Our survey provides a comprehensive and, in both the Czech and global context, a unique view of the stress subjectively felt by students of general medicine throughout the country (Czech Republic), its effect on the quality of life of students and their motivation to remain in the Czech healthcare system. Thanks to the scale and the even distribution of students across the faculties, we were able to name the main sources of stress at individual medical faculties.
Our above-presented results show that the vast majority of Czech medical students experience excessive stress during their studies, which increases the risk of students´ somatic problems (OR = 7.97, p < 0.001), targeted alcohol use (OR = 2.69, p < 0.001) and the use of anxiolytic or antidepressant medication to reduce it (OR = 9.16, p < 0.001), which reduces the students´ quality of life. Students experiencing higher levels of excessive stress are more likely to leave their studies based on their own decision (OR = 3.91, p < 0.001) and not to enter clinical practice after graduation (OR = 1.27, p = 0.18).
In the Czech Republic, the degree of non-completion of studies after six or more years is reported to be in the range of 7.7%−21.6%, depending on the studied faculty. (13, 14) In comparison, in the UK, USA and Canada, the literature mentions about 5%, 4.8% and 0.5% decline of medical students each year. (15) The specific effect of subjectively felt stress on the motivation of students to further continue to stay in the healthcare system of the given country has so far been little researched. In some parts, the work of the Thai authors Pitanupong and the collective, who investigated the proportion of medical students who thought about leaving medicine during their studies, and tried to identify the reasons for these thoughts, is comparable to our survey. The results show that 22.9% of students admitted to thoughts about leaving medicine in the preclinical part, while 22.6% of students admitted to leaving medicine in the clinical part. (16) As the main reasons for these considerations, students cited the difficulty of studying, dissatisfaction with the study environment and their lack of interest in the content of the lesson. In comparison with these results, we note that Czech medical students admit to thinking about leaving medicine more often, in 48.3% overall. Given the higher reported levels of stress in women, this difference can be partly explained by the proportion of women in our survey, where in the above-cited Thai study women represented 54% and in our survey women represented 73%.
Excessive stress and anxiety in medical students are associated in the literature with excessive alcohol consumption with a prevalence of around 20%. This prevalence is higher than in the non-medical peer group, despite relatively high alcohol consumption in the control (non-medical) population. (17, 18, 19, 20, 21, 22, 23, 24) In our survey, the prevalence of alcohol consumption reaches almost 30% (up to 35% for men). The statement in the questionnaire that the respondents agreed with was defined as the use of alcohol for the purposeful reduction of excessive stress (i.e. not for fun or during celebrations or other occasions).
In accordance with our results, high demands on students in terms of study volume, competitive environment among medical students, lack of time for friends, family and leisure activities, high expectations of family and society or great responsibility of the future profession are repeatedly mentioned in the literature as main and specific sources of stress. Others include frequent examining, worry about the future, loneliness or encountering death. (25, 26, 5) A 2018 American authors´ survey (27) of over 1,100 students adds additional factors such as faculty teaching systems, faculty attitudes, and student-hostile environments that compare to our stressors named “Teacher and examiner attitude” and “Teaching system”. Together, more than 10% of all students in our survey consider these stressors to be the main ones, and at the same time, they are typical examples of unnecessary stress, the targeted reduction of which medical faculties around the world should strive for.
In literature, the female gender is repeatedly associated with a higher risk of feeling excessive stress, but also of burnout syndrome. (28, 29) The lifetime risk of developing depression is higher in women than men in the general population. (30, 31, 21) On the other hand, several studies can be found that find no difference in the prevalence of depression among medical students by gender. (32, 33, 34, 35, 36, 37, 38, 21) Even among our respondents, women report more often the subjective experience of stress (women 96.34% versus men 90.84%, p < 0.001). Similarly, when comparing reported somatic problems, women are more often burdened (73.79% of women versus 61.00% of men, p < 0.001) and likewise when comparing the frequency of seeking professional help (24.77% of women versus 14.24% of men, p < 0.001). When comparing the use of anxiolytics/antidepressants, we get a result of 19.60% of women versus 12.82% of men. Only the use of alcohol in connection with stress is reported more often by men (27.25% of women versus 35.38% of men, p < 0.001). The question in this area and in the context above is that to what extent our results reflect the general tendency of women to experience life situations as stressful and to what extent our results are a reflection of hostility, discrimination or sexism at Czech medical faculties.
Works published so far with a similar focus indicate different percentages of students experiencing excessive stress during their medical studies. Work by Konjengbam et al indicates a prevalence of stress of 28.4% among medical students studying in India. (39) In their work, Sarikaya et al report an even lower proportion of students suffering from excessive stress during their studies, namely 25.6% among Turkish medical faculty students. (40) Other results were obtained by Sidik et al with a cohort of Malaysian students and Fares et al with a cohort of Lebanese medical students, who in their studies found excessive stress in 57% and 62% of medical students, respectively. (41, 29) The work of A.N. Supe talks about the prevalence of stress of 73% among medics in Seth G.S. Medical College in India with higher prevalence in higher grades. (42) Compared to these works and while respecting the different methodologies of the cited works, Czech medical students report a greater subjective burden of excessive stress with all its consequences, which we described above.
Why Do We Need To Reduce Excessive Stress?
Based on what we mentioned above, it can be said that Czech medical students are exposed to excessive stress with all its consequences during their studies. Psychological and somatic problems or the use of alcohol and pharmaceuticals to reduce stress are not desirable phenomena for future doctors. Although studying medicine is demanding in itself and requires a great deal of energy, time, patience and sacrifice, in our survey we have shown that there is unnecessary stress, which represents up to tens of percent across faculties. The degree of representation of individual stressors varies between different faculties. It is necessary to strive for a systematic reduction of unnecessary stress across the faculties by means of targeted measures, which can increase the quality of life of students and, by extension, the quality of the health care provided.
In addition to reducing the above-mentioned consequences of excessive stress, i tis also necessary to consider the systemic and economic side of the matter. The society invests high costs (higher than hundreds of thousands crows to lower millions of crowns) in the education of one students, which will potentially be wasted if such a student does not finish his studies due to excessive stress or pursues another field after graduation. Reducing unnecessary stress during studies by both medical faculties and students can undoubtedly save the entire system considerable financial resources and perhaps even improve the staff situation in the Czech healthcare sector.
Strengths and limitations of study
Since the preparation of the survey, we have been aware of a possible sampling bias, given that students who are more sensitive to stress may be more likely to fill out a similarly focused questionnaire, but due to the scope of our survey and the equal representation of students from individual faculties, our survey provides a robust result. Additionally, similar cohorts of students within faculties were compared.
Our survey took place during the coronavirus pandemic, when some medical students were ordered to help the overburdened healthcare system. At that time, the majority of teaching at Czech universities took place via distance learning, and it was medical students in the upper years who were exempted from the regulation, when practical teaching was mostly preserved. According to a survey carried out at the Charles University, the largest Czech university, under which five of the eight Czech medical faculties fall, these circumstances were reflected in a better mental state of medics, who, thanks to a sense of the meaning of their future profession, even showed a lower prevalence of anxiety and depressive symptoms than other students of higher education at the Charles University. (14, 43) This bias must also be taken into account when evaluating our results.