Assessing Mental Health Differences in Medical Students Between Traditional vs. PBL Curriculums

doi:10.21203/rs.3.rs-2954025/v1

Download PDF

Research Article

Assessing Mental Health Differences in Medical Students Between Traditional vs. PBL Curriculums

https://doi.org/10.21203/rs.3.rs-2954025/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 19 Dec, 2023

Read the published version in BMC Medical Education →

You are reading this latest preprint version

Background

The prevalence of mental health struggles among students in medical school is widely reported however, little is known about how it is impacted by medical school curriculum. This study aimed to evaluate differences in anxiety, depression, and emotional exhaustion in medical students based on gender, class year, and curriculum.

Methods

An anonymous online survey consisting of questions from established, validated questionnaires about demographics, anxiety, depression, emotional exhaustion, and personal health behaviors was sent to 817 medical students who attended Rowan-Virtua School of Osteopathic Medicine during the Spring of 2021.

Results

The survey was completed by 222 students. Females experienced higher levels of anxiety, depression, and emotional exhaustion than males. Students in the problem-based curriculum (PBL) had lower levels of emotional exhaustion than their peers in the lecture-based curriculum (LBL). Increase in emotional exhaustion was most pronounced between 1st and 2nd year students. Emotional exhaustion was inversely correlated with sleep and exercise.

Conclusions

On average, students who were either male or in the PBL curriculum experienced less mental distress in the form of anxiety, depression, and emotional exhaustion than their peers. While gender continues to be an established factor in how mental distress is experienced, the reduced levels of emotional exhaustion in PBL students is a novel finding that can potentially shed light on how to better optimize medical education. Despite the lower number of PBL students, to our knowledge, this is the first study comparing two different curricula within a single institution. This finding along with a focus on good sleep and exercise habits may provide a path for improving mental health in medical students.

medical students

emotional exhaustion

anxiety

depression

PBL

curriculum

The field of medicine tends to attract individuals who exhibit perseverance (1, 2). Unfortunately, this same quality may lead to burnout, which is characterized as emotional exhaustion, depersonalization, and reduced sense of personal accomplishment (3). The repercussions of burnout are far-reaching, affecting both the individual and the system in which they operate. A prime example is physician burnout which has an estimated prevalence of around 50%, a rate markedly higher than professionals in other fields (4, 5). Physician burnout can have personal consequences, such as dissolution of relationships, suicidal ideation, and problematic drug and alcohol use, as well as professional consequences, which include erosion in quality of care, increased risk of medical error, and early retirement (6, 7). This leads to a significant cost to the healthcare system, estimated at $4.6 billion each year nationally when taking into account reduced clinical hours and physician turnover (8).

The onset of burnout is insidious, often starting early in training. Among medical students, about half express feelings of burnout and 1 in 9 report suicidal ideation (9). While reported rates of suicidal ideation decrease among residents/fellows and early career physicians, the rates of burnout remain relatively constant (10). Burnout early in medical training can have dire consequences. Students become more susceptible to depression, leading to impaired concentration and apathy that may hinder their ability to pass courses. This increases their risk of dropping out of medical school and potentially distancing themselves from the profession entirely. Furthermore, students with burnout are more inclined to engage in unethical behaviors and less likely to hold altruistic views about their responsibility to society as a future physician (11). The depersonalization aspect of burnout may cause students to be less empathetic toward patients, viewing them as a set of symptoms rather than a person, which can lead to problems with medical errors later on in their training .

While medical student distress in the form of anxiety, depression, and burnout has been well documented in the literature, (9–14) there is a scarcity of studies examining the impact of curriculum on mental health. The traditional, lecture-based learning (LBL) curriculum has long been the standard in medical education; however, problem-based learning (PBL), sometimes referred to as a case-based learning curriculum, has seen increased implementation among U.S. medical schools in recent decades. In a PBL curriculum, students attend small peer group sessions where they are presented with a problem or case, on a subject matter they cover independently prior, to discuss in the presence of an instructor. This format encourages critical analysis of a variety of perspectives, fosters a deeper understanding of the content, and promotes self-directed learning habits (15–19). Several studies suggest improved academic performance and perceptions of learning among students in PBL compared to their peers in LBL (20–22). However, there is limited literature on the impact of the two differing curriculum styles on medical student mental health. The unique structure of the Rowan-Virtua School of Osteopathic Medicine (Rowan-Virtua SOM) having both LBL and PBL curricula allowed us to investigate this topic by disseminating a mental health survey assessing common elements of psychological distress among medical students. This study seeks to explore the impact of gender and curriculum on anxiety, depression, and emotional exhaustion, a key component of burnout, as students progress through medical school.

In this cross-sectional study, an anonymous web-based survey utilizing Qualtrics, an online surveying platform, was emailed to all 817 medical students at Rowan-Virtua SOM. Recruitment emails were sent between the end of March and start of June of the 2021 academic year during a time specific to each class cohort’s schedule when students would be most available. Participants provided consent on the initial page prior to starting the survey. Survey responses were tracked anonymously using Qualtrics and reminders were sent to non-respondents every two weeks, with the last reminder being sent two weeks prior to the survey closing. The survey was advertised as an anonymous, voluntary 10–15 minute survey on mental health. Students were not required to complete all sections of the survey for submission. Data was collected and stored on Qualtrics. As an incentive, participants were offered a chance to win one of the four $25 Amazon gift cards (one for each class year) by participating in a separate, post-survey raffle hosted on Google Forms.

Survey Measures

The survey is a modified version of the mental health survey used by Gold et al.,(23) with their permission. Results collected and analyzed were derived from the following sections: (i) Demographics, (ii) Stress and Burnout, and (iii) Personal Health and Coping Behaviors. The questions were formatted using the Likert scale rating. A modified version of the Maslach Burnout Inventory limited to emotional exhaustion questions, served as our assessment for burnout, as emotional exhaustion is a strong predictor for burnout (24).

Mental health was assessed using the Patient Health Questionnaire-4 (PHQ-4), a brief and validated screening scale for anxiety and depression (25). Personal health behaviors were assessed with questions about sleep and exercise.

Statistical Analyses

Statistical comparisons were carried out using Graphpad Prism v8.1 and/or SPSS v28. Graphical representations of the data were created using Graphpad Prism v8.1. Pearson’s chi-squared test and independent t-test were utilized to compare the differences between data sets and a value of p < 0.05 was considered statistically significant.

Demographics

Of the 817 students to whom the survey was sent, 222 students completed the entire survey. The composition of respondents included 45 from the PBL curriculum (20%) and 177 from the LBL curriculum (80%), aligning closely with the PBL to LBL curriculum distribution at Rowan-Virtua SOM (22% vs 78%, respectively). Of the students who completed the survey, 122 (55%) were female and 100 (45%) were male. Overall, Rowan-Virtua SOM is composed of 50% females and 50% males. Respondents included 77 first year students (class of 2024; 35%; 19 PBL, 58 LBL), 55 second year students (class of 2023; 25%; 7 PBL, 48 LBL), 66 third year students (class of 2022; 30%; 14 PBL, 52 LBL), and 24 fourth year students (class of 2021; 11%; 5 PBL, 19 LBL).

Anxiety, Depression, and Emotional Exhaustion

Out of the 222 responses, 79 (36%) met the criteria for moderate or severe mood disorder based on a composite score on the PHQ-4 questionnaire (Fig. 1a). According to the PHQ-4 subscales, 109 (45%) students screened positive for anxiety and 60 (27%) screened positive for depression (Fig. 1b). Levels of anxiety and depression did not differ significantly from one class year to another (Fig. 2). When grouped by preclinical (1st /2nd ) and clinical (3rd /4th ) years, the distribution of students positive for anxiety and depression was similar between cohorts (50% vs 48% and 26% vs 29%, respectively) (Fig. 3). On average, females reported significantly higher levels of anxiety and depression than males (Fig. 4). This difference was reflected in the frequency distribution showing that a greater percentage of females meet the criteria for anxiety and depression compared to males on both subscale and composite PHQ-4 scales (Fig. 5).

A curriculum comparison showed that PBL students tend to have lower levels of anxiety, depression, and general mood disorder than LBL students, but this was not statistically significant (Fig. 6). Factoring in gender into the curriculum comparison of anxiety and depression also showed no significant difference (Fig. 7).

Degree of emotional exhaustion did not change significantly between preclinical and clinical cohorts; however, a significant increase was noted between first year and second year students (Fig. 8a). When comparing curricula, PBL students showed lower levels of emotional exhaustion than LBL students (Fig. 8c). A gender comparison demonstrated higher levels of emotional exhaustion in females than males (Fig. 9b).

Personal Health Behaviors

An evaluation of personal health behaviors and PHQ-4 scores showed a correlation between moderate or severe mood disorder (scores ≥ 6) and both decreased sleep (≤ 5 hours/night) and exercise (≤ 2 days/week) among students (Fig. 9), but not between alcohol consumption and incidence of moderate or severe mood disorder (data not shown). An analysis evaluating emotional exhaustion and personal health behaviors revealed a decrease in sleep and exercise with increasing emotional exhaustion (Fig. 10).

Our data shows that anxiety was twice as common as depression and that over a third of students screened positive for moderate or severe mood disorder. This finding parallels previous studies that show higher levels of psychological distress among medical students compared to the general population, suggesting that medical training is a time of great personal stress / emotional distress for many students. Notably, our findings showed higher rates of both depression and anxiety than previous studies which may reflect the implementation of our study during the height of the COVID-19 pandemic (12).

Further evaluation by gender revealed higher levels of anxiety, depression, and burnout in female students, a finding supported by previous studies (13, 14). Among female respondents, almost half had high PHQ-4 scores (> 6), a finding that correlates strongly with functional impairment, disability days, and healthcare use (25). In comparison, only a quarter of male respondents had similarly high scores. This discrepancy is reflected in the general population where women are twice as likely as men to have anxiety and depression (26).

Notably, there was no variation in anxiety or depression between students in different class years; this did not change even when grouped by preclinical (1st /2nd ) and clinical (3rd /4th ) years, suggesting the transition from an academic to clinical environment has a negligible impact on mood. However, there was a noticeable increase in the level of EE, a strong predictor of burnout, as students transitioned from first to second year (24). This may be due to the increased pressure to study in preparation for the first board exam in addition to previous obligations from first year. Interestingly, the increased rates of EE did not continue into third year despite the need for preparation for the second board exam. This might suggest that as students advance in training, they acquire the experience and resilience necessary to better manage the increased stress that comes with increased expectations. From third to fourth year, the incidence of EE did not change significantly. However, it should be noted that the survey for fourth year students was distributed at the end of the academic year, after the residency match, a notoriously stressful process, had concluded.

We found that the PBL curriculum, which is based on working in small groups, may be less stressful for medical students than the traditional LBL curriculum. Although outside the cutoff for statistical significance, anxiety and depression tended to be lower in PBL students than LBL students. Anxiety and depression are strongly associated with burnout which when represented as EE, was significantly lower among PBL students (27). While novel, this finding may not be entirely surprising since previous studies have suggested that PBL provides an improved educational environment compared to LBL (22). Compared to LBL, which is characterized by large class sizes and one way dissemination of information by the instructor, PBL offers small group sizes and collaboration led by a facilitator. These factors may positively influence students’ perceptions of their learning environment and provide regular interpersonal engagement which may translate to an overall better mindset as they progress through medical school. When evaluating anxiety and depression by both curriculum and gender, we found no difference between curriculum groups; female students had similar rates of anxiety and depression regardless of whether they were in the PBL or LBL curriculum.

Another interesting finding in this study was the inverse relationship between EE and sleep and exercise. This raises the question of whether EE, as a component of burnout, leads to decreased sleep and exercise or vice-versa. One study identified too little sleep as a predominant factor in the development of burnout, supporting the idea that adequate sleep is important in preventing burnout (28). However, there is likely a bidirectional relationship between sleep and burnout. For medical students, establishing good sleep habits early on can help reduce burnout, potentially reducing the risk of making detrimental medical mistakes in the future (29).

This study supports prior studies documenting the prevalence of anxiety, depression, and burnout among medical students (13) which as Dyrbye et al. pointed out previously, can contribute to suicidal ideation (9). The potential consequences warrant investigation into reducing such prevalence. We highlight new evidence suggesting that students completing their preclinical years of medical school under the PBL curriculum have less EE than students in the traditional LBL curriculum. This previously undescribed result may represent an additional benefit of the PBL curriculum model which applicants might consider when making their medical school choices. Schools with only an LBL curriculum may seek to offer more PBL-like structure or an entire PBL curricular track.

Limitations

One of the limitations of this study is the subjective nature of some of the survey questions and corresponding answers. Another limitation is the smaller sample number of PBL respondents compared to LBL respondents. This is a consequence of the already smaller PBL class sizes. Despite these limitations, the study is the first of its kind where a comparison between two curricula is conducted within a single institution.

PBL: Problem-based curriculum

LBL: Lecture-based curriculum

EE: Emotional exhaustion

Ethics approval and consent to participate

This study was approved for data collection and analysis by the Institutional Review Board (IRB) of Rowan-Virtua SOM, Stratford, USA (PRO-2020-171). All methods were carried out in accordance with IRB guidelines and regulations. Informed consent was obtained from all students who participated in the study via Qualtrics on the initial page prior to starting the survey.

Consent for publication

Not applicable.

Availability of data and materials

The dataset supporting the conclusions of this article is available in the Figshare repository, https://doi.org/10.6084/m9.figshare.22247161.v1.

Competing interests

The authors declare that they have no competing interests.

Funding

No funding was provided to support this study.

Authors' contributions

M.J.: conception and design, collection of data, data analysis and interpretation, manuscript writing; S.S.: collection and assembly of data, data analysis and interpretation; D.J.: collection and assembly of data, data analysis and interpretation; B.M.: data analysis and interpretation; D.M.: data analysis and interpretation; K.L: data analysis and interpretation. All authors read and approved the final manuscript.

Acknowledgments

We want to thank Rowan-Virtua School of Osteopathic Medicine and the participants of this study. We also thank Lisa Price for reviewing and providing valuable feedback.

Footnotes

Not applicable

Miller-Matero L, Martinez S, MacLean L, Yaremchuk K, Ko A. Grit: A predictor of medical student performance. Education for Health. 2018;31(2):109-13.
Abd Elwahab SM, Cosgrave J, Doherty E, Lowery A. Grit personality trait of doctors and medical students in level 4 acute hospital. The Surgeon. 2022;20(4):216-24.
Freudenberger HJ. Staff Burn-out. Journal of Social Issues. 1974;30(1):159-65.
Del Carmen MG, Herman J, Rao S, Hidrue MK, Ting D, Lehrhoff SR, et al. Trends and Factors Associated With Physician Burnout at a Multispecialty Academic Faculty Practice Organization. JAMA Netw Open. 2019(2574-3805 ).
Rotenstein LS, Torre M, Ramos MA, Rosales RC, Guille C, Sen S, et al. Prevalence of Burnout Among Physicians: A Systematic Review. JAMA. 2018(1538-3598 ).
Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Archives of Internal Medicine. 2012;172(18):1377-85.
West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. Journal of Internal Medicine. 2018;283(6):516-29.
Han TDS, Christine A. Sinsky, et al. Estimating the Attributable Cost of Physician Burnout in the United States. Annals of Internal Medicine. 2019;170(11):784-90.
Dyrbye LN. Burnout and Suicidal Ideation among U.S. Medical Students. Annals of Internal Medicine. 2008;149(5):334-41.
Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, et al. Burnout Among U.S. Medical Students, Residents, and Early Career Physicians Relative to the General U.S. Population. Academic Medicine. 2014;89(3):443-51.
Dyrbye LN, Massie FS, Eacker A, Harper W, Power D, Durning SJ, et al. Relationship Between Burnout and Professional Conduct and Attitudes Among US Medical Students. JAMA. 2010;304(11):1173-80.
Dyrbye LN, Thomas MR, Shanafelt TD. Systematic Review of Depression, Anxiety, and Other Indicators of Psychological Distress Among U.S. and Canadian Medical Students. Academic Medicine. 2006;81:p 354-73.
Villwock JA, Sobin LB, Koester LA, Harris TM. Impostor syndrome and burnout among American medical students: a pilot study. Int J Med Educ. 2016;7:364-9.
Moutinho IL, Maddalena NC, Roland RK, Lucchetti AL, Tibiriçá SH, Ezequiel OD, et al. Depression, stress and anxiety in medical students: A cross-sectional comparison between students from different semesters. 2017(1806-9282 ).
Chang BJ. Problem-based learning in medical school: A student's perspective. Ann Med Surg (Lond). 2016;12:88-9.
Barrows HS. Problem-based learning in medicine and beyond: A brief overview. New Directions for Teaching & Learning. 1996;1996(68):3-12.
Schmidt HG, Moust JHC. Factors affecting small-group tutorial learning: A review of research. Problem-based learning: A research perspective on learning interactions. Mahwah, NJ, US: Lawrence Erlbaum Associates Publishers; 2000. p. 19-51.
Norman GR, Schmidt HG. The psychological basis of problem-based learning: a review of the evidence. 1992(1040-2446).
Hmelo-Silver CE. Problem-Based Learning: What and How Do Students Learn? Educational Psychology Review. 2004;16(3):235-66.
Faisal R, Bahadur S, Shinwari L. Problem-based learning in comparison with lecture-based learning among medical students. J Pak Med Assoc. 2016(0030-9982).
Sharifzadeh M, Agah J, Khosravi A, Samadi S, Davari Sani SJ. Collaborative method consisting lecture, problem-based learning and weblog for clinical courses of medical students in comparison with lecture method. 2021(2277-9531 ).
Qin Y, Wang Y, Floden RE. The Effect of Problem-Based Learning on Improvement of the Medical Educational Environment: A Systematic Review and Meta-Analysis. Med Princ Pract. 2016;25(6):525-32.
Gold JA, Johnson B, Leydon G, Rohrbaugh RM, Wilkins KM. Mental health self-care in medical students: a comprehensive look at help-seeking. Acad Psychiatry. 2015;39(1):37-46.
Flickinger TE, Kon RH, Jacobsen R, Owens J, Schorling J, Plews-Ogan M. Single-Item Burnout Measure Correlates Well with Emotional Exhaustion Domain of Burnout but Not Depersonalization Among Medical Students. J Gen Intern Med. 2020(1525-1497 ).
Kroenke K, Spitzer RL, Williams JBW, Löwe B. An Ultra-Brief Screening Scale for Anxiety and Depression: The PHQ–4. Psychosomatics. 2009;50(6):613-21.
Kessler RC, McGonagle KA, Swartz M, Blazer DG, Nelson CB. Sex and depression in the National Comorbidity Survey I: Lifetime prevalence, chronicity and recurrence. Journal of Affective Disorders. 1993;29(2):85-96.
Koutsimani P, Montgomery A, Georganta K. The Relationship Between Burnout, Depression, and Anxiety: A Systematic Review and Meta-Analysis. Frontiers in Psychology. 2019;10.
Söderström M, Jeding K, Ekstedt M, Perski A, Akerstedt T. Insufficient sleep predicts clinical burnout. J Occup Health Psychol. 2012;17(2):175-83.
West CP, Huschka MM, Novotny PJ, Sloan JA, Kolars JC, Habermann TM, et al. Association of Perceived Medical Errors With Resident Distress and EmpathyA Prospective Longitudinal Study. JAMA. 2006;296(9):1071-8.

No competing interests reported.

Download PDF

Journal Publication

published 19 Dec, 2023

Read the published version in BMC Medical Education →

Editorial decision: Major revision
07 Aug, 2023
Reviews received at journal
28 Jun, 2023
Reviewers agreed at journal
28 Jun, 2023
Reviewers agreed at journal
26 Jun, 2023
Reviewers invited by journal
23 Jun, 2023
Editor assigned by journal
15 Jun, 2023
Editor invited by journal
21 May, 2023
Submission checks completed at journal
21 May, 2023
First submitted to journal
18 May, 2023

You are reading this latest preprint version

Assessing Mental Health Differences in Medical Students Between Traditional vs. PBL Curriculums

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

Survey Measures

Statistical Analyses

Results

Demographics

Anxiety, Depression, and Emotional Exhaustion

Personal Health Behaviors

Discussion

Limitations

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1