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A study of stress in medical students at Seth G.S. Medical College. AN SupeDepartment of Surgery, Seth G.S. Medical College, Mumbai.
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 0010703558
BACKGROUND: It is usually observed that medical students undergo tremendous stress during various stages of the MBBS course. There is a high rate of suicide among them. METHODS: To determine incidence of stress and factors controlling stress in medical students at various stages of MBBS course at Seth G S Medical college, 238 students (First year 98, Second 76, Third 64) were asked to complete a questionnaire on personal data (gender, stay at hostel, mode of travel, time spent in travel every day, medium of study in school, place of school education.), Stress inducing factors, Zung's depression scale, ways of coping, stress relievers, perceived social support and personality type. Statistical tests used were ANOVA, critical ratio and Student's 't' test. RESULTS: Majority of medical students (175/238--73%) perceived stress. Stress was found to be significantly more in Second and Third MBBS students rather than First MBBS levels (p < 0.05). Stress was not found to differ significantly on the basis of sex, stay at hostel, model of travel, time spent in travel every day, medium of study in school, place of school education. Stress was found to be significantly more in students having more than 95% of marks at 12th Standard as compared to others. Academic factors were greater perceived cause of stress in medical students. There was no significant difference in the students at different levels of MBBS regarding academic factors and social factors as a stress inducing factors. Physical factors were found to be significantly more in Second and Third MBBS students as compared to First MBBS students. Emotional factors were found to be significantly more in First MBBS students as compared to Second & Third MBBS students. Stress was more common in medical students who have dominant strategy of coping as positive reappraisal, accepting responsibility and planful problem solving. Stress was less common in medical students at Seth G S Medical College who have dominant strategy of coping as escaping and distancing from difficult situation. Family and Friend as perceived social supports were more in Second MBBS than First MBBS medical students. Stress was not found to be significantly more in students having their personality factor contributing to stress (Type A--52/67) as compared to others (Type B--123/171). This indicates that the stress was not trait oriented but was process oriented (p = NS). CONCLUSION: Stress in medical students is common and is process oriented. It is more in second and third year. Academic factors are greater perceived cause of stress in medical students at Seth G S medical college. Emotional factors are found to be significantly more in First MBBS. It is dependent on person's ways of coping and social support. Keywords: Adaptation, Psychological, Female, Human, Incidence, India, epidemiology,Male, Social Support, Stress, Psychological, epidemiology,Students, Medical, psychology,statistics &numerical data,Suicide,
The present curriculum of the MBBS course is vast. As a large syllabus is fitted in a short period, the MBBS course is extremely demanding in terms of students’ effort. The study aimed at examining the stress in medical students at Seth GS Medical college and various factors that cause and relieve stress. It also aimed at studying the various other related factors such as ways of coping and social support in medical students.
The descriptive method of the comparative type was used in order to compare the stress in medical students. Stratified random sampling technique was used to collect data from the three different levels of MBBS students. Systematic random sampling was used for the selection of sample at each level of MBBS. (Total 238, First MBBS 48 M, 50 F; Second MBBS 42 M, 34 F; Third MBBS 38 M, 26F).
In the present study following tools were used: 1. Personal data : This section includes general information and specific information regarding Stay in hostel, Mode of travel to college, Time spent in travel every day, Medium of study at school education, Mother tongue, Marks obtained at 12th Standard at the time of medical admission, Place of school education, Place of Education in junior college. 2. Stress Inducing factors: To determine the stress inducing factors perceived as stressors (Stress inducing factors) were divided in to 4 groups a) Academic: academic achievements, examination & competition amongst students. b) Physical factors: hostel and canteen facilities, environmental situations, noise in classroom and library etc. c) Emotional factors: emotional comfort of student and other associated factors such as love affairs, jealousy and fights etc. d) Social factors: Social aspects in the college, parental influence & socio-economic support. These were then subjected to construction validity by the experts in education and others. There were total 28 items.{ 7 in each group) Each item was scaled as 1(Little or no stress), 2 (Moderate stress), 3 (Considerable stress) and 4 (Great stress). A total score was obtained from summing up of scores for each sub group. Average scores for each subgroup of individual were compared for further analysis. 3. Stress Reducing factors: To determine the stress relievers, various factors perceived as stress relievers (Stress reducing factors) were divided in to 6 groups a) Friends, b) Gymkhana c) Physical factors d) Co-curricular activities: These include “Shidori” (A three-tier course of co-curricular activities) and student - teacher preceptor programme. The programme has been envisaged to be conducted for a student at 3 time points in his/her UG career. To test this idea we implemented the programme for 3 separate batches of students: at entering medical college, at the beginning of clinical terms and during internship. Three aspects were covered in Shidori-1 : Group dynamics, study skills and communication skills in a workshop manner. Shidori-2 is conducted for 2nd MBBS students and includes Bedside manners, Communication skills and Coping skills. Shidori-3 is for interns and included following topics: Relationship between medical representative and doctor, Rational drug prescribing, Rational diagnostics use, Doctor-patient communication, and time management and assertive behaviour training. e) Teacher's behaviour f) Personal hobbies. These were then subjected to construction validity. Each item was scaled as 1(Little), 2(Somewhat), 3 (Considerable) and 4 (Very much). A total score was obtained from summing up of scores for each subgroup. The average score for each factor was calculated by dividing the total score for that factor by number of items. Average scores for each subgroup of individuals were compared for further analysis. 4. Zung’s self rating scale for depression[1]. This scale was preferred to others as this tool evaluates depression in normal non-psychotic individuals and has been time tested. This scale assesses the perceived feelings of the students regarding their emotional status. The test form was labelled as “section three” as it is important that respondents be unaware that it is a depression scale. The tool consists of 20 items with scale ranging from 1 to 4. The total score was summation of all scores. The value ranges from 20 to 80. Stress was considered as a continuous variable ranging from low to moderate to high degree of experienced feeling. A high degree of stress was reflected in high scores on the Zung’s scale and a low degree was reflected in low scores on this scale. Score more than or equal to 40 was considered as stress. 5. Way-of-coping scales by Folkman and Lazarus[2] Coping is defined as the person’s constantly changing cognitive and behavioural efforts to manage specific external and/ or internal demands that are appraised as taxing or exceeding the person’s resources. Folkman and Lazarus developed “Way of coping scales” to study coping styles of any individual. This scale was used for present study. The scale consists of 50 items. The coping scale has eight sub scales. These were developed from factor analytic procedures using alpha and principal factoring. The eight sub scales are as follows a) Confrontive coping ( ? = 0.70) Total number of items = 6: This describes aggressive efforts to alter the situation. It also suggests a degree of hostility and risk taking. b) Distancing (? = 0.61) Total number of items = 6. This describes efforts to detach oneself. It also concerns creating a positive outlook. c) Self- Control ((? = 0.70) Total number of items = 7: This describes efforts to regulate one’s own feelings and actions. d) Seeking social support (? = 0.76) Total number of items = 6: This describes efforts to seek informational and emotional support. e) Accepting responsibility (? = 0.66) Total number of items = 4: This acknowledges one’s own role in the problem with concomitant theme of trying to put things right. f) Escape-avoidance (?=0.72) Total number of items=8: This describes wishful thinking and behavioural efforts to escape or avoid. These are different from distancing as these items suggest escape and avoidance, in contrast with the items on the distancing scale, which suggest detachment. g) Planful Problem solving (? = 0.68) Total number of items = 6: This describes deliberate problem-focused efforts to alter the situation coupled with an analytic approach to solving the problem. h) Positive reappraisal (? = 0.79) Total number of items= 7: This describes efforts to create positive meaning by focusing on personal growth. Scores (1 to 4) were calculated by summing up the ratings for each sub scale. The scores are calculated for each way of coping and average score for each coping strategy was calculated. Average scores for every strategy were compared and dominant strategy of every individual was determined for further analysis. 6. The Multidimensional Scale of Perceived Social Support(PSS) by Zimet[3] Social support involves some kind of relationship transaction between individuals. It provides “Coping assistance” to an individual. It is also a positive factor that aids in the maintenance of health as well as in disease recovery. Multidimensional Scale of Perceived Social Support was used in the present study. It assessed perceptions from three specific sources: Family, Friends and Significant other(Special person)”. The inventory consists of 12 items divided into three groups ( 4 items each). Each item is rated on a five point scale ranging from 1 (Strongly disagree) to 5 (Strongly agree). The value for total scale ranges from 12 to 60. The value for each group (4 items each) will range from 4 to 20. 7. Stress Quiz to determine type of behavioural pattern of an individual[4]: The stress quiz determines the behaviour pattern of an individual. Type A Behaviour: There are two main characteristics of the type A person- Time-urgency and Hostility. Type A behaviour produces more stress and has more cardiac risk. Type B Behaviour: Type B pattern has absence of all habits and traits that harass the severely affected type A person. Type B person is not afraid to admit mistakes and co-operates with others. He/ she takes break when fatigued and is not devastated by criticism. For the purpose of this study, the scores obtained on the ‘Stress Quiz” were used. The inventory contains 30 items. Each item was scaled as 1 (never), 2 (Seldom), 3 (Sometimes), 4 (Frequently) and 5 (Always). Maximum score for each item is 5. Therefore 150 would be the maximum score. Any score more than 90 indicated the presence of personality factor (Type A) contributing to the stress. Statistical tests used were ANOVA, critical ratio and Student’s ‘t’ test.
Majority of medical students (175/238 -73%) at Seth G S Medical college perceived stress. Stress was found more in Second and Third MBBS students than First MBBS levels. There was no difference in the perceived stress on the basis of level of MBBS. [Table - 1] There was no difference in the perceived stress on the basis of sex of the medical students. (M 95/128, F 80/110, critical ratio, p=NS). There was no difference in the perceived stress on the basis of Place of stay (Hostel or Non- Hostel). (Hostel 61/91, Non -hostel 114/147, critical ratio, p=NS). There was no difference in the perceived stress on the basis of Mode of travel to college and Time spent in travel every day. (Mode of travel: Foot- 59/88, car/ taxi 7/7, Bus 37/45, Train- 58/81, Bus and Train 14/17. ANOVA- p =NS; Time spent in travel - < 1hr- 56/80, 1-2 hr- 55/74, more than 2 hrs- 64/84, ANOVA, p=NS). There was no difference in the perceived stress on the basis of medium of study at school education. (English-141/186, non-English 34/52. Critical ratio, p=NS). There was no difference in the perceived stress on the basis of Mother tongue. (Marathi- 88/121, Hindi 26/34, Gujarati - 30/41, Others - 35/42, ANOVA, p =NS). There was difference in the perceived stress on the basis of Marks obtained at 12th Standard.( > 95%- 77/93, 90-95%- 54/80, <90% 44/65, ANOVA, p= Significant at 0.05, Students t test between First and Second, First and Third group significant at 0.05 and 0.01 level respectively). There was no difference in the perceived stress on the basis of Place of school and Junior college education. (Metro city -141/188, Small town 32/45, Rural 2/5; ANOVA- p= NS). There was difference in the various stressors (Stress inducing factors such as Academic, Physical, Social And Emotional) on the basis of different levels MBBS and of the total sample. a) Academic factors were greater perceived than all other factors as cause of stress. Physical and Social factors were greater perceived than emotional factors as cause of stress (Dominant stressor- Academic 159, Physical 31, Emotional 10, Social 38) b) There was no difference in the students at different levels of MBBS regarding academic factors and social factors as a stress inducing factors.(ANOVA, p =NS) c) Physical factors were found to be significantly more in second and third MBBS students as compared to First MBBS students.(student’s t test, p<0.05) d) Emotional factors is found to be significantly more in First MBBS students as compared to second & Third MBBS students.(student’s t test, p<0.05) There was no difference in the perceived stress on the basis of their individual dominant stressor. (Academic -114/159, Physical 21/31, Emotional 8/10, Social 32/38, ANOVA, p=NS). There was difference in the perceived stress on the basis of their individual dominant coping strategy. a) Stress is more common in medical students who have dominant strategy of coping as positive reappraisal, accepting responsibility and planful problem solving. b) Stress is less common in students who have dominant strategy of coping as escaping and distancing from difficult situation. c) Stress is more in medical students who have dominant strategy of coping as planful problem solving as compared to accepting responsibility, self control and seeking social support. ANOVA, p= Significant at 0.05 d) Stress is more in medical students who have dominant strategy of coping as positive reappraisal as compared to accepting responsibility, and escaping. There was no difference in the perceived stress on the basis of individual’s preferred institutional stress relieving factor. (Physical-19/ 26, Friends 20/25, Gymkhana 8/10, Teachers behaviour 40/51, Shidori 6/7, Hobbies 82/119, ANOVA, p=NS). There is no difference in special person as perceived social support system at different levels of in medical students. Family as perceived social support is more in Second MBBS than First MBBS medical students. Friend as perceived social support was more in Second MBBS than other level medical students. (ANOVA, p= Significant at 0.05). There was no difference in perceived stress in the medical students on the basis of various levels of PSS such as family and friend in total sample and at different levels MBBS (ANOVA, p=NS). There was no difference in perceived stress in the medical students on the basis of various levels of PSS such as special person at different levels MBBS. There was difference in perceived stress in the medical students on the basis of various levels of PSS such as special person in total sample. Students having high scores on special person as PSS have more stress compared with students having mod scores.( ANOVA, p= Significant at 0.05). There was no difference in the perceived stress in medical students on the basis of their personality.(i.e. Personality factor contributing to stress) (Type A -52/67, Type B- 123/171) (Students “t” test - t = 0.18 p = NS).
This study confirmed the general impressions that there is considerable amount of stress in medical students at Seth GS Medical College. This is similar to other studies elsewhere which have reported such findings[5]. However the incidence of 73.5% (175/238) in this series is much higher than that reported by others. Stress was found to be more in Second and Third MBBS students rather than First MBBS levels. This was surprising as Second MBBS is generally thought to be a year where there was less stress. However Kumarswamy[6] also found that stress was more in Second MBBS and this may be due to greater fear of not attaining their goal of being a doctor. The other reason may be due to excessive load of both para-clinical and clinical subjects as compared to only clinical subjects in third year. The high stress in Third MBBS may be due to competition for the postgraduate seats. There was no difference in the stress on the basis of gender, stay in hostel, stressors, mode of travel and time spent in travel every day, place of school and junior college education indicating that academic achievement is more important than other factors in inducing stress in medical students. Stress was more in students having more than 95% of marks at 12th Standard at the time of medical admission as compared to all others. This confirms that students who are high achievers are more under stress. This may be due to higher parental, peer and self expectations on academic performances. Academic factors were greater perceived causes of stress in medical students at Seth GS medical college. This was similar to the findings reported by others[7],[8]. Final examinations and large amount of information were recognised as most important factors causing stress. There was no difference in stress on the basis of dominant stressor of an individual indicating that the stress is not stressor specific. There was no difference in the students at different levels of MBBS regarding Academic factors and Social factors as stress inducing factors. However, Physical factors were found to be significantly more in Second and Third MBBS students as compared to First MBBS students. Emotional factors were found to be significantly more in First MBBS students as compared to second & Third MBBS students. This may be due to entry into a large professional college which makes students feel insecure in the initial period. The distribution of the coping strategies was similar to what was found by Folkman and Lazarus[2]. Stress was more common in medical students at Seth GS medical college who have dominant strategy of coping as positive reappraisal, accepting responsibility and planful problem solving. This may be due to student’s realisation of self mistakes and struggle to fight it out. Stress was less common in students who have dominant strategy of coping as escaping and distancing from difficult situation. Stress was significantly more in medical students who have dominant strategy of coping as positive reappraisal as compared to accepting responsibility, and escaping. Stress was more in students who have dominant strategy of coping as planful problem solving as compared to accepting responsibility, self control and seeking social support. Stress was not found to differ significantly in medical students on the basis of preferred institutional stress relieving factor. This suggests that each institutional stress relieving factor has its contribution in relieving stress. Hobbies was the most common stress relieving factor in medical students. There was no difference in special person as perceived social support system at different levels. However, surprisingly Family as perceived social support is more in Second MBBS than First MBBS students. Friend as perceived social support is more in Second MBBS than other level. This may be due to students spending more time in medical colleges than at home. Friend as a perceived social support decreases in Third MBBS due to competition amongst students. There is no difference in perceived stress in the medical students at Seth GS Medical college on the basis of various levels of PSS such as Family and Friend in total sample and as Special person, Family and Friend at different levels MBBS. However there is significant difference in perceived stress on the basis of various levels of PSS such as Special person in total sample. Students having high scores on special person as PSS have more stress compared with students having moderate scores. This is contradictory to what has been described by others.[9] This may be due to Special person or Friend making more efforts to help the highly stressed students. Stress is not found to be significantly more in students having their personality factor contributing to stress (Type A) as compared to others (Type B). This indicates that the stress in Seth GS Medical college is due to the process and not due to personality traits of the students.
Study concluded that stress in medical students is common and is process oriented. Academic factors are greater perceived cause of stress in students at Seth GS medical college. Emotional factors are found to be significantly more in First MBBS. However stress is not stressor or trait specific. It is also dependent on personal ways of coping strategy and social support. It also suggested need for measures to reduce such stress and future research.
The researcher is extremely thankful to Dr. G. Kerawalla, Department of education, University of Mumbai for all the guidance and help.
[Table - 1], [Table - 2]
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