Background: Medical students are exposed to high amounts of stress. Stress and poor academic performance can become part of a vicious circle. In order to counteract this circularity, it seems important to better understand the relationship between stress and performance during medical education. The most widespread stress questionnaire designed for use in MedicalSchool is the “ PerceivedMedicalSchoolStress Instrument ” (PMSS). It addresses a wide range of stressors, including workload, competition, social isolation and financial worries. Our aim was to examine the relation between the perceivedMedicalSchoolstress of undergraduate medical students and academic performance. Methods: We measured MedicalSchoolstress using the PMSS at two different time points (at the end of freshman year and at the end of sophomore year) and matched stress scores together with age and gender to the first medical examination (M1) grade of the students ( n = 456).
It is concluded from the study results that the mean PMSS among medical students does not differ much between the different years i.e. similar findings were observed among freshman and graduate year students. However, despite not being much different, both are higher than what may be considered healthy for medical students. Thus factors, other than increasing educational years and the resultant increase in difficulty of the course may be explored.
Stress levels among medical students at different uni- versities have been investigated using instruments focus- ing on the stressors within medical education [3,18]. The PerceivedMedicalSchoolStress (PMSS) scale is an exam- ple of such an instrument, which addresses and measures stress factors specifically related to medicalschool . It consists of stressor items such as perceived threat, feel- ings of anonymity and isolation, and worries about schoolwork and competence. Lack of time for social activities and recreation, and worries about finances and accommodation are also included. In Norwegian medical students, a high level of perceivedstress during medicalschool predicts undergraduate and postgraduate mental health problems that may require treatment [5,20]. Anxi- ety and depression in medical students have been assessed using a variety of instruments [6,21,22]. In Nor- way, various versions of the Symptom Check List (SCL- 90) have been widely used to measure anxiety and depression  in the general population, in clinical groups and medical students [6,24,25]. A short version of this measure was used to capture general mental distress in our sample, and to identify if the intervention influ- enced such health problems.
The main purpose of this study was to examine the rela- tionship between life satisfaction among medical students and a basic model of personality, stress and coping [15,16]. Personality traits, such as neuroticism and extro- version, have been found to be predictors of life satisfac- tion . As indicated above, research on the psychological adaptation of medical students has focused on distress. Perceivedmedicalschoolstress has been linked to current mental distress  and to forthcoming mental health problems , and is therefore assumed to affect life satisfaction. According to the resilience model, the way that students cope with stress factors may influ- ence their mental health in medicalschool [15,20]. We anticipated that active or problem focused coping and seeking social support would promote higher satisfaction with life, whereas passive or emotion focused coping would have a negative impact on life satisfaction. In par- ticular, we wanted to study the characteristics of students who sustained high levels of life satisfaction during med- ical school, and compare them with the characteristics of their peers to find factors of resilience that may be used to make positive changes, and hence help future medical stu- dents . We assumed that stress factors pertaining to medicalschool might have a negative impact on students' life satisfaction, and wanted to examine if this effect can be counteracted with efficient coping strategies. We also anticipated that particular personality traits would affect students' susceptibility to the educational challenges. A recent study from our group  followed a cohort of Norwegian physicians from their final term in medicalschool to the ninth postgraduate year and found lower levels of life satisfaction in the fourth and ninth postgrad- uate years compared to comparable population samples. The study also found that the level of life satisfaction was even lower at the end of medicalschool, but it did not
Previous studies have investigated these vulnerability traits as well as protective traits predicting either mental health problems or perceivedstress levels during med- ical school or internship. However, the present study investigates these two perceivedstress variables as mediators of the relation between personality traits and mental health measures, and also whether the stress variables moderate these relationships. Applying structural equation analyses, we found that perceivedmedicalschoolstress during the final year of medicalschool and later job stress during internship served as both predictors and mediators between personality traits, measured early in medicalschool, and mental health measures, assessed during internship. To our knowledge, this is the first paper describing a medi- ation effect from perceivedstress. In this study, junior doctors with high scores on neuroticism experienced more job stress, and the same individuals had an in- creased risk of developing stress reactions. This sug- gests that doctors with a certain personality profile are more likely to develop mental health problems if they interpret environmental factors as more stressful than individuals with a more extrovert profile.
Background: Stress is defined as a condition or feeling experienced when a person perceives that demands exceed the personal and social resources the individual is able to mobilize. Medicalschool is recognized as a stressful environment that may have a negative effect on students’ academic performance, physical health, and psychosocial well-being. This stress when it exceeds the limit of tolerability causes various physical and mental health problems. Identifying this root cause will help us to put a barrier to many future mental health problems in a student’s life. Methods: It was a cross-sectional study done in Mysore Medical College among undergraduate students. Perceivedstress scale was used to assess the level of stress and Medical student’s Stressor questionnaire was used to assess the source of stress.
In line with other studies, the medical students in our study showed higher levels of perceivedstress than the age specific German norm population . However, medical students reported also strong personal resources (optimism, self-efficacy, joy and resilient coping strat- egies), suggesting that the coping efforts were not effect- ive in reducing perceivedstress. The students in our study also showed higher stress levels than medical stu- dents in their second year examined in 2005 by Fliege et al. . There are at least two possible explanations for this result: First, it is possible that the general level of perceivedstress among medical students has increased within the last ten years. Second, it is possible that the first semester is a time, where many personally relevant changes take place within the students ’ lives: Examples are leaving home and living on their own for the first time, orientation in a new city away from home, estab- lishing new relationships, and habituation to the pro- cesses and examinations at medicalschool. These findings were in line with the results of earlier studies showing that university students have to deal with stressors like academic and social demands, examination outcome and personal competence . In addition, medical students face training specific stressors such as dissecting corpses [22, 23] and interactions with suffer- ing, chronical ill and dying patients . In contrast to other studies, no statistically significant differences were found between female and male students [17, 21, 81], students with and without migration background  and students who work and do not work in addition to their medical training [7, 20, 21]. One reason that higher levels of perceivedstress were not found in the sub- groups might be the already very high level of stress expressed by the students in our study and therefore the ceiling effect could have prevented further variations to be found within the different subgroups. In addition, the PSQ-20 did not focus on the specific aspects of medical student stress. Therefore, differences between subgroups might have been undetected. Perceivedstress was mainly characterized by tension and worries. Higher levels of perceivedstress were positively related to higher levels of emotional distress, operationalized by anxiety and de- pression. At the same time, higher levels of perceivedstress were associated with lower levels of joy.
The PSS measures the degree to which life events are appraised as stressful (12). This method of assessing stress reflects the definition of psychological stress proposed by Lazarus and Folkman (9). In this scale, perceivedstress is viewed as an outcome variable that measures the level of stress experienced as a function of objective stressful events, coping processes, and personality factors (6). Additionally, the scale can provide information about the processes through which stressful events influence pathology. It can be used in conjunction with an objective scale to determine whether self-appraised stress mediates the relationship between objective stress and illness (6). This scale was specifically designed for use with community samples with at least a junior high school education (11).
Various stress factors reported among medical students are academic demands, exams, inability to cope, increased psychological pressure, mental tension and too much work load. The transition from pre-clinical to clinical training has also been identified as a crucial stage of medicalschool regarding student stress [5, 7, 8, 9]. Coping has been viewed as a stabilizing factor that may assist an individual in psychosocial adaptation during stressful events. Coping methods often used by students, to reduce level of stress include effective time management, social support, positive reappraisal, and engagement in leisurely pursuits .
Perceivedstress was measured using the perceivedstress scale (PSS-14) , which comprised of 14 ques- tions with responses varying from 0 to 4 for each item and ranging from never, almost never, sometimes, fairly often and very often respectively on the basis of their occurrence during one month prior to the survey. The PSS has an internal consistency of 0.85 (Cronbach a co-efficient) and test-retest reliability during a short ret- est interval (several days) of 0.85 . It assesses the degree to which participants evaluate their lives as being stressful during the past month. It does not tie appraisal to a particular situation; the scale is sensitive to the nonoccurrence of events as well as ongoing life circumstances. PSS-14 scores are obtained by reversing the scores on four positive items, for example 0 = 4, 1 = 3, 2 = 2, etc. and then summing across all 14 items. Items 4, 5, 6, 7 and 10 are the positively stated items. The scale yielded a single score with high scores indi- cating higher levels of stress and lower levels indicating lower levels of stress. The PSS-14 has a possible range of scores from 0 to 56. The range of PSS scores were also divided into stratified quartiles. The upper two and lower two quartiles were combined (28 being the opera- tional cut off value for the upper bound) and were labeled as stressed and not stressed respectively. This cut off value was selected in accordance to a similar study from Egypt .
In regards to H3, only internalising problems were significantly elevated for girls as compared to boys. The perceivedstress levels were also higher in girls than in boys, but after Bonferroni adjustment, these were no longer significant. Considering that this sample may have been high in protective factors due to the medium to high SES, the results seem to be in line with previous research which found a heightened vulnerability of adolescent girls in families with parental CMC for internalising problems and stress (Barkmann et al., 2007; Compas et al., 1994; Sieh, 2012; Welch, Wadsworth, & Compas, 1996). The higher vulnerability to stress and internalising problems of girls is not exacerbated by parental CMC in a way that it also translates into a higher vulnerability to externalising problems or academic functioning, at least in a sample from a medium to higher SES and Western culture. The tendencies for adolescent functioning seem to reflect the tendency by gender of the normal population where girls also show higher levels of stress, internalising problems and grade point averages, yet lower externalising problems and lower school- related self-esteem than boys (Bongers, Koot, Van der Ende, & Verhulst, 2003; Kessler & McLeod, 1984; Rudolph, 2002; Voyer & Voyer, 2014).
Methods: This was a 1-year prospective web-based questionnaire study comprising one cohort of medical students in their fifth year who were working as clerks as part of their 6-year medical education programme at one medicalschool in Taiwan between September 2017 and July 2018. Web-based, validated, structured, self-administered questionnaires were used to measure the students ’ resilience at the beginning of the clerkship and their perceived training stress (i.e. physical and psychological demands) and professional quality of life (i.e. burnout and compassion satisfaction) at each specialty rotation. Ninety-three medical students who responded to our specialty rotation surveys at least three times in the clerkship were included and hierarchical regressions were performed. Results: This study verified the negative effects of medical students ’ perceived training stress on burnout and compassion satisfaction. However, although the buffering (protective) effects of resilience were observed for physical demands (one key risk factor related to medical students ’ professional quality of life), this was not the case for psychological demands (another key risk factor). In addition, through the changes in R square ( Δ R 2 ) values of the hierarchical regression building, our study found that medical students ’ perceived training stresses played a critical role on explaining their burnout but their resilience on their compassion satisfaction.
psychological distress during their period of under- graduate training and that they have substantially higher levels of stress when compared to the normal population [36, 37]. Hence, if sufficient measures are adopted to improve EI among students, it would re- duce the stress levels and cultivate better coping amongst the students during their training years in medicalschool and also help during their practice as professionals in the future. It is well known that healthcare workers with higher job satisfaction have lower stress levels . A similar negative correlation has been observed among university students . In the present cohort, the self-satisfied group of students had a significantly lower stress level.
shown in other Asian studies [6-10]. One of the reasons for this difference was that the subjects were nursing and medicalschool students, who worked irregular hours due to their studies and clinical practice schedules. Some studies [26,27] have shown that there are a variety of stressors in clinical practice. Jimenez et al.  identi- fied three types of stressors (clinical, academic and ex- ternal) and two categories of symptoms (physiological and psychological) linked to clinical practice. The sub- jects of the study perceived clinical stressors more in- tensely than academic or external stressors. In general, most students don’t have any practical experience in the clinical field. Timmins et al.  reported that one third of the students in their study felt some degree of stress in their relationships with teachers and staff in the ward, and that the clinical experience and the death of patients were independent sources of stress. Thus, these students might feel more stress than other students or people in general. In support of this hypothesis, other studies that targeted nursing or medicalschool students also showed a high prevalence of IBS, 35.5% in Japan , 15.8% in Malaysia , 26.0% in Pakistan , and 26.1% in Nigeria . Especially, the prevalence of IBS in nursing and medicalschool students in Japan  and China were both higher than that found in other countries. Prior to recent studies, no large-scale research studies on nurs- ing and medicalschool students have been conducted. These recent studies have made it clear that nursing and medicalschool students in the Asian region have a high prevalence of IBS. However, Chang et al.  reported that more than 90% of nurses have very limited knowl- edge in regard to IBS, and are unable even to explain it clearly. It is important to expand their knowledge of their own symptoms.
The high rates of possible psychological morbidity (52% GE and 46% UG) in our students is worrying, but not dissimilar to rates in other studies of medical students [2, 3, 12]. For example, in Manchester around one-third of students were GHQ cases,  (Guthrie et al.) and in Glasgow 52% first-year medical students were GHQ cases by the third term . By way of comparison, the 2003 Health Survey for England found 10–12% GHQ-12 caseness (using 3–4 cut-off as we have done here) in men and 15–16% in women in the same age-groups as our stu- dents . Our primary focus was not on exploring rea- sons for the high levels of psychological morbidity and perceivedstress. Other authors have explored these in UG medical students and important contributory factors have been shown to be course-related, [3, 4, 28] financial,  and personal, such as, having a lack of social support or stress-related personality traits [1, 29, 30]. Similarly, we did not explore reasons for the lower stress levels and lower (although still high at 31%) rate of psychological morbidity in second-year GEs. We suggest that this may be due to a ‘settling down’ of the stress associated with starting the medical course (a major life event) or a con- sequence of starting clinical training (second-year GEs join the third-year of the UG MB ChB course). A previ- ous study at St George’s Hospital MedicalSchool showed that third-year GEs were less anxious and more prepared for the transition to clinical years than UGs . We did include measures of known stress-related personality traits (e.g., neuroticism) and a measure of recent adverse life events but we found no differences between GEs and UGs, and no differences between first- and second-year GEs. Therefore, personality and known stressors (such as bereavement, relationship problems, and serious ill- ness in self or family) do not account for the differences observed here. It was interesting that we did not find as high a prevalence as expected of potential stressors in the GE group, for example, 3% had children, 16% were married/co-habiting and around half were in full-time employment prior to starting the course. Future longitu- dinal work is required to explore stressors in GEs in more detail.
Our study and a few other studies have pointed out frequency of examination as an important stressor; therefore, there is a need to improve students ’ assess- ment process and to make it less stressful and student- friendly . Moreover, students should be supported to take part in sports and other extracurricular activities that can alleviate stress, anxiety and burnout as well as their consequences on physical and mental health [13, 29]. A study suggested student-led support programs de- signed to promote mentorship of newly admitted junior students by senior students to help them acclimatize to the new medicalschool setting . Recently, a study in
Experiences in medicalschool are associated not only with personal and professional development, but also with psychological toxicity and a negative impact on student’s quality of life. For student’s lack of self- confidence, seclusion and general personal neglect might have serious impact on their personal and social life. Adaptive and maladaptive skills developed in medical education may form the groundwork for future professional adjustment (56) multifarious obligations stemmed as stressors for medical students. Academic stressors were most potential causes of stress. Third year medical students had the greatest intensity of stress, followed by fourth year students. The least amount of stress was seen in first year students. Coping skills may be a useful intervention to mollify the pernicious effects of stress. Problem solving coping strategy was more effective as compared to wishful thinking. Our results speak volumes on frequency of stress in medical students and constitute significant material for program directors, teachers and students to reflect on. It directs the need for preserving and improving the
Women’s tendency to report lower levels of well-being related to spending many hours performing unpaid work and experiencing housework-related stress could be ex- plained by the fact that women do more of the domestic work. Previous research suggests that when men increase their share of the housework, women’s well-being will increase . However, this study shows that labor-related stress is of more importance for well-being than actual labor involvement, which indicates that other more sub- jective factors may be of greater importance than sharing work equally. Previous research has shown that the belief that men do as many hours of housework as women can improve well-being . This suggests that women who believe they share housework equally also tend to per- ceive their labor-related stress levels as lower. This should be investigated further. Men’s higher odds of re- porting a low level of perceived well-being related to WFCs could be a result of the larger fraction of work that is paid. Working many hours could make it harder to engage in family matters and more difficult to leave work behind when coming home to the family. These results support the theory that subjective factors related to labor involvement are of more importance than actual labor involvement when studying health outcomes among women and men.
Another study done in by Brahmbhatt et al also showed a higher mean score of 27.53. 11 The easy pace of life in Bikaner, may be the reason for the lesser stress experienced by the students of this college. In our study mean PSS score was significantly higher for female gender. A study by Gade et al in Nagpur showed a same result with significant association between stress and gender, females being more stressed and students from rural background being significantly more stressed as opposed to our results. Showing contrast result studies done by Shakthivel et al, Yusoff et al, Supe et al and Nandi et al with they showing no significant association between gender and stress. 9,12-15
such as heavy workload and problems with peers and superiors are correlated with high incidence of headache. Similarly,  reported that high prevalence of headache could also be attributed to novel technologies, as complex technical equipment in Acute Care Units requires rapid update of knowledge and skills, which along with constant time pressure leads to “techno-stress”. Results of the study showed significant stress symptoms were psychological stress symptoms of which mood swing 38% was the most significant. But the above result is in contrary to another study carried out by , to determine the prevalence and sources of stress among 183 nurses working in acute care unit at central hospital Zambia, sleep disturbance was reported as the most experienced symptoms of stress. The sleep disturbance was attributed to night shift as it was found out that most of the nurses do not sleep after excess work in the acute care unit, but rather go about their normal duty in the day time and then return to work again at night. The result of the study revealed that majority of the respondents’ perceived physical exhaustion and accidents in workplace such as giving wrong medication to patients 78.8%. This agrees with the study carried out by  which revealed that 60% of the participants had physical stress symptoms with physical exhaustion and accidents in the workplace as the most significant factor affecting their personal and work behavior. The physical exhaustion was attributed to stress as a result of excessive workload and too many patients to care for at the same time leads to confusion at work with frequent accidents as the result. Also, other perceived personal and behavioural stressors includes; absenteeism and lateness to work. This agrees with the study conducted by  whose study revealed that the highly stressed nurses exhibited personal or work behavioural problem like bullying, absenteeism and lateness to work.