Unseen struggles in the white coat: predictors of stress among postgraduate medical students in India

INTRODUCTION

Stress is a state of an individual that results from the interaction with the surrounding environment that is perceived as threatening to the wellbeing. It is an external constraint which directly upsets the individual both mentally and physically.¹

Medical education promises a well-respected career, but brings along a lot of tough demands on aspiring students which includes tight schedules and a vast course compacted in a short duration. This leads to an unenviable state of stress and anxiety among a lot of students.

A physically and emotionally demanding course can inadvertently lead to physical and psychological problems in students. Besides academic stressors, some students also face physical, social, emotional, and family problems which may affect their learning abilities and academic performance. Prevalence of perceived stress was slightly higher (88.9%) among medical students than among nonmedical students (83.5%).²

Student’s lifestyles play an important part in their wellbeing and ability to cope. Both constructive as well as harmful coping strategies are employed by the students. Spending time with friends, indulging in sports, music and social media are some of the common constructive coping strategies employed. The use of alcohol, cannabis and illicit drugs is reported to be on the increase among medical students which are negative coping strategies employed by them. Lifestyle changes like diminished leisure and recreational activity decreased physical activity and sleep deprivation has an impact on the emotional well-being of the medical student.³

The postgraduate junior residents play a crucial role in the medical care delivery of the multispecialty hospitals attached to the teaching medical colleges. Residents are often invariably assigned duties lasting for more than the prescribed 8 duty hours per day, which may impact the resident’s quality of life and cause them to experience sleep disorders, family problems, and even psychiatric disorders. These stress symptoms may in turn negatively impact patient care and result in frequent medical errors and suboptimal care practices. Combined with other factors such as poor coordination between seniors and juniors, financial constraints and academic pressure faced at the workplace often affects their mental health and also has a profound impact while dealing with patients.

Few studies have assessed the perception of stress and its effect on mental health among students, and still fewer have been done on medical students, post graduate medical students are a further smaller niche. Taking into consideration of above factor this study was undertaken to assess the level of perceived stress and associated risk factors among postgraduate medical students.

METHODS

This cross-sectional study was done from November 2019 to March 2020 among post graduate medical students enrolled in degree courses of all branches (MD/MS). Sample size was calculated by stress prevalence rate of 86.0 percent, with a desired precision level of 5%, and non-response rate of 10%.²

Employing finite population correction, the sample size was determined to be 154, taking into account a total population of 781 postgraduate medical students in government medical colleges and 102 in private medical colleges. Application of population proportion sampling (PPS) for both government and private medical colleges yielded a final sample size of 205. Participants were recruited by using two stage random sampling.

During first stage of sampling a list of government and private colleges which were approved by the competent government authorities was prepared after thorough research on internet and websites of authorities and an institute was selected from each type of institute randomly. During second stage of sampling according to proportion of postgraduate medical students in each college, 181 postgraduate medical students from government medical college and 24 from private medical college selected randomly from each branch of MD/MS course by list of students obtained from institutes (using population proportionate sampling).

Post graduate medical students of all the three years, enrolled in degree courses of all branches (MD/MS), were included in the study. Students pursuing diploma courses and those not willing and consenting to participate in the study for their own reasons were excluded.

For data collection PSS-10 scale was used to assess the perceived stress and predesigned, pretested, self-administered, structured questionnaires were used for associated risk factor after taking written consent.

A pilot study was conducted to validate the PSS-10 scale and structured questionnaire and decided cut off of PSS-10 scale.

Ethical clearance was obtained from the institutional ethical committee before commencing of the study (Ref. code: 97th ECM II B-Thesis/P145).

The data obtained was coded, entered and analysed using the statistical software, Statistical Package for Social Sciences (SPSS version-26). Pearson’s Chi square test was applied and p values have been quoted where applicable. Qualitative variables were presented in the form of frequency and percentages. Logistic regression analysis was done to find out various predictors of perceived stress.

RESULTS

Out of the total 205 participants, 118 (57.6%) were male, and 87 (42.4%) were female. On grouping the postgraduate medical students according to year of post-graduation, 78 (38.0%) were from 1^st year, 64 (31.2%) from 2^nd year and 63 (30.7%) from 3^rd year. On grouping the postgraduate medical students according to age, <25 were 35 (17.1%), 25-30 years were 134 (65.4%) and >30 years were 36 (17.5%). Further distribution of study participant can be supplementary Table 1.

The prevalence of perceived stress among the postgraduate medical students was 91.2%. The distribution of perceived stress among government postgraduate medical students was 93.0 percent and 87.1 percent among private postgraduate medical students.

**Clinical duties (n=139).

Table 1 shows the association of perceived stress with biosocial characters in which female sex, and students residing in hostel, family income, no of earning family members, and satisfaction level with financial condition, satisfaction with family condition were significantly associated with perceived stress.

Figure 1 shows distribution of perceived stress among postgraduate medical students.

Table 2 shows the association of perceived stress with academic characteristics and working environment

Table 3 shows the association of perceived stress with lifestyle habits and addictive habits in which absence of daily leisure activity, <8 hour sleep duration, not adequate perception of sleep duration, alcohol consumption, smoking cigarette/bidi, and internet smoking were significantly associated with perceived stress.

Table 4 shows that nine predictors for perceived stress among postgraduate medical students were found to be statistically significant (p<0.05) in univariate analysis and out of them, four predictors were found to be statistically significant in multivariate analysis.

Figure 2 shows the predictors of perceived stress in postgraduate medical students.

DISCUSSION

In the present study, female postgraduate medical students exhibited higher perceived stress compared to their male counterparts, likely due to the additional physical, familial, and societal responsibilities they face, especially in the Indian context. This added burden increases their overall stress levels.

Postgraduate medical students residing in hostels reported higher levels of perceived stress, which can be attributed to the lack of comfortable and personal space in hostel’s environments. The absence of a familiar and private space can significantly contribute to feelings of stress.

The study found a significant association between perceived stress and biosocial characteristics such as family income, the number of earning family members, and satisfaction with financial and family life. Students from families with lower income, fewer earning members, or dissatisfaction with financial conditions and family life may experience higher stress levels due to added financial and emotional pressures. This finding is consistent with Seedhom et al, who also identified financial problems as a major stressor for postgraduate medical students.³

There was no significant association between perceived stress and whether students were in clinical or non-clinical branches, as both fields present unique challenges and stressors leading to similar levels of perceived stress. However, academic characteristics such as lack of time to review learned skills, an exhaustive course curriculum, pressures of thesis work, and concerns about future employment were significantly associated with perceived stress. The demanding nature of postgraduate medical education significantly contributes to stress, aligning with findings from Yousuf et al, and Rajan et al, who reported high levels of dissatisfaction with the academic environment among students.^4,5

The work environment also played a significant role in perceived stress. Extra work, difficult interactions with patients’ relatives, fear of assault or misbehaviour by patients’ relatives, long duty hours, and uncalled-for demands from faculty and seniors create a stressful work environment. The workload and working conditions are major contributors to stress, as noted by Rajan et al, who identified extra duties, non-conducive clinical training environments, and work overburden as significant stressors.⁵

Perceived stress was present in 57.1% of postgraduate medical students with less than 24 hours of emergency duty per week and in all students with more than 24 hours, a difference found to be highly significant (p<0.001). Excessive duty hours, particularly more than 24 hours of emergency duty per week, lead to severe physical and mental exhaustion, significantly increasing stress levels. This finding aligns with Yousuf et al, who also reported high stress levels among students with extensive duty hours.⁴

Finally, students who slept less than 8 hours per day reported higher stress levels compared to those who slept more than 8 hours, a finding that was statistically significant. Adequate sleep is essential for mental and physical health, and students experiencing sleep deprivation are more likely to experience stress. This finding is supported by Sahasrabuddhe et al, Joshi et al, and Guruprakash, Mehta et al, who reported high stress levels associated with insufficient sleep and shifting sleep timings.^6-8

This study’s cross-sectional design limits causal inferences and generalizability beyond the specific region and timeframe. Self-reported data may introduce response biases.

CONCLUSION

To conclude, it has been found that postgraduate medical students have higher level of perceived stress. And main stressors were less personal time, long working hours with no adequate breaks, no time for academic work, harassment by the faculty, high patient load, critical patients assigned, night duty, less sleep duration, and poor work environment. Addressing these factors through targeted interventions is crucial to improving student well-being.

Perceived stress has higher association of morbidity both physical and mental therefore to overcome stress and its consequences among postgraduate medical students a monthly or quarterly assessment of their wellbeing is a must. Also, a confidential mutual reporting system should be included for feedback without disparity. Implementation of prescribed duty hours is required and there is a need to include positive coping strategies for stress management such as meditation practices, yoga and mindfulness. Accommodation facilities should be improved for the better so that the post graduate medical students are able to adjust better.

This study is highly relevant as it identifies key stressors affecting postgraduate medical students, a group that plays a crucial role in healthcare. By highlighting factors such as gender, living conditions, financial instability, academic pressures, and work environment, the research provides actionable insights for institutions to implement targeted interventions. Addressing these stressors is essential for improving the well-being, performance, and retention of medical students, ultimately leading to better healthcare outcomes.

ACKNOWLEDGEMENTS

Authors would like to thank all postgraduate medical students for their support for this research study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee (Ref. code: 97th ECM II B-Thesis/P145)

REFERENCES

1. 1. Salam A, Yousuf R, Bakar SMA, Haque M. Stress among medical students in Malaysia: a systematic review of literatures. Int Med J. 2013;20(6):649-55.
2. 2. Mumtaz Y, Jahangeer A, Habib A, Adnan S, Mumtaz Z. Stress in postgraduate trainee doctors of public and private Universities of Karachi. Pak J Med Sci. 2010;26(2):420-5.
3. 3. Seedhom AE, Kamel EG, Mohammed ES, Raouf NR. Predictors of perceived stress among medical and nonmedical college students, Minia, Egypt. Int J Prev Med. 2019;10:107.
4. 4. Yousuf A, Ishaque S, Qidwai W. Depression and its associated risk factors in medical and surgical post graduate trainees at a teaching hospital: a cross sectional survey from a developing country. J Pak Med Assoc. 2011;61(10):968-72.
5. 5. Rajan P, Bellare B. Work related stress and its anticipated solutions among post-graduate medical resident doctors: a cross-sectional survey conducted at a tertiary municipal hospital in Mumbai, India. Indian J Med Sci. 2011;65(3):100-6.
6. 6. Sahasrabuddhe AG, Suryawanshi SR, Bhandari S. Stress among doctors doing residency: a cross-sectional study at a tertiary care hospital in the city of Mumbai. Nat J Community Med. 2015;6(01):21-4.
7. 7. Joshi AR, Nagpal M. Assessment of perceived stress in postgraduate medical students during training programme. J Clin of Diagn Res. 2018;12(6):CC01-4.
8. 8. Guruprakash KV, Mehta SG, Atul B, Prakash J, Divinakumar KJ, Khan SA, et al. A study of relationship between perceived stress, coping pattern, burnout, and general psychopathology among the postgraduate medical students. Indian Psychiatr J. 2018;27(1):141-6.
9. 9. Thapa A, Thapa DK, Sangroula RK, Thapa S, Shrestha AD, Balampaki P, et al. Technostress in medical and allied field: an empirical study among under graduate public health science students of Purbanchal University-affiliated colleges in Kathmandu. Int J Community Med Public Health. 2022;9(12):4506-13.