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A Study of Psychological Distress in Two
Cohorts of First-Year Medical Students
that Underwent Different Admission
Muhamad Saiful Bahri Yusoff1, Ahmad Fuad Abdul Rahim1,
Abdul Aziz BaBa2, Shaiful Bahari ismail2, Ab Rahman Esa1
Submitted: 30 Mar 2011
Accepted: 12 Dec 2011
? Methods:?A?comparative?cross-sectional?study?was?conducted?by?comparing?2?cohorts?of? first-
cohort)? and? the? other? group? (cohort? 2)? was? selected? based? on? academic? merit,? psychometric?
assessment,?and?interview?performance?(2009/2010?cohort).?Their?distress?levels?were?measured? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?
by? the? General? Health? Questionnaire,? and? scores? higher? than? 3? were? considered? indicative? of?
This? selection? process? might? identify? medical? students? who? will? maintain? better? psychological? ? ? ? ? ? ? ? ? ? ?
has stated that, “Health? is? a? state? of? complete? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?
and “mental?health?can?be?defined?as?a?state?of? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?
well-being? enabling? people? to? realize? their?
abilities,? cope? with? normal? stresses? of? life,?
work? productively? and? fruitfully,? and? make?
contributions?to?their?communities.” (2). Mental
health is crucial to the overall and individual
well-being, directly or indirectly, contributes to
the overall well-being of societies and countries
(2). In 2003, the WHO reported that mental
illness is the fourth leading contributor to
the global burden of diseases; approximately
450 million people suffer from a mental or
behavioural disorder and nearly 1 million people
The World Health Organization (WHO)
commit suicide each year (2,3). The WHO
projected that in 2020 mental illness will be the
second leading contributor to the global burden
of diseases (3). These facts could indicate a
substantial increase in stress in individuals’ daily
lives. Medical students and professionals are
not immune to this daily stress; in fact, studies
found that the prevalence of mental disorder
among these populations are higher compared
to the general population (5–8).
Previous studies have revealed a rate
of psychological distress
students ranging from 21.6%–50% (5,6,10–12).
Medical students are particularly vulnerable at
transitional periods such as their first year
of medical school, when they face a period
of adjustment to the new environment of
Malays J Med Sci. Jul-Sep 2012; 19(3): 29-35
Malays J Med Sci. Jul-Sep 2012; 19(3): 29-35
medical training (6,9–14). The prevalence
of psychological distress
students at the end of their first-year of medical
training has been shown to double compared
to the prevalence at the beginning of the year
(9,10). Studies also reported a high percentage
of psychological distress among medical students
at other stages of medical training (10–13).
Psychological distress among medical students
was associated with anxiety and depression
(14,15), interpersonal conflict (16), sleeping
problems (17), and lower academic and clinical
performance (18). Psychological distress also
has a negative impact on students’ abilities to
develop a rapport with patients, to concentrate
and focus on their training, and to make
decisions, which in turn leads to dissatisfaction
during their clinical practice later on (16).
Psychological distress was also linked to suicide
(19), drug abuse (20,21), and abuse of alcohol
(22). The psychological distress that leads
to these unwanted consequences has been
related to some aspects of medical training
(14). Generally, psychological distress hinders
the noble ambitions and values of students
pursuing medical education.
The aim of medical education is to produce
healthy and competent doctors to serve the
society. The student selection process, therefore,
is essential to medical training because the
quality of students admitted to medical schools
determines the quality of doctors who graduate
(23). Methods of selection are generally
grouped into cognitive
methods. Cognitive method focus on previous
academic performance, whereas non-cognitive
methods focus on less concrete variables using
measurement methods such as psychometric
assessments and interviews. Most medical
schools prefer to select their medical students
based on previous academic
because it is a better predictor of the student
success in medical study (24–26). However,
good academic achievement does not necessarily
predict a doctor’s professional performance
(24,27), and the predictive capacity of previous
academic achievement for successful medical
study diminishes with progression through
the course of medical training (24). A 9-year
prospective study found that information gained
through psychometric test and interview was
associated with measured outcomes and that
those who performed well during the interview
had greater chances of completing their
studies at medical school with honours (28).
Medical Sciences, Universiti Sains Malaysia was
given the authority to semi-independently select
their own medical students by the Malaysian
government. The school began selecting students
based on three criterias; previous academic
performance, psychometric assessment, and
cohorts had been selected based solely on
previous academic achievement. This study
aimed to compare the prevalence and levels of
psychological distress between 2 cohorts of the
first-year medical students selected through
2 different student admission processes. 1 batch
was selected based solely on previous scholastic
merit (cohort 1), and the other was selected
based on academic
assessment, and interview
(cohort 2). To our knowledge, no reports
comparing these types of student selection exist
in the literature. It is hoped that this article will
contribute to the literature regarding medical
student admission and mental health.
Starting from June 2009, the School of
Materials and Methods
A comparative cross-sectional study was
cohort 2 in the School of Medical Sciences,
Universiti Sains Malaysia (USM).
Cohort 1 students were selected based solely
on their previous academic merit; specifically,
their final Cumulative Grade Point Average of
the Science Foundation Course of the Malaysian
Ministry of Education, or equivalents, which
were the High School Certificate of Malaysia
(HSC) or Advanced Level General Certificate of
Cohort 2 students were selected based
on previous academic
cohort 1) in addition to psychometric assessment
and interview performance. The Malaysian
Universities Selection Yearly Inventory (MUnSYI)
was used as the psychometric assessment to
assess the suitability of candidates for medical
study. Unfortunately, the details of the MUnSYI
are not available to the public because it is
protected under the Official Secrets Act 1972
(Act 88) of Malaysian Law. A short list
of applicants, selected based on their previous
academic merits and
The study samples were cohort 1 and
merit (similar to
Original Article | Psychological distress and student admission
assessment, were then called for an interview.
The main objectives of the interview were
as follows: 1) to assess the interest, general
knowledge, and expectations of applicants about
medical education and a medical career, 2) to
assess the personal attributes of the applicants
in relation to their suitability for studying
medicine at USM, 3) to assess the applicants’
adequacy in communicating in both Malay and
English languages as basic requirements for
a successful medical study, and 4) to observe
any physical traits that might hinder the
applicants from completing the medical studies
or performing clinical functions.
Every enrolled medical students from
cohort 1 and cohort 2 were invited to participate.
215 students were enrolled in cohort 1, and
196 students were enrolled in cohort 2. Both
cohorts underwent a
structure in terms of content, teaching, and
learning methods and assessment. Both cohorts
also studied in the same physical learning
clearance from the School of Medical Sciences
and the Human Research and Ethics Committee
of USM prior to the conduct of the study.
Health Questionnaire (GHQ-12) was used in
this study. Demographic data pertaining to
sex (male and female), race (Malay, Chinese,
Indian, and other), and entry qualifications
(matriculation, HSC, or A-Level) were obtained
from the participants. Data for both groups were
collected within 2 months after enrollment so
that researchers could measure the students’
baseline distress levels upon entry to medical
school. This time point was selected as
the baseline because it was considered a
non-stressful period for the medical students.
The GHQ-12 is a widely used instrument
to measure mental health status (29). It has been
validated in many populations, including medical
students (29–32). The internal consistency
coefficients of the questionnaire have ranged
from 0.78–0.95 in various studies (33). The items
of GHQ-12 assess 12 manifestations of stress,
and respondents are asked to rate the presence
of each manifestation in themselves during
recent weeks. Respondents choose from four
responses: ‘not at all’, ‘no more than usual’,
‘rather more than usual’, and ‘much more than
usual’. The scoring method is binary; the 2 least
symptomatic answers are scored as 0 and the
12-item self-administered General
2 most symptomatic answers are scored as 1;
i.e., 0-0-1-1. The minimum and maximum scores
of the GHQ-12 are 0 and 12, respectively. Higher
GHQ-12 scores indicate poorer mental health
status. In previous studies the sensitivity and
specificity of the GHQ-12 score at a cut-off point
of 4 have been shown to be 81.3% and 75.3%,
respectively, with a positive predictive value of
62.9%. Therefore, students who scored 4 or more
were considered to have ‘distress’ (29–32).
GHQ-12 to the 215 new first-year medical
students of cohort 1 and to the 196 new first-year
medical students of cohort 2 at approximately
2 months after enrollment. Completion of
the questionnaire was voluntary and did not
affect the students progress in the course. Data
were collected in two face-to-face sessions
with the students in a lecture hall via guided
self-administration. Students took less than
10 minutes to complete the questionnaire, and
questionnaires were collected immediately after
they were completed.
Data were analysed using SPSS version
18 (SPSS Inc., US). An α-level of P < 0.05 was
adopted. Descriptive statistics were conducted
for the analysis of demographic data and the
prevalence of psychological distress. For the
purpose of statistical analysis, race was grouped
into either Malay or non-Malay, and entry
qualification was grouped into matriculation
constructed and normality tests (Kolmogoroz-
Smirnov and Shapiro-Wilk) were performed
to test for normality of the distributions of
GHQ-12 scores for each cohort. The distribution
of GHQ-12 scores in both cohorts were skewed
to the left; however, the normality tests were
significant (P < 0.001); therefore the Mann-
Whitney test was used to compare the median
GHQ-12 score between the 2 cohorts of medical
students. The Chi-square test was used to test
for differences in demographic variables (sex,
race, and entry qualification) and for differences
in the prevalence of psychological distress
between the 2 cohorts. Multiple binary logistic
regression (stepwise and enter method) was
conducted to compare the risk of developing
distress between the 2 cohorts.
from cohort 1 and 196 (100% of the class)
A total of 215 (99.1% of the class) students
Malays J Med Sci. Jul-Sep 2012; 19(3): 29-35
students from cohort 2 participated in this study.
The demographic profile of the participants
is shown in Table 1. The distributions of gender
and entry qualification did not differ significantly
between cohorts (P > 0.05). However, the
distribution of ethnic groups was significantly
different between the 2 cohorts (P < 0.001).
Mann-Whitney test analysis showed that
there was a significant difference of the median
GHQ-12 score between cohort 1 (median = 2,
IQR = 4) and cohort 2 (median = 1, IQR = 3)
(Z = -3.2, P = 0.001).
The prevalence of medical students having
significant psychological distress (CI 95%; lower
limit, upper limit) in cohort 1 and cohort 2
were 26.3% (n?= 56; 23.6%, 29.0%), and 14.3%
(n?= 28; 12.6%, 16.0%), respectively. A Pearson
Chi-square test analysis showed that the
significantly different between the 2 cohorts
(X2 (df) = 9.02 (1), P = 0.003), as shown in
Multiple binary logistic regression showed
that cohort 1 had a 2.019 times higher risk
of developing distress compared to cohort 2
(b = 0.704, Wald (df) = 7.316 (1), P = 0.007), as
shown in Table 2.
In sum, the results indicated that cohort
2 had better psychological health compared to
of psychological distress was
among medical students of cohort 2 (14.3%)
was lower compared to the prevalence in cohort
The prevalence of psychological distress
Table?1:?Demographic profiles of the 2 student cohorts
Sex, n (%)Male
Race, n (%) 0.012
a Pearson Chi-square test.
Figure?1: Comparison of prevalence of psychological distress in 2 cohorts
of first-year medical students at the beginning of their training.
Original Article | Psychological distress and student admission
1 (26.3%) and was also lower compared to the
prevalence in previously reported samples, which
have ranged from 21.6%–50% (5,10,11,34–36).
The current study only examined psychological
distress at a very early stage of medical training.
Because previous studies have indicated that
psychological distress can vary at different stages
of medical training (10–13), the current samples
should be followed during their clinical training
years; such follow-up would provide stronger
and more constructive evidence to support the
The significantly lower number of medical
students having psychological
cohort 2 compared to cohort 1 suggested better
psychological health in this cohort. This was further
supported by cohort 2, which have significantly
lower risk of developing psychological distress
compared to cohort 1. These findings indicated
that the multimodal selection process based
on academic merit, psychometric assessment,
and interview performance was able to identify
medical students with better psychological health
better than the selection process that was based
solely on academic merit. To our knowledge,
this is the first study to report such a finding.
It is important to highlight that previous studies
found the prevalence of psychological distress
among medical students at the end of the first
year of study to be twice as high compared to the
beginning of the first year (9,10).
The current results are not enough to
confirm the advantage of the expanded student
selection process. Such confirmation requires
follow-up of these medical students over a longer
duration. A prospective study design is necessary
to explore the long-term differences between
the 2 selection processes. Many researchers
proposed that selecting psychologically healthy
candidates will buffer the negative effects of
some aspects of medical training (5,10–12,14,37).
Accordingly, better identification of medical
students with good psychological health might
eventually produce future doctors who are
psychologically healthy. Downie & Chartlon
(1992) echoed that the type of medical students
recruited at the beginning of training will
determine the type of doctors produced at the
The aim of the student admission process is
not to pick candidates for specific jobs, but rather
to choose persons of strong potential who are
healthy (physically, emotionally, psychologically,
and mentally), who will eventually find their
interest and niche somewhere in medicine and
who will subsequently take the field of medicine
to a higher level (38). In accord with that notion,
findings from the current study provide initial
evidence that multimodal student selection
can successfully identify the medical students
that are psychologically healthy. This finding is
commensurate with recent evidence that cognitive
superiority alone does not protect medical
students from distress even up to the internship
This study has several limitations that
should be considered in interpreting its findings
and in designing future studies. The first is related
Table?2:?Factors related to psychological distress among the 2 student cohorts
0.704 7.3161 2.019 1.2113.366
-0.238 0.6511 0.789 0.443 1.404
Sex Reference group
a Multiple Binary Logistic Regression (stepwise enter method) was applied.
X2 (df) = 12.06 (4), p = 0.017, -2 Log likelihood = 403.29.
Malays J Med Sci. Jul-Sep 2012; 19(3): 29-35
to the study design. The cross-sectional design
used in this study produces only a snapshot of a
particular time; therefore, a longitudinal study
design is necessary to explore the advantages of
the new student admission process over time. The
second limitation concerns other confounding
factors such as socio-economic status, parent
education level, stress at home, distress level
prior to entry of medical training, psychiatric
status prior to medical training, personality
and family relationships. These factors should
be controlled either during sample selection or
during data analysis to isolate the effects of the
new multimodal student admission process.
The third limitation is that data were collected
face-to-face, which may not be seen by
participants as completely anonymous (even
though participants did not provide names
on the questionnaire). This data collection
procedure might have led to response bias.
The fourth limitation is that our single
psychological health measurement was unlikely
to provide a comprehensive
psychological health. Other psychological health
measurements should be used during follow
up in future studies.
than cohort 1. Cohort 2 were less vulnerable to
develop psychological distress compared to cohort
1. This study provides evidence that multimodal
student selection might better identify medical
students with good psychological health.
Cohort 2 had better psychological health
Sciences, Universiti Sains Malaysia for supporting
and allowing us to involve their first year medical
students in this study. Our special thanks to the
academic staff for their help.
Our special thanks to the School of Medical
Conception and design, provision of study
materials; collection, assembly, analysis, and
interpretation of the data; critical revision and
final approval of the article; administrative,
technical, or logistic support: MSBY, AFAR, AAB,
Obtaining of funding: AAB, SBI
Statistical expertise, drafting of the article: MSBY
Dr Muhamad Saiful Bahri Yusoff
MD (USM), MSc Med Edu (USM)
Medical Education Department
School of Medical Sciences
Universiti Sains Malaysia Health Campus
16150 Kubang Kerian
Tel: +609-7663 940
Fax: +609-7673 370
1. World Health Organization (WHO). Definition of
health. [Internet]. Geneva (CH): WHO; 1948 [cited
2010 August 28]. Available from: http://www.who.
2. World Health Organization (WHO). Investing in
mental health. [Internet]. Geneva (CH): WHO;
2003 [cited 2010 August 28]. Available from: http://
3. World Health Organization (WHO). Mental Health:
Depression. [Internet]. Geneva (CH): WHO; 2003
[cited 2010 August 28]. Available from: http://www.
4. Dahlin M, Joneborg N, Runeson B. Stress and
depression among medical students: A cross-sectional
study. Med?Educ. 2005;39(6):594–604.
5. Guthrie E, Black D, Bagalkote H, Shaw C, Campbell
M, Creed F. Psychological stress and burnout in
medical students: A five-year prospective longitudinal
study. J?R?Soc?Med. 1998;91(5):237–243.
6. Yusoff MSB, Rahim AFA, Yaacob MJ. Prevalence and
sources of stress among Universiti Sains Malaysia
Medical students. Malaysian? J? Med? Sci. 2010;
7. Yusoff MSB, Rahim AFA. Prevalence & sources of
stress among postgraduate medical trainees: Initial
findings. Asean?Journal?of?Psychiatry. 2010;11(2):
8. Cooper C, Rout U, Faragher B. Mental health,
job satisfaction, and job stress among general
practitioners. Br?Med?J. 1989;298(6670):366–370.
9. Vitaliano PP, Maiuro RD, Russo J, Mitchell ES.
Medical student distress: A longitudinal study. J?Nerv?
10. Aktekin M, Karaman T, Senol YY, Erdem S, Erengin
H, Akaydin M. Anxiety, depression, and stressful life
events among medical students: A prospective study
in Antalya, Turkey. Med?Educ. 2001;35(1):12–17.
11. Firth J. Levels and sources of stress in medical students.
Original Article | Psychological distress and student admission Download full-text
12 Guthrie EA, Black D, Shaw CM, Hamilton J, Creed
FH, Tomenson B. Embarking upon a medical career:
Psychological morbidity in first year medical students.
13. Miller PM, Surtees PG. Psychological symptoms and
their course in first-year medical students as assessed
by the Interval General Health Questionnaire
(I-GHQ). Br?J?Psychiatry. 1991;159(8):199–207.
14 Shapiro SL, Shapiro DE, Schwartz GE. Stress
management in medical education: A review of the
literature. Acad?Med. 2000;75(7):748–759.
15. Rosal MC, Ockene IS, Ockene JK, Barrett SV, Ma
Y, Hebert JR. A longitudinal study of students’
depression at one medical school. Acad? Med.
16. Clark EJ, Rieker PP. Gender differences in
relationships and stress of medical and law students.
17. Niemi PM, Vainiomaki PT. Medical students’
distress–quality, continuity and gender differences
during a six-year medical programme. Med? Teach.
18. Linn BS, Zeppa R. Stress in junior medical students:
relationship to personality and performance. J?Med?
19. Hays LR, Cheever T, Patel P. Medical student suicide,
1989–1994. Am?J?Psychiatry. 1996;153(4):553–555.
20. Newbury-Birch D, White M, Kamali F. Factors
influencing alcohol and illicit drug use amongst
medical students. Drug? Alcohol? Depend. 2000;
21. Pickard M, Bates L, Dorian M, Greig H, Saint D.
Alcohol and drug use in second-year medical students
at the University of Leeds. Med?Educ. 2000;34(2):
22. Flaherty JA, Richman JA. Substance use and addiction
among medical students, residents, and physicians.
23. Downie RS, Charlton B. The? Making? of? Doctor:?
(US): Oxford University Press; 1992.
24. Tutton P, Price M. Selection of medical student
– affirmative action goes beyond the selection process.
25. Cohen-Schotanus J, Arno MMM, Rreinders JJ,
Jessica A, Van Rossum HJM, Van Der Vleuten CPM.
The predictive validity of grade point average scores
in a partial lottery medical school admission system.
26. Kulatunga-Moruzi C, Norman GR. Validity of
admissions measures in predicting performance
outcomes: The contribution of cognitive and
non-cognitive dimensions. Teach? Learn? Med.
27. Norman G. Editorial – The morality of medical school
28. Powis DA, Neame RL, Bristow T, Murphy LB.
The objective structured interview for medical
student selection. Br? Med? J? (Clin? Res? Ed).
29. McDowell I. Measuring? health:? A? guide? to? rating?
scales?and?questionnaires. 3rd ed. New York (US):
Oxford University Press; 2006.
30. Yusoff MSB, Rahim AFA, Yaacob MJ. The sensitivity,
specificity and reliability of the Malay version
12-items General Health Questionnaire (GHQ-12)
in detecting distressed medical students. Asean?
31. Goldberg D, Gater R, Sartorius N, Ustun TB, Piccinelli
M, Gureje O, et al. The validity of two versions of the
GHQ in the WHO study of mental illness in general
health care. Psychol?Med. 1997;27(1):191–197.
32. Yusoff MSB. The validity of two Malay versions of the
General Health Questionnaire (GHQ) in detecting
distressed medical students. Asean? Journal? of?
33. Jackson C. The General Health Questionnaire.
34. Saipanish R. Stress among medical students in a Thai
medical school. Med?Teach. 2003;25(5):502–506.
35. Sherina MS, Lekhraj R, Nadarajan K. Prevalence
of emotional disorder among medical students in a
Malaysian university. Asia?Pacific?Family?Medicine.?
36. Zaid ZA, Chan SC, Ho JJ. Emotional disorders among
medical students in a Malaysian private medical
school. Singapore?Med?J. 2007;48(10):895–899.
37. Yusoff MSB, Rahim AFA. mpact of medical student
well-being workshop on the medical students’
stress level: A preliminary study. Asean?Journal?of?
38. Richards P, Stockill S. The?New?Learning?Medicine.
14th ed. London (GB): BMJ Publishing; 1997.
39. West CP, Shanafelt TD, Cook DA. Lack of association
between resident doctors’ well-being and medical
knowledge. Med?Educ. 2010;44(12):1224–1231.