A cross-sectional assessment of stress, coping, and burnout in the final-year medical undergraduate students

Abstract

Background:

Medical students undergo significant stress during training which may lead to own suffering or problem in patient care. High level of burnouts and depression is also not uncommon. The transition from preclinical to clinical training has been regarded as crucial to student in relation to the stress.

Methodology:

An assessment of perceived stress and its relation to general psychopathology, the pattern of coping, and burnout in the final-year medical student was done to bring out clear nature, pattern, and extent of the problem.

Results:

Perceived stress had statistically significant association with general psychopathology and depressive-anxiety component of burnout. Acceptance, positive reframing, humor, planning, and active coping correlated with lower score on perceived stress.

Conclusion:

Higher score on perceived stress was associated with higher scores on general psychopathology and burnout. Age of joining MBBS course and doctor in the family did not affect the stress significantly. People who displayed positive coping strategies had lesser stress and general psychopathology.

There is ample support to the fact that the medical students go through a lot of stress during their medical study.[1,2] Sources of stress may be academic, social, financial, or personal problems. While academic stress involves dealing with death/suffering and relating with teachers, being a medical student itself comes with a lot of changes in personal life, leisure, and social commitments. Workload, overwhelming wealth of information, financial constraints, family dynamics, and examination pressure further increases the stress.[3,4,5] Burnout is group of symptoms which arises in professional in relation to the work. Pressure to perform in medical education can make an erstwhile, a hardworking and committed person increasingly dissatisfied or disillusioned with various aspects of work and life.[6] Evidence suggests that mental illness during medical training may predict later problems in terms of personal suffering or patient care.[7] Medical student does not seek professional help for themselves which they would otherwise render to their patients in similar situations.[8,9,10]

Little is known about the prevalence of mental distress in medical students; some have been extrapolation from medical fraternity of various hierarchies. Most of them have been from questionnaire data or qualitative group interviews. Psychiatric caseness was found in 22%–36%,[11] depression in 14%–21%,[12,13,14] and anxiety in 29%[15] in various studies in medical professionals. Indian studies have found the stress in up to 73.5% of the medical students.[16] Knowledge about the psychiatric conditions is important and would require attention if found. It also may suggest a vulnerability which a medical student need not be responsible for. Studies have found higher depression rates in medical student vis-a-vis general population even before their starting medical training.[17]

Whether it is the demand of medical education or the inherent disposition of the individual which leads to the manifestation of the problem has been questioned by many researchers in the past. Clear delineation has remained impossible.[18,19,20] Greater perception of stress leads to more mental distress. Burnout though a measure of induced distress has also been associated with neuroticism and Type A behavior.[21] Researchers have found the burnout to be as high as 45% in multicentric studies on medical students.[2]

Off late, there is trend toward developing curricula with integration of preclinical training and clinical training at an early phase of education. Although medical students have more negative attitude toward traditional curricula, there is no evidence that either model attracts more vulnerability.[22] However, the transition from preclinical training to clinical training in traditional curricula has been recognized as crucial to stress.[23] While internal disposition does affect the distress and burnout, it has been seen that the coping strategies of an individual also impact the manifestations significantly. Coping strategies, which are behavioral or psychological efforts employed to master or minimize stressful events, affect the medical students variably. Studies have revealed that the active coping strategies such as positive reframing, planning, and acceptance affect the mental health outcome favorably.[24]

With the above literature in review, we felt that there are less structured studies on medical students in particular (not medical professionals) in their transition phase from preclinical to clinical (final-year medical students) phase, data in Indian paradigm being further less. An assessment of perceived stress, coping pattern, burnout, and general psychopathology in final-year medical undergraduate students was done with objectives of determining the level of perceived stress and its relation with coping, burnout, and general psychopathology.

METHODOLOGY

The study was undertaken in a Government Medical College with an established MCI curriculum. One hundred students in their final year of medical training were taken up for the study. All the students were briefed about the study and informed consents were taken. They were then assessed using the following:

1. Structured pro forma for recording demographic profile and relevant medical and social history

2. Perceived Stress Scale:[25] A most widely used 10-item psychological instrument to measure the degree to which situations in an individual's life are appraised as stressful, which measures the perceived stress over the last 1-month duration

3. BRIEF COPE: The Brief COPE[26] is a self-report questionnaire used to assess a number of different coping behaviors and thoughts a person may have in response to a specific situation

4. General Health Questionnaire-12 (GHQ-12):[27] a self-administered standardized 12-item screening test sensitive for the presence of psychiatric disorders in individuals. Score of more than 2 was taken as abnormal

5. Maslach burnout inventory:[28] Valuable tool for assessing professional burnout in human service, education, business, and government professions. Burnout is assessed on following paradigms: depressive-anxiety syndrome, depersonalization, and reduction of person achievement. Scoring on each component yields mild, moderate, and high level of burnout

6. Appropriate tests of significance & correlation were done and statistically analyzed.

RESULTS

The mean age of the study population was 22.45 years (standard deviation [SD] - 0.77) with the mean age of joining MBBS curriculum being 18.48 (SD - 0.80). Both median and mode for joining the MBBS course was 19 years. Nearly 18.3% of students have doctor as their relative, common being their father. Favorite pastime was listening to music in 14.1% of the cases. Favorite sport of the student was football (28.3%). Examination, viva voce, and studying were few common causes which made people anxious seen in 23.3%, 13.3%, and 12.4%, respectively. Others were case taking, missing class, getting up late, loud sounds, etc. Sleeping and listening to music were common modes of reducing anxiety in 18.4% and 9.2%, respectively. Others were jogging, going to gym, eating, watching comedy shows, etc.

Mean and SDs of important psychological variables are shown in Table 1. Nearly 53.5% of students were above cutoff on scores of general psychopathology. On depressive-anxiety score, 76.8% had low-level burnout, 18.1% had moderate level burnout, and others (5.1%) had high burnout. On depersonalization, component 29.3% had mild level burnout, 30.3% had moderate level burnout, and a significant portion of students (41.4%) had high-level burnout. On reduction of personal achievement component, 26.4% had mild level burnout and 27.2% had moderate level burnout whereas 46.4% students had high level of reduction of personal achievement.

Table 1.

Mean and standard deviation of important psychological variables

The mean and SD of various components of coping are shown in Table 2. Acceptance, positive reframing, humor, denial, self-blame, and substance abuse were found to be more commonly practiced coping.

Table 2.

Mean and standard deviation of components of coping skills

Analysis of association of various psychological variables with the perceived stress scale scores is shown in Table 3. The same was reconfirmed with various studies in Table 4. Perceived stress had statistically significant association with general psychopathology and depressive-anxiety component of burnout. Additional ANOVA of age at present (F = 1.260, P = 0.250) and while joining MBBS course (F = 0.989, P = 0.417) did not reveal any statistical association with the scores on perceived stress scale.

Table 3.

Association of various psychological variables with perceived stress

Table 4.

Association of variance of various psychological variables with perceived stress

Statistically significant correlation is shown in Table 5. Perceived stress was found to have significant positive correlation with burnout depressive-anxiety syndrome. Perceived stress though had significant association did not show any statistical correlation with general psychopathology. Perceived stress also did not correlate with age (ρ = 0.128, P = 0.20) or age of joining MBBS course (ρ = 0.062, P = 0.54). Age (ρ = 0.311, P = 0.00) and age of joining MBBS course (ρ = 0.222, P = 0.03), respectively, however had significant positive correlation with burnout depressive-anxiety syndrome.

Table 5.

Correlation analysis of perceived stress with various psychological parameters

Correlation analysis of coping skill is shown in Table 6. Acceptance, positive reframing, humor, planning, and active coping correlated with lower score on perceived stress.

Table 6.

Significant correlation of perceived stress with various coping measures

DISCUSSION

The mean age of joining MBBS and current age of the study population is reflection of existing policy of applying for professional examination only after completing 12^th standard by around 17 years of age. The observation was akin to those of Supe[16] in the Indian context. Demographic distribution can be reflection of choice versus population concentration of young generation in various states. Not much research exists in such direction. Around a fifth of the students had probable inspiration from their kith and kin to join the medical profession; however, evaluation did not reveal any higher stress in these students. This finding is not in consonance with those of Chandrasekhar et al.[25] This might be due to their prior sensitization and realistic orientation by relatives. Anxiety about examination, viva voce, and study have been vocalized in the past by other researchers as well.[3,4] They used established relaxation methods to overcome their stress.

Nearly 53.5% of students were above cut-off on scores of general psychopathology. This score was higher than few researchers,[11,16,25] it was lesser than that of Inam[29] who found it to the tune of 60% and above. High-level burnout was 5.1% on depressive-anxiety; 41.4% on depersonalization; and 46.4% on reduction of personal achievement. Dyrbye et al. also found the burnout to be around 45% in their study.[2]

Perceived stress had statistically significant association with general psychopathology and depressive-anxiety component of burnout. It was also seen that higher the perceived stress, higher was the scores on burnout. Findings are akin to those of similar researches in the past.[6,28] Not much research exists on medical students exists in this direction. GHQ failed to show any correlation despite significant association. Not much research exists in this direction. Although age at present and age of joining MBBS course had significant positive correlation with burnout depressive-anxiety syndrome, they fail to achieve any statistical association with perceived stress or other entity.

People who had fewer score on perceived stress were found to have more of acceptance, positive reframing, humor, planning, and active coping as coping methods. Active coping strategies such as positive reframing, planning, and acceptance have proven to be healthy in the past as well.[24]

CONCLUSION

Higher score on perceived stress was associated with higher scores on general psychopathology and burnout. Age of joining MBBS course and doctor in the family did not affect the stress significantly. People who displayed positive coping strategies had lesser stress and general psychopathology.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.