Stress is a widely accepted phenomenon in the medical
profession and medical training (1,2).
Stress has been defined as the “perceived imbalance between the demands encountered in daily living and
a person’s capability to respond” (3-5).
Stress in medical students occurs when an imbalance exists between the demands
of medical curriculum and the students’ capability to deal with them (6). Medical students experience higher stress
than both the general population and students in other fields (7). This increased stress has been attributed to
exhaustion due to high curricular workloads, tight time schedules, hierarchical
structures in the field and enormous emotional pressure, such as during contact
with suffering and dying patients (8).
Prolonged perceived stress
not only can have negative effects on cognitive functioning and learning of
but is a risk factor for psychiatric disorders and may be a predictor of later mental
health problems (10). Studies assessing the consequence of prolonged
exposure to stress in medical students have found that medical students are at increased
risk of anxiety, depression, burnout and personal distress due to the
detrimental effects to personal wellness the demands of medical school cause (11,12).
A 2005 systematic review of psychological
distress among Canadian and U.S. medical students found an increased prevalence
of psychological distress, depression and
anxiety compared not only to the general population, but also age matched to
doctors later in training, suggesting that medical school is perhaps the most
stress-intensive time in a physician’s career (13). It also demonstrated an association
between distress and
decline in academic performance (13). A recent systematic review by Hope
and Henderson suggests that an increase in psychological distress, depression
and anxiety in medical students also exists in Europe (14).
Whereas multiple studies have been performed assessing
perceived stress in medical students, very few studies have focused on
international medical students. The few studies performed to date have focused
on students with a language barrier as an added stressor, but did not
specifically compare the perceived stress of international students to those
from the country where the students attend Medical School (15,16).
In recent years an increasing number of Canadians have
chosen to study Medicine at Irish Medical schools; the
majority of students citing
the reason as the inability to obtain a placement in a Canadian medical school
(17). The most recent data from 2010 found
approximately 650 Canadians studying at Irish Medical Schools (18).
While the number of Canadians at Irish Medical Schools has been increasing, the
population has not been well studied to date. One 2013 study found no
difference in knowledge acquisition in Irish vs. international medical
students, however no other parameters were compared (19). While Canadians studying medicine
abroad face the same stressors as the typical medical student, there are added
challenges such as being removed from a family support system, adjusting to a
new culture/country, and facing the pressure of obtaining a residency back in
Canada with only 23.6% Medical Students from Ireland successfully obtaining a
residency match in Canada in 2017 (20). These added stressors may increase the
perceived stress in this population.
The aim of
this study is to examine the level of perceived stress in Canadian students
studying at an Irish Medical School and compare this level to that of Irish
hypothesized that the rate of perceived stress will be higher in Canadian
students than in Irish medical students.
This study is
of importance as prolonged increased stress is a predictor for mental health
disorders (10). Thus, if stress in Canadian
medical students is increased, as hypothesized here, this finding would help to
increase awareness and may lead to recommendations of developing support
programs for this population. Interventions may be most crucial in certain
stages, thus students in all years of study will be surveyed.
1.0 Research Design
This study with
will be a cross-sectional study of perceived stress in both Irish
and Canadian medical students at the University College Cork (UCC). Although a
longitudinal study following students from first through final years may be of
greater impact, this study design will allow for completion within a reasonable
amount of time (which is predicted to increase response rate from medical
students, who do not have a plethora of time) with limited resources. Sampling
across different years will allow for some temporal element to be assessed. Cases will
not be matched. FR1
(some sources noting higher stress in females (22)) and year of study will be captured as potential
confounding factors in the questionnaire and will be controlled for in data
3.0 Study population and sampling
proposes use of cluster sampling; this study assumes that the Canadian medical
student population in Cork is similar to that of other parts of Ireland.
In- and exclusion criteria:
Inclusion criteria apply for the proposed study. Participants must:
a UCC medical student in the graduate entry program, with a valid UCC student
number and email
have Canadian citizenship AND have lived in Canada for at least 6 out of 10
years in the last decade OR have Irish citizenship AND have lived in Ireland
for the past 6 out of 10 years at least 6 out of 10 years in the last decade.
criteria will be applied.
Sample size considerations:
study comparing stress levels as per Perceived Medical School Stress (PMSS)
scale has been done in Sweden (23). A response rate of 90.4% of the 342
students approached was reported (23).
Here, 3 groups of students of different years of study (n=95-113) were
surveyed and significant results obtained. However, other studies on stress in
medical students with sample sizes as low as 60 have obtained significant
results (21) Around 300 students are currently enrolled in the graduate entry
program at UCC, with almost half being Canadian. Assuming a similar response
rate, a response from 270 students may be obtainable. This study will aim at a
sample size of 160, 80 Canadian and 80 Irish students.
4.0 Data collection methods and instruments
The Perceived Medical School
Stress (PMSS) scale, as first described by Vitaliano et al. (24), will
be used to quantify the degree to which a student is experiencing stress. This 13-item
questionnaire has been validated, is a frequently used measure of stress in medical
school and is a predictor of mental health problems upon graduation (10). A
recent systematic review has called for the PMSS to be the standard for future
studies on stress in medical students (25).
pamphlets will be distributed to students in lecture halls and an announcement
regarding the study will be made in classes prior to pamphlet distribution.
this, the UCC medical student data base will be emailed with information about
the study, as well as the link to the web questionnaire and consent form (see
Appendix A+B). Prior to starting the survey, the consent form will need to be
completed. Two email reminders will be send out and date of completion will be
noted. Student participation will be incentivized via entering every student
into a draw for a €40 voucher to a place of their choosing.
4.1 Data entry: Information gathered from the web questionnaire will be
transferred into SPSS for statistical analysis.
5.0 Data analysis
stress level differences between Irish and Canadian medical students will be
compared. Data from the PMSS will be scored. This study will test for normal
distribution of stress in medical students using a Kolmogorov-Smirnov test. If
normal distribution is confirmed, the mean PMSS score between Irish and
Canadian medical students will be compared using a student- t- test. If not
confirmed, a Mann-Whitney U test will be done.
A multivariate analysis using logistic regression will be done, looking
at impact of gender, year of study and age. A statistician will be consulted.
6.0 Mechanisms to assure the quality of the study
collection will be standardized as everyone will receive the same survey via email
at the same time. Response rate may be an issue and will be incentivized with
entry into a draw for a €40 voucher upon completion of the survey. The survey
also is short and can be completed within 5 minutes which is most conducive to
the lifestyle of a medical student.
Limitations: Only one medical school is surveyed
here. Results may not be generalizable to all medical schools depending on the
composition of their population and their specific curriculum. This study is reliant
on a questionnaire, which may be preferentially filled out by students with
lower stress; stressed individuals are less likely to take time to participate.
To minimize this a short questionnaire is used.
7.0 Study Timetable
8.0 Ethical considerations
Ethical approval will be obtained from the Clinical Research Ethics
Committee prior to undertaking of the survey. Consent will be gathered from all
participants. Risk and Benefits are outlined here. Data will be linked to a UCC
student number for the purpose of preventing multiple entries of one person and
to allow the winner of the draw to be contacted. Following this, all data will
be de-identified and personal identifiers will not be used in the analysis,
presentation and publication of the data.
containing identifiers will be kept on password protected computers in password
protected files. All individuals are made aware of being able to withdraw from
the study at any time. There are no conflicts of interest to declare.
9.0 Resources required
€20- cost of
the above there are no other foreseeable costs associated.
do you deal with the fact that there are much more Irish than Canadian
students? How do you deal with students from other countries?