personal. Comprehensive, stigma-free institutional interventions, including curriculum reform, accessible counseling services, structured peer support, and faculty development, are urgently needed to promote resilience and safeguard the future healthcare workforce.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-07762-y.

Introduction

The landscape of medical education is fraught with challenges that extend beyond the rigorous academic demands, intense clinical training, and high emotional burdens [1]. Globally, a substantial body of research highlights that medical students experience elevated rates of burnout, depression, and anxiety compared to their non-medical peers [2–4]. Burnout, conceptualized as a triad of emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment [5], poses significant threats to both students’ mental health and their academic and professional competence. International research consistently reports high prevalence rates of distress among medical students, with burnout estimates ranging from 32.8 to 48.9% across different educational contexts [6]. The consequences are extensive, including impaired academic performance, substance misuse, suicidal ideation, and erosion of professional empathy [7, 8].

While the global burden of burnout is well-documented, emerging evidence suggests that the problem is particularly pronounced in low- and middle-income countries (LMICs) such as Pakistan [9]. Medical students in Pakistan face a confluence of stressors, including overwhelming academic workloads, high-pressure clinical environments, societal expectations, and hierarchical, sometimes punitive, training systems [10, 11]. Studies report depression prevalence rates ranging from 30 to 60% among Pakistani medical students [12, 13] with high levels of emotional exhaustion and helplessness compounded by limited institutional support and stigma surrounding mental health [14]. Predictors of burnout among medical students frequently include excessive workload, sleep deprivation, and limited personal time, leading to emotional exhaustion and depersonalization [15]. In Pakistan, these challenges are intensified by societal pressures, fierce academic competition, and the prevalence of hierarchical and occasionally harsh training environments [10]. As a result, many students experience significant emotional distress, including anxiety, depression, and a diminished sense of personal accomplishment [16]. These issues highlight the urgent need for a more comprehensive understanding of the mental health challenges faced by Pakistani medical students. Despite growing awareness, in-depth exploration of its predictors, consequences, and the subsequent interventions to address these concerns in Pakistan remains fragmented and inconsistently applied across institutions [17]. Furthermore, qualitative research that captures the complex experiences, stressors, and support needs of medical students in Pakistan is still lacking [18]. Within the Pakistani context, systemic factors including authoritarian teaching styles, high parental expectations, and limited recreational opportunities further exacerbate vulnerability to burnout [21]. The consequences of unaddressed burnout are substantial, including diminished academic performance, erosion of empathy, increased absenteeism, and early professional disillusionment [1, 16]. Additionally, the literature highlights the multifactorial nature of burnout, shaped by an interplay of individual, institutional, and sociocultural factors. International studies have identified predictors such as perfectionistic personality traits, poor work-life balance, unsupportive learning environments, and personal stressors [19]. In response, global initiatives have increasingly emphasized the importance of comprehensive support systems, including wellness programs, mentorship opportunities, and curricular reforms to enhance work-life balance [20]. However, in Pakistan, such initiatives are often inconsistently applied, and students continue to report a need for accessible counseling services, peer support networks, and culturally sensitive mental health education [14]. Burnout among medical students is an increasing concern and has been examined through various theoretical perspectives. This research is guided by the Study Demands–Resources (SD-R) Theory, which conceptualizes burnout as a consequence of an imbalance between the academic demands encountered and the personal or institutional resources available to manage them [21]. So, addressing these critical gaps, the present study aims to qualitatively explore the predictors, impacts, and perceived support needs related to burnout and mental health challenges among Pakistani medical students. By centering student narratives, this study seeks to inform the development of contextually relevant interventions and institutional reforms to promote resilience and well-being within medical education in Pakistan.

Methodology

Study design

This study employed a qualitative descriptive design using a single focus group discussion to explore the determinants and implications of burnout and mental health challenges among medical students in Pakistan. A qualitative descriptive approach was selected to enable an in-depth exploration of students’ subjective experiences, providing a nuanced understanding of the psychological, social, and academic factors contributing to burnout within the unique cultural and institutional context of Pakistani medical education. The focus group methodology was chosen for its effectiveness in generating rich, collective insights through participant interactions, allowing diverse experiences and coping strategies to be shared. To ensure transparency and rigor, the study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [22].

Theoretical foundation

The present study was guided by the Study Demands–Resources (SD-R) Theory, which is an adaptation of the Job Demands–Resources (JD-R) Model tailored for academic settings [21]. The SD-R framework views academic burnout as a reaction to the disparity between substantial study demands, such as academic pressure, workload, and performance expectations, and the scarcity of study resources, like support, autonomy, and coping strategies. This framework was instrumental in shaping the focus group questions and the thematic analysis, facilitating an exploration of how institutional, academic, and personal elements contribute to burnout and how the presence of supportive resources might mitigate its effects among medical students.

Study setting

In Pakistan, the undergraduate medical education program (MBBS) lasts five years and is overseen by the Pakistan Medical and Dental Council (PMDC), with an optional internship year following graduation. The program is structured to encompass two years focused on basic sciences and three years dedicated to clinical training. Pakistan has an annual intake of approximately 15,000 medical students. Of the nearly 3,000 medical colleges worldwide, Pakistan hosts over 114 medical colleges, of which around 38% are public and 62% are private institutions [23]. This research was carried out in Rawalpindi and Islamabad, two neighboring cities in northern Pakistan that are recognized as academic centers and contain numerous prominent public and private medical schools linked with tertiary care hospitals and universities. Participants were selected from a broad array of colleges in both cities to ensure diverse representation.

Study and participants

A purposive sampling approach was employed to recruit 12 medical students from institutions in Rawalpindi and Islamabad. Participants were initially identified based on their self-report of stress or mental health concerns, and then screened for signs of burnout and related issues. Eligibility criteria included:

• Currently enrolled in 2nd year or above in an undergraduate medical program in Rawalpindi or Islamabad.

• Aged 18 or older.

• Effective communication skills.

• Mild to moderate burnout symptoms, as indicated by the Maslach Burnout Inventory-Student Survey (MBI-SS) [24].

Students who had completed both the MBI-SS and the Depression, Anxiety, and Stress Scale (DASS-21) [25] were invited to participate in the focus group discussion. Participants were excluded if they had interrupted their studies, were no longer actively enrolled, or demonstrated severe symptoms of depression, anxiety, or stress, based on self-report or additional screening measures. This ensured that participants could meaningfully contribute insights into burnout and mental health challenges in the Pakistani medical education context. Eligible participants were provided with detailed information via email about the study’s aims, objectives, and confidentiality protocols.

Data collection

A focus group discussion guide was developed to facilitate structured, in-depth conversations and ensure comprehensive coverage of relevant themes. The guide was informed by a review of the existing literature and was collaboratively developed by the research team, incorporating input from subject matter experts, including mental health professionals and educators familiar with the academic and emotional demands on medical students. This ensured that the questions were relevant and sensitive to the context. The full focus group discussion guide can be found in Supplementary File 1.

The guide was pilot-tested with a small group of volunteer students, and feedback led to minor modifications, such as adjustments in question wording and the addition of prompts to encourage deeper discussion. The final version of the guide included open-ended questions that explored the following areas:

• Experiences and symptoms of burnout.

• Contributing factors to burnout (e.g., academic pressure, workload, lack of social support).

• Perceived implications of burnout and poor mental well-being on academic performance and personal well-being.

• Possible solutions or recommendations to create a safe and productive learning environment.

Sociodemographic data, including age, gender, institution, year of study, and type of financial support, were also collected.

The focus group was conducted in a secluded and quiet room at a medical college, ensuring a comfortable and confidential environment. At the start of the session, participants were reminded of the study’s objectives, background, and confidentiality measures. They went through the participant information sheet and gave their written informed consent. Participants were made aware of their right to leave the session at any point without needing to give a reason. It was explained that once the data were anonymized and transcribed, it would not be possible to remove specific quotes or transcripts. The session was facilitated by a member of the research team with experience in qualitative research, while another researcher observed and took field notes to capture non-verbal cues and contextual information. With the participants’ consent, the entire session was audio-recorded. The discussion lasted for 90 min. The research team transcribed the audio recordings verbatim shortly after the session. The transcripts were reviewed against the recordings to ensure they were accurate and complete.

Reflexivity

The research team, comprising psychologists and educators with expertise in student mental health and higher education in Pakistan, contributed valuable insights to the topic. Although this background facilitated a deeper understanding of burnout-related issues, it might have also shaped the researchers’ viewpoints during the analysis. The lead researcher had no direct connection with the participants, which helped minimize power dynamics and foster open discussion. To mitigate potential bias, the team engaged in reflective journaling, peer debriefing, and regular discussions to ensure that the findings were firmly rooted in the participants’ narratives.

Data analysis

A total of 12 medical students participated in the focus group discussion. Participants were enrolled in medical colleges located in Rawalpindi and Islamabad. The majority were in their 4th year of study, with ages ranging between 20 and 24 years. Of the participants, seven were female and five were male. Regarding financial support, most students were self-funded, while a smaller proportion were on scholarships. For thematic analysis, the transcripts from the focus group discussion were imported into qualitative data analysis software (e.g., NVivo) for systematic coding and thematic analysis. The audio recordings were reviewed alongside the transcripts to ensure contextual accuracy and capture nuances in tone and meaning. Thematic analysis, following the six-phase process outlined by Braun and Clarke, was employed [26].

The research team began by immersing themselves in the data, reading and re-reading the transcripts to gain a comprehensive understanding of the participants’ narratives. Open coding was conducted to identify meaningful units of text that reflected participants’ experiences, perceptions, and implications related to burnout. These initial codes were grouped into broader themes, capturing the key determinants and implications of burnout.

The themes were reviewed iteratively to ensure internal consistency and alignment with the study’s objectives. Discrepancies were resolved through discussion, and revisions were made to refine and define each theme more clearly. To enhance analytic rigor, all three researchers independently reviewed the themes and collaboratively refined them, incorporating interdisciplinary perspectives to strengthen the interpretation.

Member checking was conducted by inviting participants to review their transcripts to ensure the accuracy and representation of their experiences. An audit trail was maintained to document all coding decisions and revisions, promoting transparency and dependability. Regular team meetings facilitated the resolution of challenges and uncertainties in the analysis process. Additionally, the study adhered to the Standards for Reporting Qualitative Research (SRQR) to ensure comprehensive and ethical reporting, reinforcing the credibility, confirmability, and transferability of the findings [22].

Results

Table 1 outlines the demographic details of the 12 individuals who took part in the focus group discussion. Ages of the participants varied between 21 and 24 years. The group consisted of 7 females and 5 males, encompassing students from their 2nd year through to their final year of medical school. Participants were selected from both public (n = 4) and private (n = 8) medical universities in Rawalpindi and Islamabad, ensuring a range of academic backgrounds and institutional settings.

Table 1.

Participants demographic profile

Participant	Age	Gender	Study Year	Institution Type
P1	21	Female	3rd Year	Private
P2	22	Female	4th Year	Private
P3	23	Female	Final Year	Private
P4	22	Male	3rd Year	Private
P5	24	Female	Final Year	Public
P6	21	Female	2nd Year	Private
P7	22	Male	4th Year	Public
P8	23	Female	Final Year	Private
P9	21	Male	2nd Year	Private
P10	21	Female	3rd Year	Public
P11	23	Male	Final Year	Public
P12	24	Male	4th Year	Private

Thematic analysis of the focus group discussion revealed six key themes contributing to burnout and mental health among medical students in Pakistan: academic pressure, extended working hours, emotional and psychological stress, inadequate support systems, personal and institutional factors, and future uncertainties. These interconnected themes underscore the complex challenges students face, significantly impacting their mental health, academic performance, and overall well-being. Each theme is described below, accompanied by relevant sub-themes, expressed support needs, and illustrative participant quotes, highlighting the nuanced experiences and determinants of burnout within the context of Pakistani medical education (Table 2).

Table 2.

Themes, Sub-Themes, and expressed support needs

Key Theme	Sub-Themes	Expressed Support Needs
Academic Pressure	• Overwhelming academic workload • Constant fear of failure • Pressure from self and others to excel	• Workload reduction strategies • Academic mentoring • Flexible expectations and pacing
Exhaustion from Clinical Demands	• Long, draining clinical shifts • Lack of time for rest and recovery	• Flexible scheduling • Access to rest spaces and mental health breaks
Emotional and Psychological Distress	• Anxiety about exams and future • Emotional exhaustion and fatigue • Feelings of isolation and disconnection	• Peer support programs • Counseling services and stress management workshops
Lack of Reliable Support Systems	• Absence of institutional mental health services • Gaps in peer connections • Lack of structured mentorship	• On-campus counseling infrastructure • Peer-led support and mentoring initiatives
Social and Family Pressures	• Parental expectations to succeed • Financial burden • Harmful social comparison with peers	• Financial support and guidance • Family awareness programs • Culture of collaboration over competition
Uncertainty About Career Pathways	• Worries about job prospects and postgraduate plans • Fear of unemployment or underemployment	• Career counseling and future planning • Support for building realistic work-life expectations

Theme 1: academic pressure

One of the most prevalent and recurring themes that emerged from the focus group discussions was the overwhelming academic pressure experienced by medical students. Participants consistently highlighted the heavy academic workload, exacerbated by the fear of failure and the high expectations placed on them by themselves, their families, and their institutions. The sheer volume of material they were required to master, combined with an unrelenting schedule of assessments, quizzes, and practical exams, left many students mentally and physically exhausted.

“The sheer amount of material we have to study is impossible to keep up with. Every day feels like a race, and I don’t know how much longer I can keep going.” (Participant 4).

The lack of sufficient breaks and the relentless cycle of evaluations created an environment in which academic success became the primary determinant of self-worth. Many students expressed that despite their continuous efforts, a pervasive sense of inadequacy remained, leading to heightened emotional distress.

“I’m so focused on getting good grades that I’ve completely lost track of my health.” (Participant 1).

A significant dimension of academic pressure was the profound fear of failure. Participants questioned their self-worth and even felt incapable of meeting academic demand and expectations, indicating a loss of personal accomplishment.

“I’m terrified of failing. If I don’t get the highest grades, I feel like I’m letting everyone down, especially my family.” (Participant 2).

“I constantly fear that I’ll disappoint my professors. If I make a mistake in front of them, it feels like I’ve failed.” (Participant 5).

This fear created an environment where even small setbacks were perceived as major failures, further eroding students’ confidence and mental resilience. Such experiences reflect a broader culture of perfectionism common in highly competitive academic environments, where mistakes are stigmatized rather than viewed as learning opportunities.

Moreover, students noted that pressure extended beyond academics, as expectations to be “perfect” were also internalized from peers and family members.

“There’s this constant pressure to be perfect, not just from professors, but also from peers and my family.” (Participant 8).

In light of these overwhelming pressures, participants strongly emphasized the need for structural reforms within their academic institutions. Many advocated for better workload management, the introduction of rest periods, and more balanced schedules to help mitigate stress.

“If they could just give us some time to breathe, to step back, and not have every moment filled with studying, maybe it wouldn’t be so overwhelming.” (Participant 7).

Students also expressed a strong desire for academic counseling and mentoring support, emphasizing the importance of having trusted individuals to guide them through their academic journeys.

“There needs to be someone we can turn to for advice, someone who can guide us through these pressures. A mentor would make a huge difference.” (Participant 6).

Additionally, clearer communication regarding academic expectations and more flexibility in course requirements were seen as essential steps to alleviate unnecessary stress. As one participant stated,

“If the professors could give clearer expectations on what is required, and not just pile on everything, it would relieve some of the stress.” (Participant 3).

Theme 2: exhaustion from clinical demands

Extended working hours emerged as a key contributor to burnout among medical students. Participants reported ongoing emotional exhaustion that persisted beyond examination periods, as they struggled to balance long clinical shifts, intense academic demands, and limited rest, leading to sustained burnout rather than temporary stress. This theme highlights the physical toll exacted by medical education, particularly during clinical rotations where students were expected to demonstrate sustained engagement and high productivity, often without sufficient breaks or institutional support. Students reported spending extensive hours in hospital settings, frequently standing or moving for long periods, assisting in patient care, and attending lectures either before or after their clinical duties. The demands of these schedules left many physically depleted and struggling to meet academic responsibilities effectively.

“I would be on my feet for almost 10 hours, and then I had to study for a test the next day. There’s just no time to recover.” (Participant 5).

Sleep deprivation and physical fatigue were often compounded by emotional exhaustion. Participants described symptoms such as irritability, forgetfulness, and diminished motivation, classic markers of burnout. Moreover, students were expected to take on demanding clinical responsibilities and maintain composure, even when experiencing severe exhaustion and emotional strain.

“Even when I was so tired I could barely think straight, I still had to smile, take vitals, and attend rounds. There’s no space to be human.” (Participant 10).

Many students shared that basic self-care, such as proper meals, hydration, and rest, was frequently neglected. Although they acknowledged the value of clinical exposure for their professional development, frustration arose from the lack of structured recovery time and the absence of support mechanisms to address fatigue.

“The system just assumes we’ll keep going. There’s no recognition that we’re burning out.” (Participant 6).

There was a strong consensus that while clinical training is essential, the absence of structured rest significantly compromises students’ capacity to learn, retain information, and perform optimally. Participants advocated for better management of clinical schedules to allow for adequate rest and recovery.

“It would help if we had a more flexible schedule. Sometimes it feels like we’re running a marathon with no breaks. If there were a way to better manage time or space out the workload, it would make a huge difference.” (Participant 3).

Additionally, the need for dedicated rest spaces within clinical sites was emphasized. Students suggested that even short breaks in designated areas could significantly alleviate stress and restore energy during long shifts.

“Having a designated space to just relax for a few minutes during the day would be so helpful. Even just 10 minutes to unwind, without worrying about exams or assignments, would make a big difference in how we handle stress.” (Participant 5).

This theme underscores the pressing need for medical institutions to re-evaluate clinical scheduling practices. Prioritizing students’ physical well-being alongside academic achievement is essential to mitigating burnout and fostering a healthier, more sustainable learning environment.

Theme 3: emotional and psychological distress

Emotional and psychological distress emerged as a deeply personal and complex theme, affecting nearly all participants. Students described persistent feelings of emotional numbness, disconnection, anxiety, and a growing sense of hopelessness as they struggled with the relentless pressures of medical training. Many reported a significant loss of enthusiasm for their studies and questioned their commitment to pursuing a career in medicine, which is a strong indicator of reduced personal accomplishment. Moreover, Emotional detachment was often characterized as a survival mechanism against overwhelming demands and emotional fatigue, highlighting a core aspect of depersonalization.

“It’s like I’ve become numb. I don’t even feel anything anymore. It’s just another day of going through the motions.” (Participant 3).

Despite being constantly surrounded by peers, students frequently expressed profound feelings of loneliness and emotional isolation. The highly competitive environment fostered a culture of silent suffering, making it difficult for students to express distress or seek support. Fear of judgment, misunderstanding, or being perceived as weak discouraged open conversations about emotional struggles.

“Everyone is struggling silently. You can’t even open up without worrying someone will think you’re not strong enough.” (Participant 9).

The internalization of stress is often manifested in physical symptoms of burnout, including sleep disturbances, chronic fatigue, and impaired concentration. For many, these symptoms served as early warning signs of more severe mental health concerns that they felt ill-equipped to address without assistance.

Participants voiced skepticism about existing institutional mental health resources. While counseling services were nominally available, students expressed uncertainty regarding their accessibility, confidentiality, and effectiveness, further discouraging help-seeking behaviors. In the absence of reliable institutional support, many students turned to informal coping mechanisms such as emotional support from family and friends, religious practices, and peer networks, to manage their psychological distress.

“There’s counseling on paper, but we don’t know how to access it or if it’s even confidential. That fear holds people back.” (Participant 8).

Students emphasized the urgent need for safe, non-judgmental spaces where emotional struggles could be acknowledged without stigma. They advocated for the creation of dedicated support programs, including peer support groups and therapy services designed specifically for medical students.

“We need a space where we can talk to someone who understands what we’re going through, without feeling judged. Having peer support or therapy options available would make a difference.” (Participant 2).

Additionally, participants stressed the importance of proactive stress management programs and accessible counseling services tailored to the unique demands of medical training.

“Sometimes, it feels like we’re carrying the weight of the world on our shoulders, and there’s no one to help us manage that stress. Having proper counseling and programs that teach us how to cope would ease the burden.” (Participant 4).

This theme highlights the critical need to prioritize students’ emotional well-being in medical institutions. Addressing stigma, improving trust in support services, and offering accessible, culturally sensitive mental health resources are essential steps toward creating a learning environment where students feel empowered to seek help and manage emotional distress effectively.

Theme 4: lack of reliable support systems

A significant concern raised by participants was the perceived lack of effective institutional and mental health support within their academic environments. While support services technically existed, students often found them inaccessible, poorly advertised, or distrusted them due to confidentiality concerns. Many described mental health initiatives as largely symbolic rather than functional, with services lacking visibility, responsiveness, and cultural sensitivity.

“I know we have a counselor, but I have no idea how to book an appointment, and honestly, I don’t think they’d understand what we’re going through.” (Participant 1).

Fear of stigma emerged as a significant barrier to seeking help. Students reported a culture of silence surrounding mental health, where accessing support services was perceived as a sign of weakness or incompetence. This perception was reinforced not only by peers but also by faculty and broader institutional attitudes.

“You don’t want to be labeled as the one who can’t cope. That can follow you in this field, and it’s scary.” (Participant 12).

The fear of long-term professional consequences deterred many students from accessing the limited support available.

Another key gap identified was the absence of structured mentorship programs. Students felt a strong need for mentors who could provide both academic guidance and emotional support. In the absence of nurturing faculty relationships, many students navigated critical stages of their education feeling isolated and overwhelmed.

“There’s no one to talk to about how you’re doing. We have academic advisors, but not emotional support systems.” (Participant 6).

Participants stressed that meaningful support systems must be easily accessible, confidential, and proactively integrated into the academic framework. Merely offering counseling services was insufficient if students felt they could not safely or easily access them.

“Having mental health services that are easily accessible and confidential would help. It’s hard to focus on studying when you’re struggling inside, and knowing there’s a place to go would ease a lot of anxiety.” (Participant 7).

Moreover, students emphasized the value of peer-led support networks and mentorship programs to foster a sense of community and shared understanding.

“It would help a lot if there were more structured mentorship programs. Someone who has gone through it before could give advice and support, and just knowing there’s someone to talk to makes you feel less alone.” (Participant 3).

This theme highlights the urgent need for institutions to move beyond surface-level initiatives and develop robust, student-centered support systems.

Theme 5: social and family pressures

In addition to academic and institutional challenges, students reported significant external pressures stemming from personal, familial, financial, and societal expectations. These pressures were deeply woven into their experiences and played a considerable role in amplifying burnout. A major stressor for many participants was the weight of family expectations. Students described the pressure to embody the ideal of the “successful doctor” as overwhelming, often feeling responsible for fulfilling their families’ aspirations.

“Everyone expects me to be the perfect doctor—there’s no space to fail or even slow down. It’s like I’m carrying my whole family’s hopes.” (Participant 7).

This emotional burden contributed to heightened feelings of entrapment, guilt, and emotional fatigue, hallmarks of emotional exhaustion, the central dimension of academic burnout.

Financial pressures emerged as another significant factor. Some students self-funded their education or came from families under economic strain, which intensified their anxiety about academic performance.

“My father works so hard to pay my tuition. If I don’t succeed, it feels like I’ve failed him, not just myself.” (Participant 4).

The pressure to justify financial sacrifices through academic success compounded emotional distress and feelings of inadequacy.

The competitive environment, exacerbated by social media, also fueled insecurity and burnout. Students described feeling trapped in a cycle of constant comparison and self-doubt, where achievements never seemed sufficient.

“Even when I study hard, someone is always doing more. It makes me question if I’m good enough to be here.” (Participant 2).

This relentless comparison undermined their self-confidence and sense of belonging.

Participants articulated several strategies to address these external pressures.

They emphasized the importance of financial counseling to help manage educational costs and reduce associated stress.

“Financial counseling could help us figure out how to balance our education costs without constantly feeling stressed.” (Participant 5).

They also called for initiatives to educate families about the demands of medical education, aiming to recalibrate unrealistic expectations.

“If my family understood the demands, they wouldn’t focus so much on perfect grades.” (Participant 8).

To mitigate unhealthy competition, students advocated for collaborative learning models that emphasize teamwork over rivalry.

“We should be working together to learn, not trying to outdo each other.” (Participant 2).

Students also highlighted the need for resilience training focused on managing external expectations and fostering a strong sense of identity beyond academic achievement.

“We need resilience training to manage the pressure and not let it define us.” (Participant 4).

This theme highlights the complex interplay between personal, familial, financial, and societal expectations in shaping student well-being.

Theme 6: uncertainty about career pathways

The final theme encapsulates the existential anxiety experienced by many students regarding their future roles as healthcare professionals. Despite being early in their careers, participants expressed profound concerns over residency placements, employment prospects, and achieving a sustainable work-life balance post-graduation. A major source of stress was the highly competitive nature of residency programs, both within Pakistan and internationally. Students feared failing to match into their desired specialties, despite enduring years of rigorous training and personal sacrifice.

“I keep thinking, what if I go through all of this and don’t even get the residency I want? All this stress, for nothing.” (Participant 11).

This uncertainty amplified feelings of helplessness and disillusionment. Concerns extended beyond residency, with many participants expressing insecurity about long-term employment opportunities. Fears included unemployment, underemployment, and accepting unfulfilling or poorly compensated roles despite extensive training.

“We put in so much, and still, there’s no guarantee of a decent job at the end of all this.” (Participant 3).

These apprehensions fueled a pervasive sense of instability about the future. Students also expressed doubts about their ability to achieve a fulfilling work-life balance. Observing the overwhelming demands of the medical profession led some to question whether the sacrifices were worthwhile.

“If this is what life as a doctor is like, I don’t know if I even want it anymore.” (Participant 9).

These fears of perpetual stress and burnout in their future careers further contributed to emotional exhaustion. In addition, they also articulated several strategies to address their career-related anxieties. They emphasized the urgent need for structured, accessible career counseling programs to provide clear, realistic information about specialty options, application processes, and alternative career pathways.

“We’re so focused on passing exams that we have no idea what comes next. We need real guidance, not just vague advice.” (Participant 9).

Students advocated for integrating life-skills education into medical training, focusing on strategies to manage professional demands without compromising personal well-being.

“They should teach us how to balance our careers and personal lives now, not after we burn out in residency.” (Participant 7).

This theme underscores the critical importance of embedding proactive career support and life-skills education within medical curricula. Thus, the analysis identified interrelated themes reflecting the multifactorial nature of burnout and mental health challenges among medical students.

Discussion

This study provides an in-depth understanding of the burnout and mental health challenges experienced by undergraduate medical students in Pakistan. Key themes, including academic pressure, extended working hours, emotional distress, lack of support, societal expectations, and career uncertainties, illustrate the complex and multifaceted nature of burnout. These findings are consistent with Maslach’s multidimensional model of burnout, particularly in highlighting students’ emotional exhaustion, feelings of detachment from their studies, and perceived decline in personal accomplishment [27].

Participants consistently reported overwhelming academic demands, encompassing extensive curricula, frequent assessments, and intense competition. These findings align with those of Irshad et al. (2022), who observed high levels of burnout among medical students resulting from academic overload and fear of failure [28]. Similarly, studies from China have shown that burnout among medical students is primarily driven by academic stress [29]. However, while international studies often highlight the existence of institutional support systems such as stress such as mindfulness based interventions, stress management programs and peer social support groups that help mitigate such stress [30, 31], the Pakistani context revealed a more relentless pursuit of academic excellence with minimal relief mechanisms [32]. The competitive environment, as described by participants, discourages collaboration and fosters an atmosphere of individualistic pressure, further amplifying emotional neglect and self-isolation.

Building on the emotional challenges faced by students, emotional and psychological distress emerged as another prominent theme. Participants reported symptoms such as emotional exhaustion, depersonalization, and feelings of inadequacy. This is consistent with findings from Gujranwala, where 40% of medical students scored high on emotional exhaustion and sought emotional support as a coping strategy [33]. Globally, a meta-analysis by Arsenio et al. (2024) found that medical students are at a significantly higher risk of depression and anxiety compared to the general population, largely due to the inherent demands of medical education [34]. However, a notable difference lies in the stigma surrounding mental health, which appears particularly entrenched in Pakistan’s cultural context [17]. This stigma not only deters students from seeking help but also perpetuates a cycle of silence and untreated psychological distress.

The lack of institutional and mental health support further exacerbated students’ vulnerabilities. Participants expressed dissatisfaction with the accessibility, confidentiality, and perceived efficacy of existing services. These perceptions are consistent with research showing that students without supportive resources or recreational outlets experience significantly higher rates of burnout [10, 35].

This dynamic corresponds with the Study Demands-Resources (SD-R) Theory, which holds that burnout results from an imbalance between academic demands and the resources, either personal or institutional, that are available to manage those demands [36]. In this case, consistent stressors-massive academic workload, and emotional pressure- were conspicuous by the absence of adequate coping mechanisms or systemic support, thus providing fertile grounds for burnout. In contrast to many Western institutions where mental health services are becoming more normalized and integrated into academic settings [37], Pakistani medical schools often prioritize academic achievement at the expense of psychological well-being [11]. This institutional gap leaves students without essential support during critical periods of emotional and academic strain.

In addition to academic and institutional pressures, personal and societal expectations were significant contributors to burnout. Participants described the immense pressure from families and society, echoing findings from previous Pakistani studies that linked societal prestige associated with the medical profession to overwhelming stress [38]. Financial burdens, particularly among students from lower-income backgrounds, further compounded these challenges. While international literature also recognizes cultural glorification of the medical profession [39], socio-economic disparities prevalent in low- and middle-income countries like Pakistan intensify these adverse effects [28], creating a unique set of pressures distinct from those experienced in resource-rich settings.

Another recurrent concern among participants was the uncertainty surrounding future career prospects. Many expressed anxieties about securing residency positions, obtaining employment, and achieving a sustainable work-life balance. This reflects findings from a cross-sectional study in Pakistan, where 21.8% of medical and dental students contemplated changing careers due to academic pressure and bleak future prospects [40]. Although career uncertainty is a global issue among medical students, its intensity appears heightened in Pakistan due to limited postgraduate training opportunities and an unpredictable healthcare employment market [41]. This pervasive uncertainty further undermines students’ motivation and exacerbates psychological distress.

Although coping mechanisms were not initially a core theme, their importance became evident throughout participants’ narratives. Students frequently relied on emotional support from family and friends, religious practices, and informal peer networks as primary strategies to manage stress. These findings resonate with previous studies noting reliance on familial and spiritual resources among Pakistani students [42]. However, unlike the structured institutional interventions such as including counseling, wellbeing s seminars, and faculty-driven support programs observed internationally [43], these coping strategies remain informal, inconsistent, and of varying effectiveness. Participants expressed a clear need for more formal and accessible support systems, such as peer-led networks, mentorship programs, and professional counseling services, to help manage the intense stress they face. Without systematic, culturally sensitive support mechanisms, individual coping efforts may offer only temporary and limited relief, underlining the need for institutional frameworks that can provide sustained and holistic support for students’ emotional and mental well-being [11].

Overall, the findings of this study corroborate and extend existing literature on burnout and mental health challenges among medical students. While there are similarities with global patterns, the unique interplay of cultural, institutional, and socio-economic factors in Pakistan necessitates targeted, context-specific interventions. Future efforts must prioritize the destigmatization of mental health care, the strengthening of institutional support structures, and the addressing of broader societal expectations that perpetuate burnout. Implementing confidential mental health services within medical schools, revising academic curricula to reduce unnecessary stressors, and initiating national campaigns to normalize mental health discussions are critical steps toward supporting the well-being and success of Pakistan’s future healthcare professionals.

Implications and recommendations

Based on the results of this qualitative research, the following suggestions are offered to assist educational institutions in enhancing the mental health and well-being of healthcare students. These recommendations aim to tackle significant issues such as academic stress, emotional turmoil, and insufficient institutional assistance:

• Re-evaluating Academic Policies: Institutions should reconsider their academic frameworks to create a balance in workload and foster student wellness by implementing regular breaks, decreasing lecture hours, and providing flexible scheduling, especially during clinical years.

• Promoting Mental Health Facilities: Medical schools need to establish and actively advertise accessible, confidential, and stigma-free mental health resources to ensure ongoing support for students encountering academic and emotional difficulties.

• Faculty Awareness and Support: Programs for faculty development should aim to enhance understanding of student burnout and equip educators with skills to respond with empathy. Additionally, flexible attendance and assessment policies should be adopted to support students during challenging times.

• Integrating Mental Health into Accreditation Criteria: National medical education organizations ought to integrate student mental health and well-being as essential elements in accreditation standards, guaranteeing that institutions provide a nurturing learning environment.

• Funding For Wellness and Support Initiatives: Policymakers should allocate specific funding to create extensive wellness initiatives, mentorship programs, and financial counseling services to mitigate the pressures that lead to student burnout.

Strengths and limitations

This qualitative study offered detailed insights into the experiences of medical students facing burnout and mental health issues, uncovering intricate viewpoints that quantitative approaches might miss. The application of thematic analysis enabled a comprehensive understanding of the complex nature of burnout, emphasizing factors related to academics, emotions, institutions, and society. Nevertheless, the study is not without limitations. The reliance on a single focus group discussion (FGD) with 12 participants limits the ability to generalize the outcomes. There is also a potential for social desirability bias, as participants might have felt the need to portray themselves positively. Future investigations should focus on involving larger and more diverse groups from various medical institutions across different regions of Pakistan to improve generalizability. Additionally, longitudinal qualitative and mixed-methods research is recommended to monitor the progression of burnout over time and to pinpoint critical periods for intervention. Comparative research between public and private educational institutions could further clarify how different educational settings affect student well-being and mental health results.

Conclusion

In summary, this research offers important insights into the burnout and mental health struggles experienced by medical students in Pakistan. The results indicate that burnout has multiple dimensions, influenced by academic demands, long hours, emotional challenges, insufficient institutional assistance, personal and societal expectations, and uncertainties about the future. The research emphasizes the critical necessity for educational institutions to establish thorough mental health support systems, which should include revising academic policies, enhancing access to confidential mental health services, and training faculty to recognize the mental health needs of students. Moreover, policymakers need to prioritize student mental health in accreditation criteria and provide funding for the creation of wellness and support initiatives. By addressing these aspects, key stakeholders can cultivate a more supportive learning atmosphere that promotes resilience, well-being, and professional achievement among future healthcare practitioners.

Authors’ contributions

Conceptualization: SK and SK; Methodology and Data Collection: SK and HK.T; Data Analysis: SK, HK.T, and SK; Original Draft Preparation: SK; Review and Editing: SK and HK.T. All authors have read and approved the final version of the manuscript.

Funding

Not Applicable.

Data availability

The datasets generated and analyzed in this study include qualitative interview data containing sensitive and personal information. To protect participant confidentiality, these data cannot be publicly shared. However, upon reasonable request, additional information regarding the study can be provided by the corresponding author.

Declarations

Ethics approval and consent to participate

All methods were carried out by relevant guidelines and regulations, including the Declaration of Helsinki. Ethical approval for the study was obtained from the Ethical Review Committee (ERC) (598-AAA-ERC-AFPGMI) at Armed Forces Postgraduate Medical Institute (A Constituent Institute of National University of Medical Sciences). Informed consent was obtained from all participants before their involvement in the study. Participants were fully informed about the study’s purpose, the voluntary nature of their participation, and their right to withdraw at any time without penalty. Confidentiality and anonymity were strictly maintained throughout the research process.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.