Stress students with a language barrier as an added

Stress is a widely accepted phenomenon in the medicalprofession and medical training (1,2).Stress has been defined as the “perceived imbalance between the demands encountered in daily living anda person’s capability to respond” (3-5).Stress in medical students occurs when an imbalance exists between the demandsof medical curriculum and the students’ capability to deal with them (6). Medical students experience higher stressthan both the general population and students in other fields (7).

This increased stress has been attributed toexhaustion due to high curricular workloads, tight time schedules, hierarchicalstructures in the field and enormous emotional pressure, such as during contactwith suffering and dying patients (8). Prolonged perceived stressnot only can have negative effects on cognitive functioning and learning ofstudents (9),but is a risk factor for psychiatric disorders and may be a predictor of later mentalhealth problems (10). Studies assessing the consequence of prolongedexposure to stress in medical students have found that medical students are at increasedrisk of anxiety, depression, burnout and personal distress due to thedetrimental effects to personal wellness the demands of medical school cause (11,12). A 2005 systematic review of psychologicaldistress among Canadian and U.S. medical students found an increased prevalenceof psychological distress, depression andanxiety compared not only to the general population, but also age matched todoctors later in training, suggesting that medical school is perhaps the moststress-intensive time in a physician’s career (13).

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It also demonstrated an associationbetween distress anddecline in academic performance (13). A recent systematic review by Hopeand Henderson suggests that an increase in psychological distress, depressionand anxiety in medical students also exists in Europe (14). Whereas multiple studies have been performed assessingperceived stress in medical students, very few studies have focused oninternational medical students. The few studies performed to date have focusedon students with a language barrier as an added stressor, but did notspecifically compare the perceived stress of international students to thosefrom the country where the students attend Medical School (15,16). In recent years an increasing number of Canadians havechosen to study Medicine at Irish Medical schools; themajority of students citingthe reason as the inability to obtain a placement in a Canadian medical school(17).

The most recent data from 2010 foundapproximately 650 Canadians studying at Irish Medical Schools (18).While the number of Canadians at Irish Medical Schools has been increasing, thepopulation has not been well studied to date. One 2013 study found nodifference in knowledge acquisition in Irish vs. international medicalstudents, however no other parameters were compared (19). While Canadians studying medicineabroad face the same stressors as the typical medical student, there are addedchallenges such as being removed from a family support system, adjusting to anew culture/country, and facing the pressure of obtaining a residency back inCanada with only 23.

6% Medical Students from Ireland successfully obtaining aresidency match in Canada in 2017 (20). These added stressors may increase theperceived stress in this population.    Aim: The aim ofthis study is to examine the level of perceived stress in Canadian studentsstudying at an Irish Medical School and compare this level to that of Irishmedical students.

 Hypothesis:It ishypothesized that the rate of perceived stress will be higher in Canadianstudents than in Irish medical students.  Relevance: This study isof importance as prolonged increased stress is a predictor for mental healthdisorders (10). Thus, if stress in Canadianmedical students is increased, as hypothesized here, this finding would help toincrease awareness and may lead to recommendations of developing supportprograms for this population. Interventions may be most crucial in certainstages, thus students in all years of study will be surveyed.  1.0  Research DesignThis study withwill be a cross-sectional study of perceived stress in both Irishand Canadian medical students at the University College Cork (UCC). Although alongitudinal study following students from first through final years may be ofgreater impact, this study design will allow for completion within a reasonableamount of time (which is predicted to increase response rate from medicalstudents, who do not have a plethora of time) with limited resources.

Samplingacross different years will allow for some temporal element to be assessed. Cases willnot be matched. FR1  Age, gender(some sources noting higher stress in females (22)) and year of study will be captured as potentialconfounding factors in the questionnaire and will be controlled for in dataanalysis.  3.0 Study population and sampling This studyproposes use of cluster sampling; this study assumes that the Canadian medicalstudent population in Cork is similar to that of other parts of Ireland.  In- and exclusion criteria:The followingInclusion criteria apply for the proposed study.

Participants must: 1.    Bea UCC medical student in the graduate entry program, with a valid UCC studentnumber and email 2.    EITHERhave Canadian citizenship AND have lived in Canada for at least 6 out of 10years in the last decade OR have Irish citizenship AND have lived in Irelandfor the past 6 out of 10 years at least 6 out of 10 years in the last decade. No exclusioncriteria will be applied.  Sample size considerations: A similarstudy comparing stress levels as per Perceived Medical School Stress (PMSS)scale has been done in Sweden (23). A response rate of 90.4% of the 342students approached was reported (23). Here, 3 groups of students of different years of study (n=95-113) weresurveyed and significant results obtained.

However, other studies on stress inmedical students with sample sizes as low as 60 have obtained significantresults (21) Around 300 students are currently enrolled in the graduate entryprogram at UCC, with almost half being Canadian. Assuming a similar responserate, a response from 270 students may be obtainable. This study will aim at asample size of 160, 80 Canadian and 80 Irish students.  4.0 Data collection methods and instruments The Perceived Medical SchoolStress (PMSS) scale, as first described by Vitaliano et al. (24), willbe used to quantify the degree to which a student is experiencing stress.

This 13-itemquestionnaire has been validated, is a frequently used measure of stress in medicalschool and is a predictor of mental health problems upon graduation (10). Arecent systematic review has called for the PMSS to be the standard for futurestudies on stress in medical students (25). Informationpamphlets will be distributed to students in lecture halls and an announcementregarding the study will be made in classes prior to pamphlet distribution. Followingthis, the UCC medical student data base will be emailed with information aboutthe study, as well as the link to the web questionnaire and consent form (seeAppendix A+B).

Prior to starting the survey, the consent form will need to becompleted. Two email reminders will be send out and date of completion will benoted. Student participation will be incentivized via entering every studentinto a draw for a €40 voucher to a place of their choosing.    4.1 Data entry: Information gathered from the web questionnaire will betransferred into SPSS for statistical analysis.5.0 Data analysis Perceivedstress level differences between Irish and Canadian medical students will becompared. Data from the PMSS will be scored.

This study will test for normaldistribution of stress in medical students using a Kolmogorov-Smirnov test. Ifnormal distribution is confirmed, the mean PMSS score between Irish andCanadian medical students will be compared using a student- t- test. If notconfirmed, a Mann-Whitney U test will be done. A multivariate analysis using logistic regression will be done, lookingat impact of gender, year of study and age. A statistician will be consulted.  6.0 Mechanisms to assure the quality of the study Datacollection will be standardized as everyone will receive the same survey via emailat the same time. Response rate may be an issue and will be incentivized withentry into a draw for a €40 voucher upon completion of the survey.

The surveyalso is short and can be completed within 5 minutes which is most conducive tothe lifestyle of a medical student.  Limitations: Only one medical school is surveyedhere. Results may not be generalizable to all medical schools depending on thecomposition of their population and their specific curriculum. This study is relianton a questionnaire, which may be preferentially filled out by students withlower stress; stressed individuals are less likely to take time to participate.

To minimize this a short questionnaire is used. 7.0 Study Timetable 8.

0 Ethical considerations Ethical approval will be obtained from the Clinical Research EthicsCommittee prior to undertaking of the survey. Consent will be gathered from allparticipants. Risk and Benefits are outlined here. Data will be linked to a UCCstudent number for the purpose of preventing multiple entries of one person andto allow the winner of the draw to be contacted. Following this, all data willbe de-identified and personal identifiers will not be used in the analysis,presentation and publication of the data. Any datacontaining identifiers will be kept on password protected computers in passwordprotected files. All individuals are made aware of being able to withdraw fromthe study at any time. There are no conflicts of interest to declare.

 9.0 Resources required €40 voucher-incentivize participation€20- cost ofprinting pamphletsOverall: €60 Other thanthe above there are no other foreseeable costs associated.  FR1Howdo you deal with the fact that there are much more Irish than Canadianstudents? How do you deal with students from other countries?