Stress and coping in postgraduate medical students: An observational study from a tertiary care centre

INTRODUCTION

Stress is a psychological state that occurs as a result of an individual’s encounter with their surroundings, which is considered detrimental to their well-being.¹ Medical school is said to be one of the most stressful academic programmes in the world, adversely affecting medical students’ physical and mental health.² Some of the factors that have been linked to stress among undergraduate medical students include examination anxiety, high parental expectations, peer pressure, a lack of free time, financial difficulties, relationship strife, and desires for higher education.² Global literature reports a wide variations in the prevalence of stress (27%–97%).^3–9 This variation can be attributed to the tools used to assess stress or to the different institutional and socioeconomic backgrounds of participants.

Postgraduate medical students have to learn to balance multiple professional and personal responsibilities.^10–12 Excessive stress can have a detrimental impact on their physical, emotional, and mental well-being. This, in turn, can affect their academic performance, as well as their development.

The effects of stress are mediated by one’s coping skills. Coping is a conscious effort to deal with the stress and refers to the thoughts and actions taken to handle stress. Coping strategies can be adaptive or constructive. Maladaptive or dysfunctional coping styles, however, can worsen stress.¹³ Though there might not be much difference in curriculum across medical schools in various countries but the environment of the college, teaching–learning pedagogy, authoritarian and rigid system encouraging competition rather than cooperation between learners, and lesser educational facilities and recreation opportunities could be some of the reasons that Indian postgraduate students experience stress. We aimed to assess the level of stress in postgraduate students, its sources, and to evaluate their coping styles.

METHODS

Our study was done at the Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, after obtaining ethical approval from the Institutional Ethics Committee (BREC/22/61 dated 05.07.2022). All postgraduate students with a minimum of 6 months of residency experience in any specialty constituted the study sample. The study was conducted online using a predesigned, pretested questionnaire (including an informed consent form) as a Google Form. A link was sent via email to the participants. The questionnaire covered their basic demographic details and the tools detailed below were administered. Data were collected over 2 months from February to March 2023.

RESULTS

Of 456 students from 22 different specialties approached for the study, 384 (84%) responded. The mean (SD) age of the participants was 28.2 (3.3) years, age range of 23–44 years, and 53% were females (Table 1).

All students reported some degree of stress. Students with a mean domain score above 1—i.e. those that reported scores reflecting moderate, high, and severe stress—were considered to be under stress. Thirty-one per cent were found to have severe stress. The frequency of students found to be stressed in each domain is presented in Table 2. The majority of the students (79%) considered academic related stressors to be the source of high stress which was followed by inter- and intra-personal related stressors (75%), group activity related stressors (72%), teaching and learning related stressors (69%), social related stressors (63%) and drive and desire related stressors (52%).

Female students reported statistically significantly higher stress levels than males in almost all domains. However, there was no gender difference when comparing for coping strategies used (Table 3).

Students in the age group 23–30 years reported higher levels of stress in all domains on MSSQ40, and this difference was statistically significant for academic, intra- and inter-personal, and teaching learning domains. This group also used more avoidant coping styles as compared to the other 2 age groups (Table 4).

When compared for clinical and non-clinical specialties, there was no significant difference in the stress level between the 2 groups. No difference was found across any other variable, including living arrangements, year of residency, and marital status.

Table 5 shows the correlation between stress, various socio-demographic variables and coping styles used by the participants. Raw scores of MSSQ and Brief COPE were considered to gauge the correlation. Being female was positively correlated with all the domains of stress except drive desire, while age was negatively correlated with all domains of stress except drive desire. The stress was lower in older students. However, this difference was statistically significant only for academic stress (p<0.01) and intra- and interpersonal teaching, and learning stress (p<0.05). Relationship status had only one significant negative correlation—being married increased academic stress. Year of residency also showed a negative correlation with all domains of stress, meaning that the level of stress diminished as the students progressed in their residency programme. Positive correlation of the presence of mental illness with all the domains of stress signifies the increased vulnerability to stress of students who have mental illness.

None of the sociodemographic variables showed any correlation with coping styles. However, all 6 domains of stress showed statistically significant positive correlation with all 3 coping styles, though the students used more emotion-focused and avoidant coping than problem-focused.

DISCUSSION

Medical education is considered one of the most stressful professional courses. This is reflected by high rates of stress among medical students. ^1,4,5 Most studies in this context have assessed stress among undergraduate medical students. Stress in postgraduate medical students has not been well explored. We not only explored the different perceptions of ‘stress’ amongst the postgraduate medical students, but also looked into various coping strategies adopted by them to deal with the perceived stress. We found that almost all the students reported some stress. The findings are similar to findings from the other medical colleges in India.^10,12,16 Academic stressors were considered as the major source of stress in our study and this is in concurrence with reports by other investigators.^10,12,17,18 The vastness of the medical syllabus as well as irregular study timings due to extensive duty hours, sudden and uncertain work demands can be the reasons for academic causes being the major stressor. Stress related to the teaching and learning domain (lack of supervision and teaching, poor quality or absent feedback and support by teachers, unclear learning objectives) can further add to academic stress.

Female students were found to be more stressed than their male counterparts in almost all domains of stress. Similar findings have been reported by previous studies.^16,18–20 However, Datar et al.¹² and Dyson and Renk²¹ reported no gender differences. Tariq et al.²² on the other hand, reported higher levels of stress in male postgraduate medical students than females. Our study also showed a higher stress level in the younger compared to the older age groups. This difference was statistically significant. Similar findings were shown by many investigators.^10,23,24 Higher levels of stress in the younger age group may be due to a new level of responsibility, increased workload, in addition to education and patient care activities, to which older students adapt and learn to cope better.

Although not significant, our study revealed a difference in stress levels between students from clinical and non-clinical specialties. Similar findings have been reported by Ramya et al.¹ and Shete and Garkal.¹⁰ It may be due to extended duty hours, increased workload, and dealing with patient-related issues such as trauma and death. However, Datar et al.¹² reported no difference in perceived stress between these groups.

Being married increased the academic stress in our study participants possibly since family life adds to the demands on time that is already low. Further, students with psychiatric illnesses had statistically significantly higher stress scores in almost all domains than those without illness, but this correlation was not evident with physical illness. To the best of our knowledge, no previous study has looked at this aspect, though studies have reported significantly higher stress scores in students with physical illnesses.^12,25–27 Presence of psychiatric illness can predispose people to stress as well as impact the appraisal of stress.

When compared for employment of coping strategies, our study did not find any gender difference, as has also been reported by Datar et al.¹² However, many studies have reported that male students used significantly more dysfunctional coping strategies than female students.^12,28 Similarly, there was no statistically significant association of coping strategies with any other sociodemographic variables. This is in consensus with other studies.^12,16,24 However, all 6 domains of stress showed significant positive correlation with all 3 coping styles, though the students used more emotion-focused and avoidant coping than problem-focused. Previous studies report similar findings that use of dysfunctional coping strategies, such as anger coping, distraction, and avoidance, lead to high levels of perceived stress.^12,16,29 This finding is contrary to the study by Eisenbarth et al.³⁰ which concludes that emotion focused strategies lead to high level of appraised stress and negative effect, whereas use of problem focused strategies have low level of appraised stress.

These findings suggest a need to review the current work and academic schedules of postgraduate students as well as the involvement of teachers. Support in the form of structured feedback and mentoring can help control stress. Regular stress management programmes for the postgraduate medical students with emphasis on inculcating healthy emotion-focused coping strategies may help enhance their physical and psychological well-being and improve productivity. It is important to note that many studies have reported stress in undergraduate students and it may be worthwhile to assess whether these students carry this stress further into their postgraduate career.

Our study has the strengths of a large sample size, the inclusion of both genders, and the representation of all possible specialties. However, it has some limitations. Our results cannot be generalized to other medical institutes in the country. Since a self-administered questionnaires were used, response bias cannot be ruled out. To the best of our knowledge, MSSQ40 has not been previously used in postgraduate students. Our study was cross-sectional; therefore, the findings cannot be generalized over time. Although we conducted the study at a time when there were no imminent examinations, the levels of stress may still fluctuate, e.g. becoming even higher due to various other reasons, such as thesis-related issues. Personality factors, which influence stress appraisal and coping, were not assessed. However, an insight into coping strategies and screening for stress and psychiatric morbidity in medical residents can be valuable in developing stress management programmes for them.