Urging caution regarding the generalizability of the Medical Student Stress Factor Scale: a medical student perspective

We read with great interest the article entitled “The root of the problem: identifying major sources of stress in Brazilian medical students and developing the Medical Student Stress Factor Scale” by Damiano et al., recently published in the Brazilian Journal of Psychiatry.¹

As medical students ourselves, we believe this paper raises an important awareness of the mental health crisis that appears to be spreading amongst medical students internationally.² In some regards it is unsurprising that medical students are at heightened risk of mental health issues. Here in the United Kingdom, as is the case in most countries, students begin medical education in their late teenage years/early twenties, where they are exposed to high-intensity education, fierce academic competition, and patient suffering/death, often without the necessary coping strategies to deal with such stressors.³ We additionally agree with the authors’ comments that it is the responsibility of the medical education providers to mitigate potential impact of their education practices on the well-being of their students.

However, we question this study’s conclusion that the stressors identified may lead to poor grades and unprofessional behavior.¹ The study design is not suited to support such claims, since neither grades nor measures of unprofessional behavior were recorded as outcome measures in the study population. As a result, we are unsure what these conclusions are based on and feel that further clarification from the authors is necessary.

The authors additionally claim that this tool could be used internationally to allow medical schools to identify and act upon stressors in their students; however, we would question the validity of this assertion. The domains explicitly used in the Medical Student Stress Factor (MSSF) tool appear to have been generated from one medical school in Brazil. This concerns us since the stressors identified as significant in the study are likely to reflect the specific cultural, social, and educational environment found at this institution, and not necessarily those of other medical schools, both intra- and internationally. We therefore feel it would be appropriate to seek further validation of the MSSF tool across a wide range of institutions before claims of its validity are expanded to all medical schools.

One aspect of the educational environment that was not made clear in the study methodology was the temporal relationship between examination periods and questionnaire completion. Thiemann et al.⁴ recently demonstrated a significant increase in clinical depressive and anxiety symptoms in final year medical students whose clinical examinations were within two months compared to students outside of this examination period. This highlights the need for a longitudinal assessment to identify whether the contribution of stressors to depression, anxiety, or stress symptoms is transient or protracted. Therefore, an opportunity for continued research could be to perform a similar study where the questionnaire is repeated at multiple timepoints throughout the academic year.

References

• ¹
  Damiano R, de Oliveira I, Ezequiel O,Lucchetti A, Lucchetti G. The root of the problem: identifying major sources of stress in Brazilian medical students and developing the Medical Student Stress Factor Scale. Braz J Psychiatry. 2020 July 17. Epub ahead of print.
• ²
  Moir F, Yielder J, Sanson J, Chen Y. Depression in medical students: current insights. Adv Med Educ Pract. 2018;9:323-33.
• ³
  Lee KH, Ko Y, Kang KH, Lee HK, Kang J, Hur Y. Mental health and coping strategies among medical students. Korean J Med Educ. 2012;24:55-63.
• ⁴
  Thiemann P, Brimicombe J, Benson J, Quince T. When investigating depression and anxiety in undergraduate medical students timing of assessment is an important factor - a multicentre cross-sectional study. BMC Med Educ. 2020;20:125.

Publication Dates

• Publication in this collection
  26 Oct 2020
• Date of issue
  Mar-Apr 2021

History

• Received
  11 Sept 2020
• Accepted
  05 Oct 2020