Stress in medical students

Stress in medical students is concerned with the levels of stress and its effects on those in strenuous medical programs. Stress in medical students has been recognized because it has many causes and consequences that affect the physical and psychological well-being of medical students. Excessive amounts of stress in medical training predisposes students to have difficulties in solving interpersonal conflicts, consequences in the physical aspects making weak the form of study. A significant percentage of medical students suffer anxiety disorder because stress has a strong relationship to emotional and behavioral symptomatology. Stress in medical students becomes a focus of concern nationally and globally, so the first line of detection and defense of the stress are the students. Students need to be given the tools to recognize and cope with stress, as well as being assured that they will not suffer judgement from others for recognizing their need for help in dealing with the stress. The instructors, advisers and other faculty members who notice the signs of stress in a particular student need to have a non-threatening, non-judgmental way to help medical students recognize and handle their stress.

Causes

Stress is defined as an imbalance between environmental conditions necessary for survival and the ability of individuals to adapt to those conditions. Stress in medical students has been recognized for a long time, many studies have explored the causes, consequences and solutions. There are three issues considered the most important for the development of stress in medical students. First is the fact that they have to learn a lot of new information in a short time. Second is when they have exams (evaluation period), and the last one is that they have little or no time to review what they learn.

Medical students are overloaded with a tremendous amount of information. They have a limited amount of time to memorize all the information studied. The overload of information creates a feeling of disappointment because the students do not handle all information and therefore are not successful during the examination period. Many medical students struggle with their own capacity to meet the demands of medical curriculum.

Stress responds to different situations at different levels of consciousness, psychological stress, and physiological stress. Those points of stress can be interrelated each other, and be at different levels. The most stressful period that medical students have is when they need to bridge the gap between graduation from medical school and being board eligible in a medical specialty. The Resident Service Committee of the Association of Program Directors in Internal Medicine (APDIM) divided the common stressors of residency into three categories: situational, personal, and professional.

Situational stressors include inordinate hours, sleep deprivation, excessive workload, overbearing clerical and administrative responsibilities, inadequate support from allied health professionals, too many difficult patients, and conditions for learning that are less than optimal. Second year students have other stress situations because they start to interact with the patients. This interaction includes moments when the medical students face their patients with bad news.

Personal stressors include family, who may be a source of support, but can also be a source of conflict and negative stress. Financial issues, as many residents carry heavy educational debts, and many feel compelled to moonlight in order to repay their debts. Isolation is frequently exacerbated by relocation away from family and friends. Other stressors include: limited free time to relax or develop new support systems; psychosocial concerns, brought on by the stress of residency; and inadequate coping skills. Professional stressors include responsibility for patient care, supervision of more junior residents and students, difficult patients, information overload and career planning.

Effects

Excessive amount of stress in medical training predisposes students to have difficulties in solving interpersonal conflicts, sleeping disorders, decreased attention, reduced concentration, temptation to cheat on exams, depression, loss of objectivity, increased incidence of errors, and improper behavior, such as negligence. Furthermore, stress in medical students can break the stability (homeostasis) and move from being healthy to being sick. This can cause headaches, gastrointestinal disorders, coronary heart disease, impaired judgments, absenteeism, self-medication, and the consumption of drugs and alcohol.

The students make an effort to counteract the impact of stressful situations with various coping skills. The coping includes both cognitive and behavioral efforts against the problem of the stress during examinations. Medical students who fail to manage their stress levels have a prevalence to be less competent in their work. Students do not manage the time limits of examinations well and lack time for exercise and social interactions because those two points are more stressors that the perceived discrimination on the course or the death of patients.

Physical effects

Stress levels have strong relationship with physical condition. Medical students during an examination period can experience insomnia, fatigue and nausea. Moreover, metabolism is disturbed by diarrhea or with constipation. Skin diseases are common during the examination period, which include acne, dermatitis or psoriasis. Last symptoms are provoked by long working hours and tension of completing in good terms the courses.

Medical students have been known to consume beverages to be active and alert during time of studying. This students drink large quantities of coffee, tea, Coke, and energy drinks. However, increased caffeine increases the levels of adenosine, adrenaline, cortisol and dopamine in blood. Caffeine inhibits the absorption of some nutrients, increasing the acidity of the gastrointestinal tract, and it increases the loss of calcium, magnesium, iron and many trace minerals by the urinary excretion. Furthermore, caffeine decreases blood flow to the brain by as much as 30% and it decreases stimulation of insulin to control the sugar in blood.

Stress can cause high levels of the following hormones: cortisol, epinephrine and norepinephrine, leptin, NPY, nitrite, ACTH and adrenomedullin. In the blood, elevated level of adenosine, adrenaline, cortisol and dopamine can produce fatigue, depression, behavior changes, heart disease, weight problems, diabetes and skin diseases, It also decreases the immune response, can can lead to heartburn and stomach ulcers.

Hormones of menstrual cycles (FSH and LH) during the examination periods are affected. Females can be disturbed in menstrual cycle because the FSH and LH normal levels changes radically. However, medical students have disturbed sleep cycle in these periods.

Psychological effects

Although optimal level of stress is considered good because medical students develop coping abilities. However too much stress causes problems, so previous studies have reported that a significant percentage of medical students suffering anxiety disorder because stress has a strong relationship, to emotional and behavioral symptomatology. Feelings of disappointment academically are most prevalent in those students who have a poor academic performance.

The major emotional disorders that have been observed include the inability to feel reasonably happy, loss sleep, over-worry, constantly under strain, feeling unhappy and depressed, inability to concentrate, inability to enjoy normal activities, losing confidence in one’s self, inability to overcome difficulties, inability to face up to problems, inability to make decisions, inability to play a useful part in things and thinking of own self as worthless.

Female medical students respond to the stress with stronger manifestations of anxiety, physiologically stress is related in metabolic changes, and psychological changes including and behavioural.

Stress may also harm professional effectiveness. It decreases attention, reduces concentration, impinges on decision-making skills and reduces abilities to establish strong physician–patient relationships. Medical students have noted in themselves changes their behavior. Irritability and depression are common in students in later semesters, and those mental disturbances increase when examination start.

Treatment

As too much stress causes problems, it is important to evaluate the degree of stress a student may have. Today there are methods to assess the levels of emotional stress that medical students handle. It is advisable to manage study time and include a health nutrition during all the day if it is possible. Intervention against dishonesty such as copying, prevents the risk of stress and depression in medical students.

Communication among young medical students prepares them for the stressors of real-life clinical practice. This mental preparation stimulates the students to reduce the percentages of error in a medical consult. Medical students are prepared to know the diagnosis and the treatment, but may not be successfully prepared to interact with the problems of the patient in front of them or with bad news consultation and dealing patient emotion stress. It is not common to see students praying during exams, which can lesson stress.

Emotional intelligence (EI) can be a protection against the effects of psychological stress and it may enhance well-being. However, EI is molded through personality and has not been observed that it is affected by stress situation. However, those students who are in extra-curricular activities have lower states of anxiety than those who are only concentrated in studies. To address these problems, medical schools have made change such as reducing the workweek, instituting curricular reforms (for example: shorter classes), less rote memorization and providing psychological services.

Stress in medical students has become a focus of concern globally, with the first line of detection and defense of the stress being the students themselves. Some interventions include compulsory attendance in support groups, so the level of stigma is much lower than that associated with attending individual therapy. This provides long-term continuous support and help for students to monitor the progress and preparation for a better practice.

Other stress-management programs provides trainees with coping techniques, such hypnosis, imagery and muscle relaxation, affiliation with peers and opportunities for emotional expression and intensified relationships with faculty.

The interventions of the majority of the programs use a group structure where trainees met with peers or with leaders. No ‘‘gold standard’’ exists for the content of stress-reduction programs for medical trainees. Some proposes a scheme of directed and non-directed support groups, relaxation training (including meditation and hypnosis), time-management and coping skills, mindfulness-based stress reduction, and mentoring programs. Good intervention includes relaxation basics like abdominal breathing, learning to identify and counter negative thoughts, use of the imagery in relaxation, practical ways to increase healthy eating, building positive coping, apply relaxing or activating words appropriately and re-direct time and energy based on level of importance.