I appreciate the opportunity to discuss our study¹ examining the factor structure of the Medical Education Hassles Scale-R (MEHS-R) by addressing the questions presented by Kendall and Castro-Alves.² Kendall and Castro-Alves² identified 3 questions for which they requested clarification and additional information: (1) potential survey response fatigue caused by the length of the MEHS-R, (2) the effect of program leadership on burnout, and (3) other factors that may lead to burnout in medical students. 

Regarding the first question, survey response fatigue can occur from the number of items on a survey or from the number of surveys given within a short period. Wolf et al³ included the item “filling out forms” as 1 of the 101 items on the MEHS-R. In recognition of the potential for survey response fatigue, we examined the frequency of endorsement as a hassle and variability of responses to the 101 items of the MEHS-R (unpublished data). Almost 50 items had responses with infrequent endorsement as a hassle and low variability of responses, indicating they could potentially be eliminated from the scale. Factor analysis of the modified 53-item MEHS-R identified 5 subscales with adequate Cronbach α, and the fit indices for the confirmatory factor analyses conducted were marginally higher than those of the 101-item MEHS-R analysis. However, the elimination of some items may have resulted from the rural location of the medical schools included in the study. Additional testing at a larger variety of medical schools would improve the validity of the process. Even with the elimination of almost 50 items to form the modified MEHS-R, information on many different potential hassles is necessary to identify the types of stress that predict burnout to develop effectively targeted wellness interventions. As such, the need to obtain more specific information about the stress experienced by medical students may outweigh the risk of potential survey response fatigue. 

The other 2 questions of Kendall and Castro-Alves² both relate to factors that potentially affect medical student burnout apart from the types of stress identified by our study.¹ Learning environment, including support from program leadership and clerkship organization, and some medical student workplace factors such as overnight call are significant predictors of burnout in medical students, while other factors, such as number of patients seen, are not.^4,5 Future studies could examine whether the types of stress experienced by medical students moderate the relationship of learning environment and workplace factors with burnout. Results of such studies could further aid in the development of targeted wellness interventions to reduce or prevent burnout in medical students.