Show what you know and deal with stress yourself: a qualitative interview study of medical interns' perceptions of stress and gender

Effects of grit on medical students' wellbeing during clerkships: a longitudinal observational cohort study

Introduction

In medical education, the clerkship phase is a demanding period during which medical students learn to navigate the responsibilities of medical school and clinical medicine. Grit, a personal quality regarded as a non-cognitive trait, refers to perseverance and passion; specifically, it represents the ability to endure hardship and work industriously toward a goal. Most studies analysed grit as a single concept and few studies have investigated the effect of grit on the well-being of medical students through the whole-specialty training (i.e. surgical and non-surgical specialty rotations) required in clinical clerkships. Therefore, this study investigated whether associations exist between medical students' grit, measured by the two subconstructs of perseverance and passion, and their well-being during clerkships in surgical and non-surgical specialty units.

Methods

This one-year prospective web-based questionnaire study enrolled fifth-year medical students at a tertiary medical centre in central Taiwan between September 2017 and July 2018 in their first-year clerkship. The students' sex, age, and grit were measured at the start of their clerkship. Routine surveys were conducted over one year to assess burnout and compassion satisfaction for students' well-being, and the training specialty characteristics of the surgical and non-surgical specialty departments were recorded. This study included 92 medical students and 1,055 survey responses from individual specialty rotations. Descriptive, univariate and multivariate analyses were performed.

Results

Our results revealed that medical students' perseverance, as part of grit, was related to lower burnout and higher compassion satisfaction during clerkships, but not the subconstruct of passion. Moreover, the positive trait of perseverance measured in our study had greater explanatory power for compassion satisfaction than for burnout. Furthermore, the results revealed that older medical students suffered from less burnout than their younger counterparts, and that male medical students expressed higher compassion satisfaction than their female counterparts.

Discussion

Perseverance, as a subconstruct of grit, is a positive personal quality for medical students' clerkships, and methods driving the cultivation of perseverance in medical education should be considered. In addition, even though positive traits such as perseverance equipped medical students for compassion satisfaction, additional factors attributed to medical students' burnout must be identified.

Gender influences resident physicians' perception of an employee-to-employee recognition program: a mixed methods study

BACKGROUND

Burnout is prevalent in medical training. While some institutions have implemented employee-to-employee recognition programs to promote wellness, it is not known how such programs are perceived by resident physicians, or if the experience differs among residents of different genders.

METHODS

We used convergent mixed methods to characterize how residents in internal medicine (IM), pediatrics, and general surgery programs experience our employee-to-employee recognition ("Hi-5″) program. We collected Hi-5s received by residents in these programs from January 1, 2021-December 31, 2021 and coded them for recipient discipline, sex, and PGY level and sender discipline and professional role. We conducted virtual focus groups with residents in each training program.

MAIN MEASURES AND APPROACH

We compared Hi-5 receipt between male and female residents; overall and from individual professions. We submitted focus group transcripts to content analysis with codes generated iteratively and emergent themes identified through consensus coding.

RESULTS

Over a 12-month period, residents received 382 Hi-5s. There was no significant difference in receipt of Hi-5s by male and female residents. Five IM, 3 surgery, and 12 pediatric residents participated in focus groups. Residents felt Hi-5s were useful for interprofessional feedback and to mitigate burnout. Residents who identified as women shared concerns about differing expectations of professional behavior and communication based on gender, a fear of backlash when behavior does not align with gender stereotypes, and professional misidentification.

CONCLUSIONS

The "Hi-5" program is valuable for interprofessional feedback and promotion of well-being but is experienced differently by men and women residents. This limitation of employee-to-employee recognition should be considered when designing equitable programming to promote well-being and recognition.

Perceived stress and anxiety among medical students at Helwan University: A cross-sectional study

Background

Medical students are prone to high levels of perceived stress and anxiety, which can negatively impact their academic performance, as well as their physical and mental health. This study aimed to assess the main stressors, levels of perceived stress and anxiety, and their predictors among medical students.

Design and methods

A structured questionnaire was used to collect data from 1696 medical students at Helwan University. A cross-sectional study was designed to evaluate their perceived stress, stressors, and anxiety using the Perceived Stress Scale, Medical Students Stressor Questionnaire, and Beck Anxiety Inventory, respectively.

Results

Approximately 93% of medical students experienced moderate to high levels of stress, while 54.9% of medical students experienced moderate to concerning levels of anxiety. The main stressors were academic, teaching, social, intrapersonal, group activity, and desire-related stressors. Risk factors associated with higher perceived stress included being female, young age, living away from the family, obtaining lower academic percentages, having psychiatric, neurological, or other chronic medical illnesses, and experiencing higher levels of academic, intrapersonal, drive, and group activities-related stressors. Risk factors for higher anxiety included being female, residing in rural areas, having psychiatric, neurological, or other chronic medical illnesses, perceiving a high level of stress, and experiencing higher levels of academic, intrapersonal, and social-related stressors.

Conclusions

The findings indicate that a significant proportion of medical students experience various levels of stress and anxiety. These results underscore the urgent need for a stress management program, to help medical students to cope with different stressors.

Medical students' career decision-making stress during clinical clerkships

OBJECTIVES

Many medical students experience career decision-making stress in the final phase of training. Yet, the factors that induce or reduce career decision-making stress and how progression in their clerkships relates to these factors are unknown. This knowledge gap limits the possibilities for medical schools to develop and implement interventions targeting students' career decision-making stress. This study explores content, process, and context factors that may affect career decision-making stress.

METHODS

Using cross-sectional survey data from medical master students (n = 507), we assessed content (future work self), process (choice irreversibility, time pressure, career decision-making self-efficacy), and context (supervisory support, medical school support, study load, competition) factors and their relationships with career decision-making stress. The hypothesized relationships were tested with structural equation modelling.

RESULTS

A clearer future work self and higher career decision self-efficacy were associated with lower career decision-making stress, while experienced time pressure, competition, and study load were associated with higher career decision-making stress. Choice-irreversibility beliefs, supervisory support, and medical school support were unrelated to career decision-making stress. As students' clerkships progressed, they gained a clearer future work self, but also experienced more time pressure.

DISCUSSION

Clinical clerkships help students to form a clearer future work self, which can diminish career decision-making stress. Yet, students also experience more time pressure as the period of clerkships lengthens, which can increase career decision-making stress. A school climate of high competition and study load seems to foster career decision-making stress, while school support hardly seems effective in diminishing this stress.

Identifying stressor criteria that hinder or challenge junior clinical medical student learning

INTRODUCTION

What makes something a stressor within clinical students' education is unclear. Medical students moving from a predominantly protected classroom environment to a situated-work environment provided an ideal transition point to explore the criteria that might make a learning experience a stressor and whether these stressors hinder or challenge learning.

METHOD

Data on the stressors associated with learning experiences in clinical education were collected from New Zealand undergraduate medical students. Free text comments, in a survey-based questionnaire were supplemented by focus group data. Using inductive thematic analysis with grounded theory, themes were generated about the characteristics of stressors; referred to here as stressor criteria. These stressor criteria were then classified according to their impact on perceived learning.

RESULTS

Under the broad headings of the nature of the learning task, external factors, internal factors, and social interaction; 12 stressor criteria groupings were defined. Some of these criteria were a positive challenge to learning (e.g. legitimacy of the task, novelty of the learning, social interactions) and others a hindrance.

DISCUSSION

Not all stressors hinder learning. Instead, and depending on their nature, many result in perceived assistance to learning. Stressors hindering learning need to be recognised by the teacher, especially those that can be converted from a hindrance to an assistance.

Relationship between medical students' negative perceptions of colleagues' work-life and burn-out during clerkships: a longitudinal observational cohort study

OBJECTIVE

Because work and educational environments are closely related and can affect each other, this study examined whether medical students' negative perceptions of their colleagues' work-life balance (NWLB) during their clinical rotations would be related to burn-out in clerkships and investigated the effect of students' gender on this relationship.

DESIGN

A longitudinal, prospective 2-year cohort study conducted between September 2013 and April 2015.

SETTING

Medical students from a university school of medicine in Taiwan.

PARTICIPANTS

One voluntary cohort of undergraduate medical students in clerkships was invited to participate. Among 190 medical students recruited in September 2013, a total of 124 students provided written informed consent. Participants were free to decide whether to complete each survey; therefore, varying numbers of responses were obtained during the study period. Those who responded to our survey for more than 6 months were included in our analyses. Overall, 2128 responses from 94 medical students were analysed, with each student providing an average of 23 responses for 2 years.

PRIMARY OUTCOME MEASURE

Burn-out was measured using the Professional Quality of Life Scale.

RESULTS

Our study found that a strong NWLB was related to high burn-out levels among medical students during their clerkships (p<0.001). However, the gender of the student had no effect on this relationship (p>0.05). In addition, our study indicated that medical students living with a companion had decreased burn-out levels than did those living alone during their clerkships.

CONCLUSIONS

The significance of policies promoting employee work-life balance should be emphasised because of the potential for social contagion effects on medical students. Clerkship trainees might be vulnerable to such negative contagion effects during the transition to their early clinical workplace training and may, therefore, require advanced socialisation and mentoring.

"As an ethnic minority, you just have to work twice as hard." Experiences and motivation of ethnic minority students in medical education

INTRODUCTION

Adequate representation of ethnic minority groups in the medical workforce is crucial for ensuring equitable healthcare to diverse patient groups. This requires recruiting ethnic minority medical students and taking measures that enable them to complete their medical studies successfully. Grounded in self-determination theory and intersectionality, this paper explores the experiences of ethnic minority medical students across intersections with gender and other categories of difference and how these relate to students' motivation.

METHODS

An explorative, qualitative study was designed. Six focus groups were conducted with 26 ethnic minority students between December 2016 and May 2017. Thematic analysis was performed to identify, analyse and report themes within the data.

RESULTS

The findings were categorized into three main themes: the role of autonomy in the formation of motivation, including students' own study choice and the role of their family; interactions/'othering' in the learning environment, including feelings of not belonging; and intersection of ethnic minority background and gender with being 'the other', based on ethnicity.

DISCUSSION

Ethnic minority students generally do not have a prior medical network and need role models to whom they can relate. Ensuring or even appointing more ethnic minority role models throughout the medical educational continuum-for example, specialists from ethnic minorities in teaching and/or mentoring roles in the education-and making them more visible to students is recommended. Moreover, a culture needs to be created in the educational environment in which students and staff can discuss their ethnicity-related differences.

Transition to clinical practice during the COVID-19 pandemic: a qualitative study of young doctors' experiences in Brazil and Ireland

OBJECTIVES

To explore and compare the perspectives of junior doctors in Brazil and Ireland regarding transition and professional socialisation during the COVID-19 pandemic, with the purpose of identifying better ways to support doctors as they assume their new professional role.

DESIGN

27 semistructured interviews. Transcripts were analysed using qualitative thematic analysis. Cruess' framework of professional socialisation in medicine supported the interpretation of these data.

SETTING

Public health hospitals across four Brazilian states (Santa Catarina, São Paulo, Ceará, Paraíba) and County Cork in the South of Ireland.

PARTICIPANTS

Twenty-seven male and female medical junior doctors who had graduated between November 2019 and April 2020.

RESULTS

Fourteen Brazilian and 13 Irish junior doctors were interviewed for this study. Entry to clinical practice during the pandemic had a significant impact on factors influencing the professional socialisation of junior doctors. This impact was reflected across the following six thematic areas: lack of preparedness; disrupted trajectory of role adaptation; fewer opportunities for experiential learning; solidarity and isolation; altered interactions with patients; challenges to health and well-being.

CONCLUSIONS

Transition to clinical practice is an important stage in junior doctors' professional socialisation and identity formation. The COVID-19 pandemic created the opportunity for medical graduates to enter the workforce earlier than usual. Entering the workforce during this period created a lack of confidence among junior doctors concerning the boundaries of their new role and responsibilities, while simultaneously disrupting their social integration. Priorities to mitigate the impact of COVID-19 and future pandemics on this transition are presented.

Bridging the divide between medical school and clinical practice: identification of six key learning outcomes for an undergraduate preparatory course in radiology

BACKGROUND

There exists a significant divide between what is learnt in medical school and subsequently what is required to practice medicine effectively. Despite multiple strategies to remedy this discordance, the problem persists. Here, we describe the identification of a comprehensive set of learning outcomes for a preparation for practice course in radiology.

METHODS

Assessment of interns' readiness to interact with the radiology department was conducted using a national survey of both interns and radiologists. In parallel, group concept mapping (GCM) which involves a combination of qualitative and quantitative techniques was used to identify the shared understanding of participants from a diverse range of medical specialties regarding what topics should be included in an intern preparatory course for interacting with the radiology department.

RESULTS

The survey demonstrated that most interns and radiologists felt that undergraduate medical training did not prepare interns to interact with the radiology department. GCM identified six learning outcomes that should be targeted when designing a preparatory module: requesting investigations; clinical decision support; radiology department IT and communication; adverse reactions and risks; interpretation of radiology results and urgent imaging. The thematic clusters from the group concept mapping corroborated the deficiencies identified in the national survey.

CONCLUSION

We have identified six key learning outcomes that should be included in a preparation for practice module in radiology. Future courses targeting these thematic clusters may facilitate a smoother transition from theory to practice for newly graduated doctors.

The personal motif in naturalistic case study research: developing "innerstandings" in woman's compulsive behaviour

Purpose: The purpose of this article is to show case study research focused on persons as a case and our personal engagement with the case can improve our innerstandings and understanding of person-centred care. Method: We present the methodology and epistemology of naturalistic case study research and illuminate this approach with the case study of Ellen, a young, Dutch, white-middle class woman with a compulsive disorder. We combine naturalistic case study research with the personal narratives of those involved in the research, including ourselves, and interpreted through a feminist and gender lens. Results: The case study research enhanced the personal and mutual understanding of all involved, including the researchers. Feminist and gender theory revealed the hidden personal motif for the choice of the case, and led to a re-viewing of the original story, offering a re-storying. Conclusion: We conclude that the personal motif as well as the use of our personal experiences to understand the case deserve more attention in case study research to address the complex interplay of social and intrapsychic dimensions, and develop more in-depth innerstandings for all engaged.

Knowledge self-monitoring, efficiency, and determinants of self-confidence statement in multiple choice questions in medical students

BACKGROUND

Multiple-choice question (MCQ) tests are commonly used to evaluate medical students, but they do not assess self-confidence nor penalize lucky guess or harmful behaviors. Based on a scoring method according to the appropriateness of confidence in answers, the study aimed at assessing knowledge self-monitoring and efficiency, and the determinants of self-confidence.

METHODS

A cross-sectional study of 842 s- and third-year medical students who were asked to state their level of confidence (A: very confident, B: moderately confident and C: not confident) during 12 tests (106,806 events). A bonus was applied if the level of confidence matched with the correctness of the answer, and a penalty was applied in the case of inappropriate confidence.

RESULTS

Level A was selected more appropriately by the top 20% students whereas level C was selected more appropriately by the lower 20% students. Efficiency of higher-performing students was higher when correct (among correct answers, rate of A statement), but worse when incorrect compared to the bottom 20% students (among incorrect answers, rate of C statement). B and C statements were independently associated with female and male gender, respectively (OR for male vs female = 0.89 [0.82-0.96], p = 0.004, for level B and 1.15 [1.01-1.32], p = 0.047, for level C).

CONCLUSION

While both addressing the gender confidence gap, knowledge self-monitoring might improve awareness of students' knowledge whereas efficiency might evaluate appropriate behavior in clinical practice. These results suggest differential feedback during training in higher versus lower-performing students, and potentially harmful behavior in decision-making during clinical practice in higher-performing students.

The lived experience of stress in British South-Asian medical students and junior doctors

BACKGROUND

Stress is an acknowledged element of the medical profession; how cultural backgrounds may affect the perception of stress is understudied.

OBJECTIVE

This study aimed to examine the stress-related experiences of British South Asian medical students and junior doctors, and to explore their coping mechanisms.

METHODS

Semi-structured interviews were conducted with five participants at various stages of medical training. All participants reported stress, anxiety or depression and were of a British South Asian heritage.

RESULTS

An Interpretative Phenomenological Analysis was undertaken and three master themes were identified. These themes follow a narrative journey. The first theme was Individualism and External Reasoning, and referred to the factors that influenced participants career choices - both internal (e.g. a sense of self-efficacy) and external (e.g. prior exposure to the medical career). Secondly, Stress and Vulnerability examined the stress the participants experienced as a result of either internal stressors (e.g. perfectionism) or external stressors (e.g. social comparison). The last theme, Perseverance and Coping, referred to the coping strategies that participants developed to deal with aforementioned stressors, which varied from self-harm to visualisation.

CONCLUSIONS

The choice to pursue a medical career was based on self-efficacy, prior exposure, and the perceived prestige of the vocation. Stressors and related coping mechanisms varied within the cohort, depending on social, environmental, and psychological circumstances. Whilst stress management interventions should take a personalised approach, considering individual cultural backgrounds; the systemic factors within medical training that directly lead to stress have to be addressed rather than merely acknowledged.

Investigating Stress and Sources of Stress Among Female Health Profession Students in a Saudi University

Background

Health profession students experience tremendous levels of stress throughout their education. A high level of stress may have a negative effect on the cognitive functioning and learning of students.

Objective

The study sought to determine the levels and main sources of stress and its possible correlation with academic performance in the preclinical female health profession.

Methods

The cross-sectional design involved the use of self-administered questionnaires. Data were collected from 260 students in health profession programmes in Saudi Arabia. The Medical Student Stressor Questionnaire (MSSQ) was used to collect the data from all second-, third-, and fourth-year undergraduate students.

Results

A high level of stress was observed in 42.7% of the students, and a moderate stress level was observed in 41.5% of the students. The major source of stress experienced by students was related to the academic domain (mean= 2.7±0.73), followed by the group activity domain (mean= 2.1±0.91; p< 0.05). Second-year and third-year students were significantly less likely to show high stress levels compared with fourth-year students (AOR= 0.3; 95% CI: 0.1–0.8; p≤ 0.030 and AOR= 0.4; 95% CI: 0.1–0.5; p≤ 0.001, respectively). High stress levels were not found to be associated with students’ age and academic performance.

Conclusion

Half of the students experienced high and severe levels of stress. Academic and group activity domains were perceived as the major stressors. The year of study was the only significant factor associated with stress levels. Stress among female health profession students should be acknowledged, and efforts should be made to alleviate it. Students should be guided to reduce their stress levels, as this can enhance their quality of life and study experience.

A review of the factors related to burnout at the early-career stage of medicine

Background: Globally, burnout is an increasingly prevalent problem amongst young medical professionals. This review aims to understand the factors related to burnout in the early-career stage of medicine. Drawing on the widely used Job Demands-Resources Model, the antecedents of burnout were distinguished from its outcomes.Methods: The review adopted the PRISMA guidelines. Using specific search terms, peer-reviewed articles were obtained from a range of databases and assessed against selection criteria. To meet inclusion requirements, the study had to be published between 2000 and 2018, include a validated measure of burnout, and undertake empirical assessment of factors related to burnout in medical students and/or junior medical officers/residents. Additional studies were obtained and reviewed from the reference lists of selected articles.Results: Out of the 3796 studies that were initially found, 585 were assessed against the eligibility criteria leaving 113 studies for review. These studies highlighted the negative consequences of burnout in the early medical career. Also identified were work-specific and person-specific demands that likely lead to burnout and, work and person resources that appear to reduce burnout.Conclusion: This review provides a framework to explain the growing problem of burnout amongst early-career medical professionals. However, further research is necessary to overcome the current reliance on cross-sectional designs and small sample sizes.

Stressors and resources related to academic studies and improvements suggested by medical students: a qualitative study

BACKGROUND

Prior evidence suggests that medical students' mental health is poor and deteriorates during the course of academic studies. This qualitative study therefore aims to improve our understanding of medical students' perceptions of i) stressors related to their academic studies, ii) resources that may facilitate coping with those stressors and iii) suggestions to potentially reduce stress.

METHODS

Eight focus groups were conducted with medical students enrolled at a medical school in Germany until thematic saturation was reached. A topic guide was used to facilitate the discussion. Subsequently, focus group discussions were transcribed and content-analyzed using MaxQDA.

RESULTS

Organizational factors especially related to inadequate information flow as well as exams (e.g. repeat exams, scheduling, perceived unfair grading), poor theoretical and practical teaching quality, time and performance pressure, social interactions and individual characteristics (e.g. self-expectations, fear of failure) emerged as major contributors to stress. Resources perceived to facilitate coping with those stressors pertained to some other organizational aspects (e.g. flexibility, availability of contact persons), career prospects, practical training, social support, personal characteristics (e.g. knowledge base, past experience) and leisure time. Suggestions for improvement related primarily to organizational measures rather than individual-level measures.

CONCLUSIONS

Besides well-known stressors (e.g. exams and high performance pressure), some new aspects emerged from our study including stress related to organizational factors and repeat exams. Accordingly, students' wishes for organizational-level interventions, including better information systems and better interweaving of practical and theoretical education, could be first target areas for improvement.

Physicians' Perspectives About Burnout: a Systematic Review and Metasynthesis

BACKGROUND

Doctors' burnout is a major public health issue with important harmful effects on both the healthcare system and physicians' mental health. Qualitative studies are relevant in this context, focusing as they do on the views of the physicians of how they live and understand burnout in their own professional field.

OBJECTIVE

To explore physicians' perspectives on burnout by applying a metasynthesis approach, including a systematic literature review and analysis of the qualitative studies.

DATA SOURCES

Medline, PsycINFO, EMBASE, and SSCI from the earliest available date to June 2018 REVIEW METHODS: This metasynthesis follows thematic synthesis procedures. Four databases were systematically searched for qualitative studies reporting doctors' perspectives on burnout. Article quality was assessed with the Critical Appraisal Skills Program. Thematic analysis was used to identify key themes and synthesize them.

RESULTS

Thirty-three articles were included, covering data from more than 1589 medical doctors (68 residents and 1521 physicians). Two themes emerged from the analysis: (1) stress factors promoting burnout-ranked as organizational, then contextual and relational, and finally individual-factors and (2) protective factors, which were above all individual but also relational and organizational.

CONCLUSIONS

The individual and organizational levels are abundantly described in the literature, as risk factors and interventions. Our results show that doctors identify numerous organizational factors as originators of potential burnout, but envision protecting themselves individually. Relational factors, in a mediate position, should be addressed as an original axis of protection and intervention for battling doctors' burnout.

Depressive symptoms and associated factors in medical interns at a tertiary hospital

BACKGROUND

It is known that medical doctors suffer from increased rates of depression with medical interns being most at risk. Despite this, little is known about the prevalence of depression in interns in South Africa.

OBJECTIVES

This study aimed to assess the prevalence of depressive symptoms in interns employed at Groote Schuur Hospital, a tertiary hospital in the Western Cape.

METHOD

The study was a cross-sectional study. All 91 interns were invited to participate in the study and consenting interns were required to complete a demographic and related questionnaire and the Beck Depression Inventory 2 (BDI-2).

RESULTS

Fifty-four (59.3%) of all invited interns participated in the study. Twenty-two interns (40.7%) reported a BDI-2 score of 14 or greater, indicating at least mild self-reported symptoms of depression. Features associated with a BDI-2 score of 14 or greater, included female gender, a previous diagnosis of depression, seeing a psychotherapist and previously being on antidepressant medication during internship. Other features also significantly associated with higher BDI-2 scores included suicidal ideation, thoughts of emigration, wanting to leave medicine and using substances to cope. The most significant associated feature of high BDI-2 scores was a subjective feeling of being 'burnt out'.

CONCLUSION

Interns had a higher prevalence of depressive symptoms when compared to the general population. The feeling of being 'burnt out' was the most significant factor associated with the severity of depressive symptoms. It is imperative that the mental health of both medical students and newly qualified doctors be prioritised, supported and monitored.

'Waiting in the wings'; Lived experience at the threshold of clinical practice

CONTEXT

The transition to clinical practice is challenging. Lack of preparedness and issues with support, responsibility and complex workplace interactions contribute to the difficulties encountered. The first year of clinical practice is associated with negative consequences for new doctors' health and well-being. The contemporaneous lived experience of new graduates on the threshold of clinical practice has not been described. Deeper understanding of this phase may inform interventions to ease the transition from student to doctor.

METHODS

We used interpretative phenomenological analysis (IPA) to explore the individual experience of making the transition from medical student to doctor, focusing on the period prior to commencing clinical practice. Fourteen recent graduates were purposively recruited, and semi-structured interviews were conducted with each, with respect to how they anticipated the transition.

RESULTS

We draw on the metaphor of the actor 'waiting in the wings' to describe participants' lived experience on the threshold of practice. The experience of the actor, about to step into the spotlight, was mirrored in participants' perceptions of an abrupt transformation to come, mixed feelings about what lay ahead, and the various strategies that they had planned to help them to perform their new role convincingly.

DISCUSSION

Participants in this study braced themselves for a trial by ordeal as they contemplated commencing clinical practice. The hidden curriculum shaped their understanding of what was expected of them as new doctors, and inspired dysfunctional strategies to meet expectations. Solutions to make the experience a more positive one lie in the approximation of the roles of senior medical student and newly qualified doctor, in explicitly addressing the hidden curriculum and generating cultural change. An emphasis on experience-based learning through contribution to patient care, guided reflection on the hidden curriculum and shifting cultural expectations through faculty development and strong local leadership can contribute to these objectives.

Applying feminist theory to medical education

To adequately address gendered issues of sexual harassment, wage gaps, and leadership inequities, medical institutions must interrogate medical education. Feminist theories can help to understand how power operates within our classrooms and at the bedside. This scoping review maps the four main ways in which feminist theory has been applied to medical education and medical education research-namely, critical appraisal of what is taught in medical curricula; exploration of the experiences of women in medical training; informing pedagogical approaches to how medicine is taught; and finally, medical education research, determining both areas of inquiry and methodologies. Feminist theory has the potential to move clinicians and educators from theory to action, building bridges of solidarity between the medical profession and the community it is called to serve.

Understanding Medical Students' Experience with Stress and Its Related Constructs: A Focus Group Study from Singapore

OBJECTIVE

In order to protect medical students from burnout and its untoward psychiatric effects, it is imperative to understand their stress, burnout, coping, and resilience experiences. This study aimed to derive collective definitions from the medical student perspective, to identify common themes of students' experiences, and to distinguish pre-clinical and clinical year students' experiences relating to these four constructs.

METHODS

The authors conducted focus groups of medical students in Singapore across 4 years using a semi-structured question guide. Participants shared their understanding, experiences, and the relationships between stress, burnout, coping, and resilience. Coders independently evaluated construct definitions and derived common themes through an iterative process, and compared transcripts of pre-clinical and clinical year students to determine differences in experience over time.

RESULTS

Nine focus groups (54 students, 28 females, mean age 24.3) were conducted. Students identified common definitions for each construct. Nine themes emerged within three domains: (1) relating constructs to personal experience, (2) interrelating stress, burnout, coping, and resilience, and (3) understanding the necessity of stress. Compared to clinical students, pre-clinical students reported theory-based rather than reality-based experiences and exam-induced stress, defined constructs using present rather than future situations, and described constructs as independent rather than interrelated.

CONCLUSIONS

This sample of medical students in Singapore shares a common understanding of stress, burnout, coping, and resilience, but experiences these uniquely. They perceive a positive role for stress. These findings build upon prior literature, suggesting an interrelationship between stress and its related constructs and adding the novel perspective of students from an Asian country.

A spoonful of care ethics: The challenges of enriching medical education

BACKGROUND

Nursing Ethics has featured several discussions on what good care comprises and how to achieve good care practices. We should "nurse" ethics by continuously reflecting on the way we "do" ethics, which is what care ethicists have been doing over the past few decades and continue to do so. Ethics is not limited to nursing but extends to all caring professions. In 2011, Elin Martinsen argued in this journal that care should be included as a core concept in medical ethical terminology because of "the harm to which patients may be exposed owing to a lack of care in the clinical encounter," specifically between doctors and patients. However, Martinsen leaves the didactical challenges arising from such a venture open for further enquiry.

OBJECTIVES

In this article, we explore the challenges arising from implementing care-ethical insights into medical education.

RESEARCH DESIGN

Medical education in the Netherlands is investigated through a "care-ethical lens". This means exploring the possibility of enriching medical education with care-ethical insights, while at the same time discovering possible challenges emerging from such an undertaking.

PARTICIPANTS AND RESEARCH CONTEXT

This paper has been written from the academic context of a master in care ethics and policy.

ETHICAL CONSIDERATIONS

We have tried to be fair and respectful to the authors discussed and take a neutral stance towards the findings portrayed.

FINDINGS

Several challenges are identified, which we narrow down to two types: didactical and non-didactical.

DISCUSSION AND CONCLUSION

In order to overcome these challenges, we must not underestimate the possible resistance to a paradigm shift. Our efforts should mainly target the learning that takes place in the clinical phases of medical training and should be accompanied by the creation of awareness in healthcare practice.

Measurement invariance of the Depression Anxiety Stress Scales-21 across medical student genders

OBJECTIVES

This study aimed to assess whether male and female Iranian medical students perceived the meaning of the items in the Depression Anxiety Stress Scales-21 consistently.

METHODS

A convenience sample of 783 preclinical medical students from the first to sixth semester was invited to this cross-sectional study. Of the 477 respondents, 238 were male and 239 were female. All participants completed the Persian version of the Depression Anxiety Stress Scales-21. The graded response model was used to assess measurement invariance of the instrument across the gender groups. Categorical confirmatory factor analysis was used to evaluate the construct validity of the measure. Moreover, internal consistency was assessed via Cronbach's Alpha.

RESULTS

Statistically significant differential item functioning was flagged for just item 6 in the depression subscales (c²=6.5, df=1, p=0.011). However, removing or retaining the item 6 in the stress subscale did not change our findings significantly, when we compared stress scores across two genders. The results of categorical confirmatory factor analysis supported the fit of the three-factor model of Depression Anxiety Stress Scales-21. Moreover, Cronbach's alpha was greater than 0.7 in depression, anxiety and stress subscales.

CONCLUSIONS

This study revealed that Depression Anxiety Stress Scales-21 is an invariant measure across male and female medical students. Hence, this reliable and valid instrument can be used for meaningful comparison of distress scores between medical student genders. Gender comparisons of medical students' psychological profiles provide a better insight into gender influences on the outcome of medical education and medical practice.

Comparative effectiveness of a serious game and an e-module to support patient safety knowledge and awareness

BACKGROUND

Serious games have the potential to teach complex cognitive skills in an engaging way, at relatively low costs. Their flexibility in use and scalability makes them an attractive learning tool, but more research is needed on the effectiveness of serious games compared to more traditional formats such e-modules. We investigated whether undergraduate medical students developed better knowledge and awareness and were more motivated after learning about patient-safety through a serious game than peers who studied the same topics using an e-module.

METHODS

Fourth-year medical students were randomly assigned to either a serious game that included video-lectures, biofeedback exercises and patient missions (n = 32) or an e-module, that included text-based lectures on the same topics (n = 34). A third group acted as a historical control-group without extra education (n = 37). After the intervention, which took place during the clinical introduction course, before the start of the first rotation, all students completed a knowledge test, a self-efficacy test and a motivation questionnaire. During the following 10-week clinical rotation they filled out weekly questionnaires on patient-safety awareness and stress.

RESULTS

The results showed patient safety knowledge had equally improved in the game group and e-module group compared to controls, who received no extra education. Average learning-time was 3 h for the game and 1 h for the e-module-group. The serious game was evaluated as more engaging; the e-module as more easy to use. During rotations, students in the three groups reported low and similar levels of patient-safety awareness and stress. Students who had treated patients successfully during game missions experienced higher self-efficacy and less stress during their rotation than students who treated patients unsuccessfully.

CONCLUSIONS

Video-lectures (in a game) and text-based lectures (in an e-module) can be equally effective in developing knowledge on specific topics. Although serious games are strongly engaging for students and stimulate them to study longer, they do not necessarily result in better performance in patient safety issues.

The Toxicity of Self-Blame: Sex Differences in Burnout and Coping in Internal Medicine Trainees

BACKGROUND

Burnout is a significant problem facing internal medicine residents contributing to increased risk of depression and suicidal ideation. Coping mechanisms and burnout may differ based on sex.

METHODS

The study was a retrospective cross-sectional study of reported burnout and coping mechanisms used by internal medicine residents in June 2014 at a large academic center and its community affiliate. Two hundred eighty-five postgraduate year (PGY)-1, 2, 3, and 4 and incoming PGY-1 residents were surveyed. The Maslach Burnout Inventory-General Survey and Brief Coping Orientation to Problems Experienced were given to measure levels of burnout and frequency of use of coping mechanisms. Percentages of residents who met criteria for burnout and high levels on each of the subscales of emotional exhaustion, cynicism and professional efficacy, were calculated and stratified by sex. Chi-squared tests were used for statistical significance. Average frequency of use of each coping mechanism by sex was calculated with statistical significance determined by two sided t-tests.

RESULTS

There was a 69% completion rate (198/285) with 100 men and 98 women. Woman had higher levels of burnout (30% vs. 15%, p = 0.014) and emotional exhaustion (22% vs. 9%, p = 0.005). Women used the adaptive coping mechanisms of emotional support (p = 0.001) and instrumental support (p = 0.018) more frequently but also used the maladaptive coping mechanism of self-blame more frequently (p = 0.022).

CONCLUSIONS

Greater use of self-blame as a coping mechanism may be a major factor in the higher rates of burnout and emotional exhaustion in women resident physicians as compared to men. Educators must pay attention to use of self-blame by female residents and as it may be a red flag for resident distress.

At the Razor's Edge: Surgeons have Lower Stress Levels than the General Population

Objective

To evaluate the stress level in physicians of different levels of formation and to compare it between different medical specialties and the general population.

Methods

This was a cross-sectional study, using a questionnaire validated in Brazil in 2010, the Perceived Stress Scale (PSS-10).

Results

The stress level was higher among surgical doctors in comparison with clinical doctors, regardless of the stage of formation. There was a difference between the sex of the professionals, men showing lower results. None of these was statistically significant. Comparing to the American population or South Brazilian teachers, the medical preceptors presented a significant lower level of stress.

Conclusion

The medical specialty as well as gender and level of medical formation influence in the professional stress level, being elevated in fields of higher working hours and constant pressure.

Descriptors

Stress, surgery, residents, medical students.

How to cite this article

Abreu-Reis P, Nasr A, Tomasich FS, Collaco IA, Bassani T, Clivatti GM, Fontanella AP, Ito JM, Manfrinato MFM, Hammerschmidt I. At the Razor's Edge: Surgeons have Lower Stress Levels than the General Population. Panam J Trauma Crit Care Emerg Surg 2016;5(1):26-30.

Standing out and moving up: performance appraisal of cultural minority physicians

Despite a growing diversity within society and health care, there seems to be a discrepancy between the number of cultural minority physicians graduating and those in training for specialization (residents) or working as a specialist in Dutch academic hospitals. The purpose of this article is to explore how performance appraisal in daily medical practice is experienced and might affect the influx of cultural minority physicians into specialty training. A critical diversity study was completed in one academic hospital using interviews (N = 27) and focus groups (15 participants) with cultural minority physicians and residents, instructing specialists and executives of medical wards. Data were digitally recorded and transcribed verbatim. A thematic and integral content analysis was performed. In addition to explicit norms on high motivation and excellent performance, implicit norms on professionalism are considered crucial in qualifying for specialty training. Stereotyped imaging on the culture and identity of cultural minority physicians and categorical thinking on diversity seem to underlie daily processes of evaluation and performance appraisal. These are experienced as inhibiting the possibilities to successfully profile for selection into residency and specialist positions. Implicit criteria appear to affect selection processes on medical wards and possibly hinder the influx of cultural minority physicians into residency and making academic hospitals more diverse. Minority and majority physicians, together with the hospital management and medical education should target inclusive norms and practices within clinical practice.

Perceived Stress and Coffee and Energy Drink Consumption Predict Poor Sleep Quality in Podiatric Medical Students A Cross-sectional Study

BACKGROUND

A cross-sectional survey administered to first- and second-year podiatric medical students aimed to investigate the effect of coffee intake, energy drink consumption, and perceived stress on sleep quality in medical students during their preclinical studies.

METHODS

Ninety-eight of 183 students contacted (53.6%) completed a questionnaire comprising standard instruments measuring sleep quality (Pittsburgh Sleep Quality Index), daytime sleepiness (Epworth Sleepiness scale), and perceived stress (ten-item Perceived Stress Scale). Furthermore, we investigated coffee and energy drink consumption. Logistic regression was conducted to identify factors associated with poor sleep quality and the relation between sleep quality and academic performance (grade point average).

RESULTS

High prevalences of poor sleep quality, excessive daytime sleepiness, and perceived stress were reported. In addition, higher odds of developing poor sleep quality were associated with coffee and energy drink intake, perceived stress, and excessive daytime sleepiness. The total Pittsburgh Sleep Quality Index score was inversely correlated with grade point average.

CONCLUSIONS

First- and second-year podiatric medical students have poor sleep quality. Further research is needed to identify effective strategies to reduce stress and decrease coffee and energy drink intake to minimize their negative effect on sleep quality and academic performance in podiatric medical students.

[Operation of a school adaptation program considering the interpersonal needs of medical freshmen]

PURPOSE

We examined two overarching topics: What are the Fundamental Interpersonal Relations Orientation-Behavior (FIRO-B), Perceived Stress Scale (PSS), and Self-rating Depression Scale (SDS) scores in medical students? Do their interpersonal needs correlate with stress and depression?

METHODS

FIRO-B, PSS-10, and SDS were administered to 82 freshmen in College of Medicine, The Catholic University of Korea in 2014. The data were analyzed by descriptive statistics, frequency, two-way analysis of variance, independent t-test, and Pearson correlation analysis using SPSS version 21.0 (IBM Corp.).

RESULTS

The level of interpersonal needs was medium range (mean, 24.52). The mean perceived stress score was 18.6. Also, 59.8% and 40.2% of students had normal range (<20) and high stress (≥20). The mean score for depression was 36.3. Further, 97.6% and 2.4% of students had normal range (≤49) and mild depression (≤59). Wanted behavior correlated with stress (r=0.056) and depression (r=0.021). Expressed behavior correlated negatively with stress (r=-0.206) and depression (r=-0.301).

CONCLUSION

The interpersonal needs of medical freshmen are related to stress and depression. These results can be used effectively in school adaptation programs for medical students to improve their quality of life.

Managing the complexity of doing it all: an exploratory study on students' experiences when trained stepwise in conducting consultations

BACKGROUND

At most medical schools the components required to conduct a consultation, medical knowledge, communication, clinical reasoning and physical examination skills, are trained separately. Afterwards, all the knowledge and skills students acquired must be integrated into complete consultations, an art that lies at the heart of the medical profession. Inevitably, students experience conducting consultations as complex and challenging. Literature emphasizes the importance of three didactic course principles: moving from partial tasks to whole task learning, diminishing supervisors' support and gradually increasing students' responsibility. This study explores students' experiences of an integrated consultation course using these three didactic principles to support them in this difficult task.

METHODS

Six focus groups were conducted with 20 pre-clerkship and 19 clerkship students in total. Discussions were audiotaped, transcribed and analysed by Nvivo using the constant comparative strategy within a thematic analysis.

RESULTS

Conducting complete consultations motivated students in their learning process as future physician. Initially, students were very much focused on medical problem solving. Completing the whole task of a consultation obligated them to transfer their theoretical medical knowledge into applicable clinical knowledge on the spot. Furthermore, diminishing the support of a supervisor triggered students to reflect on their own actions but contrasted with their increased appreciation of critical feedback. Increasing students' responsibility stimulated their active learning but made some students feel overloaded. These students were anxious to miss patient information or not being able to take the right decisions or to answer patients' questions, which sometimes resulted in evasive coping techniques, such as talking faster to prevent the patient asking questions.

CONCLUSION

The complex task of conducting complete consultations should be implemented early within medical curricula because students need time to organize their medical knowledge into applicable clinical knowledge. An integrated consultation course should comprise a step-by-step teaching strategy with a variety of supervisors' feedback modi, adapted to students' competence. Finally, students should be guided in formulating achievable standards to prevent them from feeling overloaded in practicing complete consultations with simulated or real patients.