**4. Discussion**

Without time limit, the literature search yielded 23 relevant articles reported on the effectiveness of stress management interventions on medical students. The earliest study was reported in 1978 (Soskis, 1978) and the most recent study was reported in 2011 (Yusoff, 2011). This section discussed on the effectiveness of those interventions with regards to five aspects which were 1) nature of participation, 2) research methods, 3) structure, facilitators and duration of intervention, 4) measured outcomes and instruments used to measure them, and 5) outcomes of the interventions.

In 2000, there were 15 studies reported stress reduction interventions on medical students (Shapiro et al., 2000) and in this present literature review there were 23 studies reported on the interventions (i.e. 11 years after Shapiro et al (2000) systematic review, only 8 additional studies were reported on stress management interventions for medical students). These facts suggested that despite large number of articles criticized on the negative impacts of stress related to medical training on medical students and call for remedies to buffer the unwanted consequences yet very few have put on effort to study on specific effects of stress management interventions on medical students (Shapiro et al., 2000). Even fewer studies have provided convincing data on the effectiveness of stress management interventions on medical students' health. Therefore, now is the right moment for medical educators to put more effort to expand the body of evidence on effective interventions in buffering the negative consequences of stress related to medical training on medical students (Butterfield, 1988; Shapiro et al., 2000).

#### **4.1 Nature of participation**

This systematic review clearly showed that the biggest limitation of the reported studies was related to sampling method of the participants which was non-randomized. As a result, voluntary nature of participation to the interventions was more likely to attract students who were highly motivated to change and thus more sensitive to any intervention done; this may lead to inaccuracy of outcomes measured. Nevertheless, logically having students voluntarily participating in the intervention may be more practical and feasible (Finkelstein et al., 2007). Perhaps, random sampling method in selecting participants of stress management interventions should be considered in future research to minimise bias due to volunteer participation. Therefore more authentic and convincing outcomes could be measured.

#### **4.2 Research methods**

This systematic review clearly showed that very few studies used robust study designs in investigating impact of stress reduction interventions on medical students and all of them were conducted in United State (US) as shown in the table 1. Although, Shapiro et al (2000) recommended in previous literature review to incorporate rigorous study design such as randomized control trial, unfortunately this recommendation has not been addressed where 11 non-randomized studies were done whereas only one randomized control trial was done post-recommendation (table 1). A possible reason for researchers preferred to conduct nonrandomized experimental studies instead of randomized control trial may be due to issues

Without time limit, the literature search yielded 23 relevant articles reported on the effectiveness of stress management interventions on medical students. The earliest study was reported in 1978 (Soskis, 1978) and the most recent study was reported in 2011 (Yusoff, 2011). This section discussed on the effectiveness of those interventions with regards to five aspects which were 1) nature of participation, 2) research methods, 3) structure, facilitators and duration of intervention, 4) measured outcomes and instruments used to measure them,

In 2000, there were 15 studies reported stress reduction interventions on medical students (Shapiro et al., 2000) and in this present literature review there were 23 studies reported on the interventions (i.e. 11 years after Shapiro et al (2000) systematic review, only 8 additional studies were reported on stress management interventions for medical students). These facts suggested that despite large number of articles criticized on the negative impacts of stress related to medical training on medical students and call for remedies to buffer the unwanted consequences yet very few have put on effort to study on specific effects of stress management interventions on medical students (Shapiro et al., 2000). Even fewer studies have provided convincing data on the effectiveness of stress management interventions on medical students' health. Therefore, now is the right moment for medical educators to put more effort to expand the body of evidence on effective interventions in buffering the negative consequences of stress related to medical training on medical students (Butterfield,

This systematic review clearly showed that the biggest limitation of the reported studies was related to sampling method of the participants which was non-randomized. As a result, voluntary nature of participation to the interventions was more likely to attract students who were highly motivated to change and thus more sensitive to any intervention done; this may lead to inaccuracy of outcomes measured. Nevertheless, logically having students voluntarily participating in the intervention may be more practical and feasible (Finkelstein et al., 2007). Perhaps, random sampling method in selecting participants of stress management interventions should be considered in future research to minimise bias due to volunteer participation. Therefore more authentic and convincing outcomes could be

This systematic review clearly showed that very few studies used robust study designs in investigating impact of stress reduction interventions on medical students and all of them were conducted in United State (US) as shown in the table 1. Although, Shapiro et al (2000) recommended in previous literature review to incorporate rigorous study design such as randomized control trial, unfortunately this recommendation has not been addressed where 11 non-randomized studies were done whereas only one randomized control trial was done post-recommendation (table 1). A possible reason for researchers preferred to conduct nonrandomized experimental studies instead of randomized control trial may be due to issues

**4. Discussion** 

and 5) outcomes of the interventions.

1988; Shapiro et al., 2000).

**4.1 Nature of participation** 

measured.

**4.2 Research methods** 

related ethical, feasibility and practicality of randomizing participants into intervention and control groups (Finkelstein et al., 2007; Piaw, 2009; Katz, 2010).

#### **4.3 Structure, facilitators and duration of intervention**

This systematic review demonstrated that majority of interventions was conducted by psychologist/psychiatrist, offered as an elective course as well as seminar or workshop, consumed a duration of 360 to 540 minutes over 3 to 8 weeks and involved 30 to 50 participants. For RCT studies, majority involved year 1 medical students as study subjects, sample size for intervention groups ranged from 4 to 50 participants and relatively RCT used random sampling method had poorer response rate compared to non-random sampling (table 9). Perhaps stress management interventions should be conducted by general faculty members of medical schools instead of few experts so that the interventions can be implemented effectively to medical students. On top of that, most of the studies had not explained theoretical basis of the intervention was designed. Perhaps, future studies should describe the theoretical basis of stress management intervention was designed so that researchers could compare and come out with more effective intervention based on more robust theory of stress management intervention for medical students. It is worth highlighted that generally the interventions were categorised into brief, short-duration, medium-duration and long-duration stress management internvetions.

#### **4.4 Measured outcomes and instruments used to measure them**

This review revealed that various aspects of health outcomes were measured ranging from students' perception up to health biomarkers. Despite the variability of measured outcomes, there were three main outcomes related to psychological health as measured by most of the studies which were anxiety, depressive and psychological distress symptoms. These outcomes were mainly measured by established psychological health measurements such as the State-Trait Anxiety Inventory, Brief symptoms Inventory, Symptoms Checklist Revised, Depression Anxiety Stress Scale and Beck Depression Inventory. Other important outcomes that should be considered in future researches such as academic performance, patient-doctor relationship, loneliness state, health biomarkers, quality of life, and suicidal thoughts.

#### **4.5 Outcomes of the interventions**

For the past 24 years, regardless of the duration of stress management interventions, this literature review revealed the interventions done on medical students had important positive outcomes on several areas related to health. The outcomes ranged from positive students feedback up to improvement of health biomarkers. The reported positive outcomes were related to 1) positive student feedbacks, 2) improved psychological health, 3) improved loneliness and mood disturbances, 4) improved physiologic and immunologic health markers, 5) improved quality of life, spirituality, and empathy, 6) improved psychological states of mind, 7) increased awareness about stress, its effects and management, and 8) improved perceived ability to cope effectively and positively. Despite of these positive outcomes, none of studies demonstrated effectiveness of the interventions

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on clinical competencies, professionalism, doctor-patient relationships, attrition and suicidal thoughts. Perhaps these outcomes should be investigated in future researches.

### **5. Conclusion**

This systematic review found that stress management interventions done on medical students were well-accepted and had important positive outcomes on several areas related to health. Despite these encouraging outcomes several limitations should be considered for future research which are (1) longer duration of follow up measurement on intended outcomes, (2) more robust research method, including proper sample size calculation, random sampling of subjects, randomised allocation of subjects to intervention group and comparable control group, (3) comparing impacts of intervention on different stages of medical training, (4) customized and personalized stress management, (5) investigate the impacts of stress management on professionalism, doctor-patient relationship and patient care in future, and (6) specify the theoretical basis of stress management was developed.

The implications of this review are significant on a few areas that might be worthwhile for further research. Future research must look at impacts of different duration and frequency of stress management interventions on students' health, personal and professional development; therefore optimal duration and frequency of these interventions to produce positive impacts can be determined. It is also worthy to explore which components of these interventions produce therapeutic effects and which are more effective. On top of that, future research must look at which of these interventions work best to which group of students, therefore personalized and customised stress management interventions can be designed accurately and effectively. Last but not least, future research must utilise rigour and robust research methodology to elicit real impacts of stress management interventions. Perhaps, the implications discussed in this review are not only confined to medical students, but it can be also utilised by researchers of other disciplines as a guideline to design, plan and conduct similar researches in their own setting. Utilization of similar health measurements for outcomes comparison in future researches is recommended.

#### **6. Acknowledgment**

We would like to express our deepest gratitude and thank to our parents, wife and family who gave great support and spared their time for the success of completing this chapter. We would like to express our thank to Professor Syed Hatim Noor, Associate Professor Mohd Jamil Yaacob, the Head Department of Medical Education, staff and colleagues for their continuous support. Last but not least my deepest appreciation to medical students who inspire me to write this chapter. Most and foremost our greatest gratitude to Universiti Sains Malaysia for providing funds under the Research University Grant 1001/PPSP/812086.

#### **7. References**

Aktekin M., Karaman T., Senol Y.Y., Erdem S., Erengin H. & Akaydin M. (2001). Anxiety, depression and stressful life events among medical students: a prospective study in Antalya, Turkey. *Medical Education*, 35(1), 12-17.

on clinical competencies, professionalism, doctor-patient relationships, attrition and suicidal

This systematic review found that stress management interventions done on medical students were well-accepted and had important positive outcomes on several areas related to health. Despite these encouraging outcomes several limitations should be considered for future research which are (1) longer duration of follow up measurement on intended outcomes, (2) more robust research method, including proper sample size calculation, random sampling of subjects, randomised allocation of subjects to intervention group and comparable control group, (3) comparing impacts of intervention on different stages of medical training, (4) customized and personalized stress management, (5) investigate the impacts of stress management on professionalism, doctor-patient relationship and patient care in future, and (6) specify the theoretical basis of stress management was developed.

The implications of this review are significant on a few areas that might be worthwhile for further research. Future research must look at impacts of different duration and frequency of stress management interventions on students' health, personal and professional development; therefore optimal duration and frequency of these interventions to produce positive impacts can be determined. It is also worthy to explore which components of these interventions produce therapeutic effects and which are more effective. On top of that, future research must look at which of these interventions work best to which group of students, therefore personalized and customised stress management interventions can be designed accurately and effectively. Last but not least, future research must utilise rigour and robust research methodology to elicit real impacts of stress management interventions. Perhaps, the implications discussed in this review are not only confined to medical students, but it can be also utilised by researchers of other disciplines as a guideline to design, plan and conduct similar researches in their own setting. Utilization of similar health

measurements for outcomes comparison in future researches is recommended.

We would like to express our deepest gratitude and thank to our parents, wife and family who gave great support and spared their time for the success of completing this chapter. We would like to express our thank to Professor Syed Hatim Noor, Associate Professor Mohd Jamil Yaacob, the Head Department of Medical Education, staff and colleagues for their continuous support. Last but not least my deepest appreciation to medical students who inspire me to write this chapter. Most and foremost our greatest gratitude to Universiti Sains Malaysia for providing funds under the Research University Grant 1001/PPSP/812086.

Aktekin M., Karaman T., Senol Y.Y., Erdem S., Erengin H. & Akaydin M. (2001). Anxiety,

Antalya, Turkey. *Medical Education*, 35(1), 12-17.

depression and stressful life events among medical students: a prospective study in

thoughts. Perhaps these outcomes should be investigated in future researches.

**5. Conclusion** 

**6. Acknowledgment** 

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*Edited by Asuncion Lopez-Varela*

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Issues of Language, Public Opinion,

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