Medical students' coping with stress and its predictors: a cross-sectional study.

Objectives: To analyse stress coping styles of medical students at different time points of medical education and to identify predictors of functional coping. Methods: A cross-sectional study was conducted among medical students (N = 497, 361 women and 136 men) before year one (n = 141), after year one (n = 135) and after year five (n = 220). Students answered the Brief Coping Orientation to Problems Experienced Inventory, the Work-Related Behaviour and Experience Patterns, the Perceived Medical School Stress Instrument and the Maslach Burnout Inventory. Multiple regression was used to examine factors associated with functional coping. Results: Single factor ANOVA indicated a significant difference for functional coping between the time points (F (2, 494) = 9.52, p < .01), with fifth-year students scoring significantly higher than students before or after year one. There was a significant difference in dysfunctional coping (F (2, 494) = 12.37, p < .01), with students before year one and after year five scoring higher than those after year one. Efficacy (ß = 0.15, t (213) = 4.66, p < .01), emotional distancing (ß = 0.04, t (213) = 3.50, p < .01) and satisfaction with life (ß = 0.06, t (213) = 4.87, p < .01) were positive predictors of functional coping. Conclusions: Scores for both functional and dysfunctional coping vary during medical education. The reasons for low coping scores after year one require further explanation. These findings represent a starting point for investigations into how to promote functional coping during early medical education.

The Development of Empathy and Associated Factors during Medical Education: A Longitudinal Study.

PURPOSE: In this longitudinal study, we investigated the development of empathy during medical education and assessed potential predictors of empathy at different time points in the course of medical studies. METHODS: In our longitudinal study, starting in 2011, we surveyed medical students at Lübeck Medical School, Germany at the beginning of their course of study and after 2, 4, and 6 years (t0-t3) using standard instruments for empathy (Jefferson Scale of Empathy, Student Version, JSE-S), anxiety and depression (Hospital Anxiety and Depression Scale, HADS), stress (Perceived Medical School Stress scale), and behavior and experience patterns (Arbeitsbezogene Verhaltens- und Erlebensmuster [Work-related Behavior and Experience Patterns]). RESULTS: A total of 43 students completed all surveys. The cross-sectional samples for the different survey time points comprised between n = 220 and 658 students. We observed a slight, but statistically significant, increase of empathy scores from t0 to t3 (t(43) = -3.09, P < .01). Across all analyses, a preference for a people-oriented specialty was associated with a higher JSE-S sum score, as well as being female, whereas we saw a negative association between HADS depression and JSE-S scores. CONCLUSION: In our study, empathy scores were shown to be relatively stable during medical education with a tendency to increase. In line with previous research, individuals preferring a people-oriented specialty and women showed higher empathy scores.

The impact of the COVID-19 pandemic on stress, mental health and coping behavior in German University students - a longitudinal study before and after the onset of the pandemic.

BACKGROUND: The COVID-19 pandemic has led to massive restrictions in public and private lives, including a shut-down of face-to-face teaching at universities in Germany. We aimed to examine the impact of these changes on perceived stress, mental health and (study-)related health behavior of students in a longitudinal study. METHODS: For two timepoints - the year before the COVID-19 pandemic (2019, n = 1377) and the year during the COVID-19 pandemic (2020, n = 1867) - we surveyed students of all faculties at one German university for perceptions and preventive behavior regarding the COVID-19 pandemic using standard instruments for stress, anxiety, depression, and behavior and experience patterns. RESULTS: About 90% of students (n = 1633) in 2020 did not have a known contact infected with SARS-CoV-2, while 180 (9.8%) did have one. Only 10 respondents (0.5%) reported an infection with SARS-CoV-2. Wearing masks and washing hands more often were practiced by ≥80% of students. Taking more care about cleanliness (51.8%) and using disinfectants (39.2%) were practiced much less. A higher percentage of female compared with male students and medical/health science students compared with science, technology, engineering, and mathematics students engaged more frequently in specific or nonspecific preventive measures. More than three quarters (77.1%) of all students rated their general health as (very) good. There were no significant differences in general health, stress, and depression between 2019 and 2020 in the students who responded at both timepoints. The distribution of behavior and experience patterns for this group showed a slight but significant difference from 2019 to 2020, namely decreasing proportions of students with a healthy pattern and a risk pattern for overexertion. Students with different behavior and experience patterns showed marked differences in perceptions and reaction to the COVID-19 pandemic as well as psychosocial stress and symptoms, with higher scores for mental health symptoms and lower scores in preventive behavior regarding risk patterns. CONCLUSION: Despite massive alterations to students' lives in 2020, there were only moderate consequences for mental health compared with 2019 in the total student group of this German university. However, identifying students at risk would offer opportunities to foster mental health in relevant subgroups.

Study-related behavior patterns of medical students compared to students of science, technology, engineering and mathematics (STEM): a three-year longitudinal study.

BACKGROUND: Medical education is perceived as demanding and stressful. Whether this is particularly pronounced in this course of study remains under debate. METHODS: We used the questionnaire "Work-Related Behavior and Experience Patterns (Arbeitsbezogene Verhaltens- und Erlebensmuster (AVEM))" to assess the development of study-related behavior and experience patterns in medical (n = 584) and STEM students (n = 757) at one German university, with a special emphasis on gender differences, over 3 years of study. Students were surveyed at the beginning of their studies (t0) and again in each consecutive summer semester (t1-t3). Both cross-sectional and longitudinal data were generated and analyzed. Results in the abstract are from the cross-sectional analysis. RESULTS: Freshman medical students presented with a larger proportion of students with a healthy pattern (58.1%) than STEM students (42.5%). In both groups this proportion decreased to 33.8%/25.1% at t2, with only a minor improvement at t3 (38.1/27.0%). Correspondingly, the proportion of students with a burnout-related risk pattern increased from 8.0% (Med)/13.7% (STEM) to a maximum of 16.9% at t2 in medical students and 27.0% at t3 in STEM students. In both groups female students showed a more unfavorable distribution of patterns and a higher vulnerability, especially in the area of resistance toward stress. CONCLUSIONS: The unfavorable development of behavior and experience patterns in both student groups demonstrates increasing study related stress and emphasizes the need for prevention and health promotion on an individual and a contextual level.

Are the results of questionnaires measuring non-cognitive characteristics during the selection procedure for medical school application biased by social desirability?

Introduction: A stronger consideration of non-cognitive characteristics in Medical School application procedures is desirable. Psychometric tests could be used as an economic supplement to face-to-face interviews which are frequently conducted during university internal procedures for Medical School applications (AdH, Auswahlverfahren der Hochschulen). This study investigates whether the results of psychometric questionnaires measuring non-cognitive characteristics such as personality traits, empathy, and resilience towards stress are vulnerable to distortions of social desirability when used in the context of selection procedures at Medical Schools. Methods: This study took place during the AdH of Lübeck University in August 2015. The following questionnaires have been included: NEO-FFI, SPF, and AVEM. In a 2x1 between-subject experiment we compared the answers from an alleged application condition and a control condition. In the alleged application condition we told applicants that these questionnaires were part of the application procedure. In the control condition applicants were informed about the study prior to completing the questionnaires. Results: All included questionnaires showed differences which can be regarded as social-desirability effects. These differences did not affect the entire scales but, rather, single subscales. Conclusion: These results challenge the informative value of these questionnaires when used for Medical School application procedures. Future studies may investigate the extent to which the differences influence the actual selection of applicants and what implications can be drawn from them for the use of psychometric questionnaires as part of study-place allocation procedures at Medical Schools.

Health-promoting factors in the freshman year of medical school: a longitudinal study.

CONTEXT: The freshman year of medical school is a stressful period in the lives of future doctors. Resilience to this stress differs greatly, leading to different health outcomes. Less resilient students, whose health may deteriorate early in their education, are at greater risk for developing stress-related diseases. Early identification of individuals at risk and the provision of tailored health-promoting interventions might prevent this. OBJECTIVES: This study was designed to investigate: (i) how the health of medical students develops over the freshman year, and (ii) whether certain protective factors can predict general and mental health status after 1 year of medical education. METHODS: A prospective, longitudinal, observational study was conducted at one medical school. Self-rated general and mental health status before and after the freshman year were used as outcomes. In addition to socio-demographic variables and leisure activities, personality and study-related behaviour and experience were surveyed as potential predictors. Both descriptive techniques and logistic regression analyses were employed to identify predictors for general and mental health separately. RESULTS: At baseline, 93% of medical students rated their general health and 88% rated their mental health as good. These frequencies declined over the first year to 76% and 84%, respectively. For general health, regular physical activity was the strongest predictor (odds ratio [OR] 4.58). Satisfaction with life (OR 1.18) and balance and mental stability (OR 1.20) emerged as positive predictors, and age (OR 0.85) and striving for perfection (OR 0.76) as negative predictors. Mental health status was predicted by emotional distancing (OR 1.25), experience of social support (OR 0.73), neuroticism (OR 0.89) and age (OR 0.85). CONCLUSIONS: Self-rated general and mental health declined throughout the first year of medical education. Physical activity proved to be a strong predictor for the maintenance of good general health. This finding may represent a starting point for health-promoting interventions, such as the provision of time slots for physical activity.

The effect of long-term high frequency repetitive transcranial magnetic stimulation on working memory in schizophrenia and healthy controls--a randomized placebo-controlled, double-blind fMRI study.

In schizophrenia patients negative symptoms and cognitive impairment often persist despite treatment with second generation antipsychotics leading to reduced quality of life and psychosocial functioning. One core cognitive deficit is impaired working memory (WM) suggesting malfunctioning of the dorsolateral prefrontal cortex. High frequency repetitive transcranial magnetic stimulation (rTMS) has been used to transiently facilitate or consolidate neuronal processes. Pilot studies using rTMS have demonstrated improvement of psychopathology in other psychiatric disorders, but a systematic investigation of working memory effects outlasting the stimulation procedure has not been performed so far. The aim of our study was to explore the effect of a 3-week high frequency active or sham 10 Hz rTMS on cognition, specifically on working memory, in schizophrenia patients (n=25) in addition to antipsychotic therapy and in healthy controls (n=22). We used functional magnetic resonance imaging (fMRI) to compare activation patterns during verbal WM (letter 2-back task) before and after 3-weeks treatment with rTMS. Additionally, other cognitive tasks were conducted. 10 Hz rTMS was applied over the left posterior middle frontal gyrus (EEG electrode location F3) with an intensity of 110% of the individual resting motor threshold (RMT) over a total of 15 sessions. Participants recruited the common fronto- parietal and subcortical WM network. Multiple regression analyses revealed no significant activation differences over time in any contrast or sample. According to the ANOVAs for repeated measures performance remained without alterations in all groups. This is the first fMRI study that has systematically investigated this topic within a randomized, placebo-controlled, double-blind design, contrasting the effects in schizophrenia patients and healthy controls.

A functional neuroimaging study assessing gender differences in the neural mechanisms underlying the ability to resist impulsive desires.

There is ample evidence of gender differences in neural processes and behavior. Differences in reward-related behaviors have been linked to either temporary or permanent organizational influences of gonadal hormones on the mesolimbic dopamine system and reward-related activation. Still, little is known about the association between biological gender and the neural underpinnings of the ability to resist reward-related impulses. Here we assessed with functional magnetic resonance imaging which neural processes enable men and women to successfully control their desire for immediate reward when this is required by a higher-order goal (i.e., during a 'desire-reason dilemma'; Diekhof and Gruber, 2010). Thirty-two participants (16 females) were closely matched for age, personality characteristics (e.g., novelty seeking) and behavioral performance in the 'desire-reason task'. On the neural level, men and women showed similarities in the general response of the nucleus accumbens and of the ventral tegmental area to predictors of immediate reward, but they differed in additional brain mechanisms that enabled self-controlled decisions against the preference for immediate reward. Firstly, men exhibited a stronger reduction of activation in the ventral pallidum, putamen, temporal pole and pregenual anterior cingulate cortex during the 'desire-reason dilemma'. Secondly, connectivity analyses revealed a significant change in the direction of the connectivity between anteroventral prefrontal cortex and nucleus accumbens during decisions counteracting the reward-related impulse when comparing men and women. Together, these findings support the view of a sexual dimorphism that manifested in the recruitment of gender-specific neural resources during the successful deployment of self-control.

Disorder-specific emotional imagery for differential and quantitative assessment of agoraphobia.

Visual emotional stimulation is supposed to elicit psycho-vegetative reactions, which are similar to as the ones elicited by exposure to actual experience. Visual stimulation paradigms have been widely used in studies on agoraphobia with and without panic disorder. However, the applied imagery has hardly ever been disorder- and subject- specific. 51 patients with an ICD-10 and DSM-IV diagnosis of agoraphobia with or without panic disorder (PDA) and matching healthy controls have been examined. Subjects were confronted with 146 picture showing characteristic agoraphobic situations (high places, narrow places, crowds, public transport facilities, or wide places) or pictures associated with acute physical emergency (panic) situations, which had been pre-selected by anxiety experts. Participants were asked to rate emotional arousal induced by the respective images on the Self- Assessment Manikin scale (SAM). Data on PDA severity (PAS) depressive symptoms (MADRS) and sociodemographic data were recorded. Saliva cortisol levels were measured before and after exposure in a second test applying the individually mostly feared stimuli combined with emotionally neutral pictures for every single patient. 117 of the PDA-specific images were rated significantly more fear-eliciting by patients than by healthy individuals. Sub-categorization into agoraphobia clusters showed differential effects of clusters with regard to gender distribution, severity of PDA and cortisol secretion during exposure. In this study disorder specific and individual characteristics of agoraphobia were assessed for use in future trials applying emotional imagery. It could be used for the differential assessment of PDA and associated neurobiological and psychological phenomena and in neuroimaging paradigms.

Antagonistic modulatory influences of negative affect on cognitive control: Reduced and enhanced interference resolution capability after the induction of fear and sadness.

The present behavioral study investigated the influence of negative affect on the neural mechanisms of cognitive control. We expected to find evidence for an antagonistic modulation of cognition by threat-relevant and threat-irrelevant negative affect (i.e. fear and sadness) that should promote bottom-up monitoring and top-down selection, respectively. Subjects performed one of three conflict tasks (Stroop, Flanker, or Simon) that tap distinct control mechanisms of conflict resolution, comprising specific attentional and motor control processes. On each task trial, target stimuli were preceded by a face stimulus exhibiting a fearful, sad, or neutral expression, providing three affect conditions. Our data provides strong evidence for substantially increased selection (attentional and motor selection) after priming of threat-irrelevant negative affect (sadness). Deviating from the results of previous studies, our analysis did not consistently yield increased monitoring after fear priming. We discuss these findings with respect to the effectiveness of different experimental affect priming procedures (i.e. stimuli) and the role of the task context, among others.

Contextual movement constraints of others modulate motor preparation in the observer.

Previous research demonstrated that observing an action seems to automatically activate a corresponding motor representation in the observer. It has been argued that this direct matching of observed on executed actions is modulated by contextual factors. An open question is whether observing another person being physically restrained has an influence on action execution in the observer. Using performance measures we found a slowing of response times when perceiving others' hands being physically restrained (Experiment 1). We did not find a slowing effect when participants responded with their feet ruling out a general perceptual interpretation of the present findings (Experiment 2). To further test our hypothesis, we measured event-related brain potentials (ERPs). The ERP results demonstrate that the observed slowing effect is reflected in a decrease of motor-related ERP components (Experiment 3). Perceiving others' hands physically restrained impairs motor preparation in the observer. Our findings suggest that observed environmental constraints are automatically mapped onto the observer's motor system. Such a mapping of motor restraints might facilitate action understanding.