This study aimed to determine anxiety-producing situations among medical students starting clinical studies from their own and their teachers’ perspectives. Students’ perceived anxieties were assessed by means of a questionnaire. The same questionnaire was given to the teachers involved in clinical training during the fourth year of medical education. Teachers were asked to complete the questionnaire as they thought the introductory students would have done. According to the students, the top five situations that produce anxiety were: giving a wrong treatment, getting diagnoses wrong, carrying out cardiopulmonary resuscitation, inadvertently hurting patients and becoming infected by patients. The situations that were found to be as anxiety producing by the teachers were mostly related to communicating with patients. It is important to identify and minimize the sources of anxiety before students are exposed. But the teacher first needs to be aware of these sources and the fact that students may respond differently to their clinical activities.
According to the current system of medical education in Turkey, the six-year education period can be considered as two different parts, namely the preclinical phase and the clinical phase. The difference between the two periods is due to numerous factors such as physical environment, context, curriculum, educational methods, training atmosphere, students’ and teachers roles, relations and other details. Most medical students look forward to the clinical phase however, it can be an anxiety producing process. It is important to specify the situations connected to this increased anxiety among students; such information can make an important contribution to the preparedness of both new students and teachers for clinical training.1
Sources of stress and anxiety among medical students have been widely investigated. Both anxiety level and its sources change in medical education as students progress. Some factors found to increase stress and anxiety were related to the curriculum, medical school environment, the amount of material to be learned, and examinations and/or grades among early medical students;2,3 whilst talking to psychiatric patients, effects on personal life, presenting cases, and dealing with death and suffering were found to be stressful events among fourth year medical students.4 The residency and practice years of medical education were considered to produce a higher level of stress for medical students in another study.5
This study aimed to determine anxiety-generating situations among new clinical medical students from their own and their teachers’ perspectives. The results may be used to establish regulations to ease the transition between the two phases of medical education.4-10
Marmara University Medical School, together with some other medical faculties in Turkey is in the process of changing its curriculum as well as revising its educational methods in light of recent developments. According to the results of a recent study, the majority of the graduates agreed that there was need for a change in the educational system.11 Graduates, who reported that “changes in the educational system are necessary”, indicated that changes should be made in areas such as educational methods, curriculum, audio-visual materials, skills of the trainers and assessment/evaluation methods. They also stated that there was some “essential medical knowledge” in the curriculum that they were not able to acquire during their medical education. Based on this information and on data obtained from clinical observations, clinical training was considered a part of several intervention areas. In order to improve the quality of clinical training, interventions were directed both to the preclinical and clinical phases of medical education. For the clinical part of the education, interventions were focused on teaching skills of the clinical teachers and on evaluation methods. For the preclinical phase of the education a new approach was introduced under the title of “Introduction to Clinical Practice” (ICP).12 Medical students were introduced to a continuous and comprehensive course starting on the first day of their medical education. The main issues covered by this three year program were clinical skills laboratory classes (CSL), first aid course, communication skills course, clinical reasoning, research projects, introduction to humanity in medicine, community health experience, and outpatient clinics experience. The aim of the program was to prepare students to care for patients and families in a humanistic, competent and professional manner.
In this study, medical students who had not been exposed to ICP were evaluated. The immediate results of this study can be used to determine the necessary areas of intervention in order to provide a better, less anxious transition between preclinical and clinical phases. The results can also be valuable for making comparisons between students exposed to the new curriculum and those who were not, regarding their perceptions of clinical training.
MATERIALS AND METHODS
Fourth year medical students were given a questionnaire that covered possible anxiety sources during the first week of their clinical training. The questionnaire was taken from a study by Moss and McManus;1 with some modifications. There were 39 questions in our questionnaire apart from those which addressed the sociodemographic characteristics of the students. Students were asked to indicate their anxiety levels on a 4-point scale: not anxious, slightly anxious, fairly anxious, and very anxious. The same questionnaire was also given to the teachers involved in clinical training in the fourth year of medical education. Forty-two teachers participated in the study.
Data was analysed in the SPSS for Windows. Chi Square, Mann Whitney U test and Student t-tests were used in statistical analysis.
Eighty-six introductory students completed the questionnaire, response rate was 78.2%. Fifty-one students were male (59.3%). Forty-two teachers (36.8% specialist, 15.8% assistant professor, 23.7% associate professor and 23.7% professor) completed the questionnaire. The difference between the overall scores of teachers and students was statistically significant (mean score of teachers=2.38, + 0.43, mean score of students=1.99, + 0.34, t=5.32 pAccording to student perception, fear of making mistakes that could harm the patients was at the top of the list of the first ten leading sources of anxiety. In the teachers’ top ten list, fear of making mistakes had also taken a high place, although there were some other tasks such as carrying out cardiopulmonary resuscitation (CPR), dealing with dying patients and suturing. Becoming infected by patients was indicated by the students as one of the important source of anxiety; however, teachers didn’t rate it as highly.
Because of differences in the overall scores of teachers and students, differences for particular situations were tested for significance using only a t-test, on a corrected score, obtained by subtracting each individual’s mean anxiety level from their score for that situation. In 13 of the 39 situations (33.3%) significant differences in mean anxiety scores between students and teachers were reported (Table 2). The student t-test was used to compare corrected mean scores of students and teachers.
Teachers reported more anxiety for: going into the operating theatre, prescribing, going into the delivery room, dealing with a sick child, being left alone with a sick patient, suturing patients, dealing with drunk/abusive patients, going to post-mortems, attending outpatient practices; while students reported more anxiety for giving a wrong treatment, becoming infected by patients, inadvertently hurting patients, and getting up early for ward rounds.
Differences in mean anxiety scores between students and teachers were also investigated by controlling students’ gender. It showed that male students had a higher mean anxiety score in getting up early for ward rounds than teachers, whilst female students had a higher score in dealing with drunk/abusive patients.
Participants in this study were new clinical medical students who were asked to indicate their worries about clinical training at the beginning of this period of their education. Although there were many consistent findings between this study and previous ones that we have conducted, it may be important to note that some of those studies have dealt with only dental or nursing students.
“Fear of making mistakes”
In this study students ranked “giving a wrong treatment” and “getting diagnoses wrong” as the first two situations and “inadvertently hurting patients” as the third to produce the highest anxiety scores. According to a study which analysed the perceived stress associated with the transition from preclinical to clinical teaching among dental students, the highest levels of anxiety associated with general clinical situations were felt for getting diagnoses wrong, hurting patients, dealing with medical emergencies, and becoming infected.8 Fear of making mistakes that could potentially harm patients was one of the leading sources of anxiety among health sciences students.1,6,15
Since stress is associated with poor performance especially in clinical training,5-6 it is important to control this source of anxiety. One solution to decrease this fear of “inadvertently hurting patients” students could be to provide opportunities for students to be competent in basic clinical skills before they start clinical training. Such a program could provide a humanistic approach in medical education for both patients and students. Overloaded curriculum and disintegration may be other reasons of this fear. In our system, students are exposed to a huge amount of factual knowledge during the first three years of medical education; however this knowledge is not well-related to clinical practice.
“Fear of becoming infected by patients”
In this study, students rated a high level of anxiety for becoming infected by patients. This result has been obtained in other similar studies.1,8 One explanation for this fear could be the lack of knowledge and/or practice of medical students in infection prevention measures. Although they are taught these subjects in the early years of medical education, a refresher course can be organized at the beginning of the clinical training.
It has been shown that students develop significant anxiety when they do not have adequate information about new medical courses to be taken in succeeding years.6,16 This may be another explanation for this fear, since our students are not informed in advance about the clinical training, the environment, the tasks that they are going to be involved in, etc.
Being a medical student itself may be one of the reasons for this expressed anxiety. It has been shown that medical school poses a number of unique difficulties for undergraduate students, such as arduous intellectual demands, cadaver dissection and, for many, a first exposure to illness and death.16 This fear remains as an important finding which will be worth investigating especially through qualitative studies. Students have also expressed their worries about the routines of clinical life such as “being up all night” and “getting up early for ward rounds”. This result was reported in another study.4
In this study teachers were asked to complete the questionnaire as the new students might have done. In general, the teachers’ mean anxiety score was significantly higher than the students. They emphasized anxiety-producing situations as such as prescribing, going into the post-mortems, going into the delivery room, dealing with sick children, being left alone with a sick patient, suturing, attending outpatient clinics practice. The situations underestimated by teachers relative to students were: getting diagnoses wrong, giving a wrong treatment, getting infected by patients, inadvertently hurting patients and getting up early for ward rounds. It may be reasonable that teachers did not realize students’ fear of making mistakes because they knew how new clinical students became gradually involved in clinical tasks and there were few such risks. Nevertheless, it is to be expected that teachers predict students’ fears based on their previous experience with newcomers.
Many of the items that were found to be anxiety- producing tasks by the teachers were related to communicating with patients. In a similar study, students did not cite these items as critical.1 This is likely due to the students’ lack of knowledge and experience in the importance of communication skills in medical practice. Another important point is that the subject of communication did not exist at all in our curriculum until recently.
Prescribing was another task in which difficulties were underestimated by students relative to teachers. Both teachers and students found carrying out some of the clinical skills to be anxiety-producing such as cardiopulmonary resuscitation, rectal and/or vaginal examination and taking blood from patients. This result is mainly due to the absence of a clinical skill training program in the curriculum of preclinical education for this student cohort. Thus, teachers did not expect students to feel comfortable in carrying out these skills.
By its very nature medical education is a stressful experience. Trainees suffer high level of stress, interpersonal relations difficulties, depression and anxiety.17 Therefore it is very important to monitor medical students during their long education process in terms of their changing level of anxieties and their source. It has been shown that high stress scores were related more to fear and disappointment in clinical practice; students who experienced high stress were less stimulated by their clinical activities and developed less confidence in practice.6 If sources can be identified and targeted early, barriers to learning can be minimized. But the teacher first needs to be aware of these sources and the fact that students may respond differently to their clinical activities.
Keeping in mind that the transition period is not yet completed; four types of systems/curricula could be identified in medical education in Turkey at present: the classical system, integrated system, Problem Based Learning, and a mixture of integrated/innovative forms. The Marmara Medical School system has been considered as belonging to last category. Although names and definitions of the systems are subjective, they still make sense. Our medical school is in the process of changing and dealing with well known problems of medical education such as: lack of effective integration between preclinical and clinical phases, overloaded curriculum, lecture-based and teacher-centred approach. We feel that many of the results of this study are due to the above problems.
Running an effective clinical skills training program and first aid course starting in the early years of medical education may help to reduce the anxiety of new clinical students. These subjects are considered in the core curriculum in many medical schools. Students who were exposed to an early introduction of clinical skills teaching regarded it as good preparation for their future studies.16,18 Marmara Medical School has included these courses in the curriculum recently.
Communicating with patients remains one of the difficult tasks of medical practice. There is evidence from the literature that communication skills can be taught in courses, and are learnt, but easily forgotten if not maintained by practice.19 Based on this knowledge and knowing that medical students did not realize its importance, a continuous course on communication skills starting from the early years of medical education may be beneficial.
Introduction of an orientation course seems to be vital before the start of clinical training.20 Such a program may help students to be aware of their tasks and responsibilities during their clinical training. This program may also include a short site visit at the hospital and practical applications of infection prevention measures. During this program students can be given tips in coping with this new life style. It has been recommended that the first clinical day should closely follow the orientation program so that anxiety related to a new clinical experience might be lessened.21
Marmara Medical School has been changing its curriculum, in order to include some of the recommended interventions. However some problems remain. Thus it is very important to explore these findings in longitudinal studies, to observe the effect of interventions and to determine support programs for vulnerable students.
- Moss, F. and McManus, I.C. The Anxieties of new Clinical Students. Medical Education. 1992; 26: 17-20.
- Foster-Williams, K., Thomas, P., Gordon, A., and Williams-Brown, S. An assessment of stress among clinical medical students of the University of the West Indies, Mona Campus. West Indian Medical Journal. 1996; 45(2):51-54.
- Stewart, S.M., Betson, C., Marshall, I., Wong, C.M., Lee, P.W., and Lam, T.H. Stress and vulnerability in medical students. Medical Education. 1995; 29 (2): 119-127.
- Firth, J. Levels and sources of stress in medical students. British Medical Journal. 1986; 3; 292(6529): 1177-1180.
- Linn, B.S. and Zeppa, R. Stress in junior medical students: relationship to personality and performance. Journal of Medical Education. 1984; 59(1):7-12.
- Oermann, M.H. and Lukomski, A.P. Experiences of students in pediatric nursing clinical course. Journal of the Society of Pediatric Nurses. 2001; 6 (2): 65-74.
- Huebner, L.A., Royer, J.A., and Moore, J. The assessment and remediation of dysfunctional stress in medical school. Journal of Medical Education. 1981; 56(7): 547-558.
- Kieser, J. and Herbison, P. Clinical Anxieties among dental students. New Zealand Dental Journal. 2000; 96 (426): 138-139.
- Audet, N.C. Caring in nursing education: reducing anxiety in the clinical setting. Nursingconnection. 1995; 8(3): 21-28.
- Totten, J.K. The Use of a transition clinical conference to reduce student anxiety at new clinical sites. Nurse Education. 1994; 19(4): 7-8.
- Kalaca, S., Kan, B., G’ney, I., akın, A., and T’z’n, N. Students’ Perception about medical education at Marmara University School of Medicine. Marmara Medical Journal. 2000; 13 (3): 131-136.
- Kalaca, ., Arzik, A., Kalaca, S., Unalan, P. Introduction to Clinical practice: An Important contribution to medical education. Marmara Medical Journal. 2001; 14(4): 255-258.
- de Saintonge, D.M. and, Dunn, D.M. Gender and achievement in clinical medical students: a path analysis. Medical Education. 2001; 35(11): 1024-1033.
- Hojat, M., Glaser, K., Xu, G., Veloski, J.J., and Christian, E.B. Gender comparisons of medical students’ psychosocial profiles. Medical Education. 1999; 33 (5): 342-349.
- Kleehammer, K., Hart, A.L., and Keck, J. F. Nursing students’ perceptions of anxiety-producing situations in the clinical setting. Journal of Nursing Education. 1990; 29: 183-187.
- Morris, M.R. and Petrie, K. J. Redefining medical students’ disease to reduce morbidity. Medical Education. 2001; 35 (8): 724-728.
- Lam, T.P., Irwin, M., Chow, L.W.C., and Chan, P. Early Introduction of clinical skills teaching in a medical curriculum-factors affecting students’ learning. Medical Education. 2002; 46:233-240.
- Shapiro, L.S., Shapiro, D.E., and Schwartz, G.E.R. Stress Management in Medical Education. Academic Medicine. 2000; 75: 748-759.
- Remmen, R., Scherpbier, A., van der Vleuten, C., Denekens, J., Derese, A., Hermann, I., Hoogenboom, R., Kramer, A., Van Rossum, H., Van Royen, P., and Bossaert, L. Effectiveness of basic clinical skills training programmes: a cross-sectional comparison of four medical schools. Medical Education. 2001; 35(2):121-128.
- Aspegren, K. BEME guide No. 2: Teaching and learning communication skills in medicine – a review with quality grading of articles. Medical Teacher. 1999; 21: 563-570.
- Lewis, L.L., Gadd, H.F., and O’Connor, K. Relationship of anxiety level and recall of information to the interval between orientation and first patient care day. Journal of Nursing Education. 1987; 26(3): 94-98.