Resilience Study in the Undergraduate Medical Curriculum

Being a medical student has both its advantages and downsides. But overall the life of a medical student is quite stressful. Repeated clinical shifts, continuous studies and a lot of facts to remember make it quite burdening. In some students, this can lead to stress, depression, erratic mood swings and other health related problems. Stress can be defined as ‘‘a state of mental or emotional strain or suspense’’ and also as ‘‘a number of normal reactions of the body (mental, emotional, and physiological) designed for self- preservation’’. Stress is normal and very much required in our lives helping us to adjust, learn and grow. It has both positive and negative effects on people. Some people are more active, creative, and productive because of stress. At the same time, prolonged stress can cause damaging problems. Many students try to cope up this stress by drug and alcohol abuse which further worsens the stress. (Shaikh BT et al., 2004).

In many medical schools, the environment itself provides a highly pressurized situation, providing an authoritarian and rigid system, one that encourages unhealthy comparison rather than cooperation between learners. It is not just the undergraduate study period which brings stress but it may continue during the internship, postgraduate study period, and later into physician's practical life. (Abdulghani HM et al., 2011). This results in reduction of students' self-esteem and has a major effect on their academic achievement. A high level of stress may have negative effect on cognitive functioning and learning of students in medical school. (Sohail et al., 2007). However some students who are resilient can cope up with this stress better. Resilience is defined an individual's ability to adapt in the face of adverse conditions and situations. Resilience is either a characteristic ability or acquired ability.

Studies show us that very little is known about the factors which bring about a positive effect on medical students and helping them to relieve the stress. There are some coping efforts classified by Engagement strategies which were associated with fewer depressive symptoms, while coping efforts classified by Disengagement strategies were associated with higher levels of depressive symptoms (Mosley TH et al., 1994). For instance, Wu (2011) reported that resilience and a wishful thinking mediated the effect of post-traumatic stress disorder and depression in 175 family members of victims of man-made trauma (Wu HC, 2011). Similarly, in a longitudinal study conducted by Cohn et al (2009)., focusing on the relationship between resilience and life satisfaction, he found that positive emotions were associated with more resilience and negative emotions resulted in lesser resilience and lower life satisfaction when compared to the general population (Cohn MA et al., 2009). The latter type is widely seen in medical students due to their highly stressed life and it was proved that resilience fully mediated the relationship between positive emotions and life satisfaction.

Studies have shown that medical students in their first year of study have more stress levels compared to the rest of the years of study as first year is a transition period from school to college and they find it extremely difficult to adjust to a new modality of teaching and learning. Fourth medical students encounter new and many stressors during the clinical years, in which resilience could prove particularly helpful during this period. New stressors and challenges during the clinical years include patient death and dying, undergoing of unfair treatment, difficult team dynamics and uncertainty in both the clinical and learning environments (Houpy JC et al., 2017). Hence, in this study we found it relevant to assess the resilience level in the first and final year students and compare the scores using a standard resilience questionnaire.

Methodology

This is a cross sectional study which was done in 285 undergraduate medical students after obtaining clearance from the Institutional Ethics Committee (IEC) of Saveetha Medical College & Hospital. 148 first year MBBS students and 137 fourth year MBBS students participated in the study after obtaining clearance from the Institutional Ethics Committee (IEC) of Saveetha Medical College & Hospital. Written informed consent was obtained from all the study participants and from the parents or guardian of all the study participants and information sheet regarding the study was given to all the participants after explaining the study details. The basic demographic details regarding name, age, sex were collected. All the undergraduate first and fourth year MBBS students in the age group 18-25 years studying in Saveetha Medical College who were willing to participate were included in the study. Students who were unwilling to participate in the study, students with medical conditions, depression and undergoing therapy or treatment were excluded.

Administration of Questionnaire

All the study related work were carried out in a break time, for the convenience of students. Detailed instructions were provided to the students prior to the filling the questionnaires. Hard copies of the questionnaires were handed over the students and collected back after filling. Any doubts or questions about the study were clarified by the researcher. Confidentiality was ensured throughout the study.

Evaluation of Resilience by Resilience questionnaire (Waginald G and Young HM, 1993):

A standardized questionnaire on resilience was administered to the students. The answers were marked on a 7 point Likert scale ranging from “1” (Strongly Disagree), “4” (Neutral) to “7” (Strongly Agree).Based on the resilience score (Total=175), they were be allocated into 3 groups – low (25-115), moderate (116-145) and high levels of resilience (146-175).

Data Analysis

Data was analysed by SPSS 20.0. The depression, anxiety and stress scores between the male and female students was analysed using Student’s t-test. P value less than 0.05 was considered as significant. A total of 238 undergraduate medical students were included in the study. Out of the 122 first MBBS students who participated in the study, a majority of 84.43% students had low resilience score of 99.43±9.72 while 40% of fourth year students out of total 116 students had low resilience in the range of 97.17±12.22 which was highly significant (P<0.0001). Amongst first year students 14.76% had medium resilience score of 122.06 ± 5.89 and majority of 47.62% of fourth year students had medium resilience of 128.24± 8.29 (P<0.0001). A significant number of 12.38% of fourth year students had high resilience score of 155.31±6.68 in comparison with the first years where only 0.81% students had high resilience(P<0.0001).

In the current scenario, during the learning period of the medical curriculum the undergraduate medical students face a highly pressurized situation. The undergraduate medical students face a lot of stressors in the form of heavy academic load, frequent examinations, fear of failure, adjustment to new environment, prolonged day time travel in the case of day scholars which may ultimately lead to high levels of anxiety and depression (Hemavathi et al., 2017). In undergraduate medical students, stress was shown to influence the body weight and decreased the quality of life in those students (Dharshini K et al, 2017). First year MBBS students find it more stressful as they are shifting from rote memory of learning in schools to the conceptual learning style for the first time, whereas the fourth year students are exposed to a heavy academic and clinical workload. The more resilient the students are, the better they will be able to handle the stress.

From the study it is evident that fourth year students have more resilience when compared to first year students. As seen above, the amount of stress that fourth year students go through is multifold to that faced by first year students, hence fourth years develop resistance to it through different experiences. When compared to the other years, these two years undergo the maximum stress in their own aspects. Final-year medical students must face the upcoming post graduate examination along with the pressure of receiving the doctor degree and internship in the same year and at the same time first-year medical students undergo a transition period from their home to a different atmosphere in college with a new academic environment. Our study throws light on the fact as to the importance of resilience in adjusting to stress and the future focus should be on the promotion of resilience building measures to be taught and practiced right from the first year of medical curriculum. This research will help us to assess the levels of stress and its effect on fourth year and first year medical students and help us in planning counselling sessions wherever required and promote resilience measures and coping strategies for stress.