Holm et al. BMC Medical Education 2010, 10:23
Self-development groups reduce medical school
stress: a controlled intervention study
© 2010 Holm et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Mari Holm*1, Reidar Tyssen2, Kirsten I Stordal3 and Brit Haver1
Background: High stress levels and mental health problems are common among medical students and there is a lack
of studies on group interventions that aim to reduce such distress during medical school.
Methods: A full class of students (n = 129) participated in group sessions during their third year of medical school in
Bergen, Norway. The subsequent third-year class (n = 152) acted as control group, in order to create a quasi-
experimental design. Two types of group intervention sessions were offered to the first class. One option was self-
development groups led by trained group psychotherapists. Alternatively, students could choose discussion groups
that focused on themes of special relevance to doctors, led by experienced general practitioners. The intervention
comprised of 12 weekly group sessions each lasting 90 minutes. Data were gathered before the intervention (T1), and
three months post intervention (T2). Distress was measured using the Perceived Medical School Stress (PMSS) and
Symptom Check List-5 (SCL-5) assessments.
Results: The intervention group showed a significant reduction in PMSS over the observation period. The subsequent
year control group stayed on the same PMSS levels over the similar period. The intervention was a significant predictor
of PMSS reduction in a multiple regression analysis adjusted for age and sex, β = -1.93 (-3.47 to -0.38), P = 0.02. When
we analysed the effects of self-development and discussion groups with the control group as reference, self-
development group was the only significant predictor of PMSS reduction, β = -2.18 (-4.03 to -0.33), P = 0.02. There was
no interaction with gender in our analysis. This implicates no significant difference between men and women
concerning the effect of the self-development group. There was no reduction in general mental distress (SCL-5) over
Conclusion: A three-month follow-up showed that the intervention had a positive effect on perceived medical school
stress among the students, and further analyses showed this was due to participation in self-development groups.
Stress and emotional disturbances among students at
medical school are relatively common, and seemingly,
this is a worldwide problem [1-4]. Studies indicate that
specific stress factors related to medical school may
induce mental health problems, and a decrease in life sat-
isfaction among students [2,5-7]. Distress may affect their
performance as students and later as carers for patients
Interventions aimed at preventing mental health prob-
lems and prolonged negative stress during medical school
have been recommended in several reports. Chew-Gra-
ham et al. recommend that support and mentoring by a
tutor outside the students' working environment should
be included in the preparation of physicians in order to
identify and deal with professional stress in an appropri-
ate manner . Examples of interventions include: stu-
dent counselling, support groups, and lectures focusing
on stress reduction and coping strategies [11-14]. How-
ever, the intervention studies reported in the literature
have limitations, such as small sample size, lack of control
groups, and only addressing selected groups of students.
Gender differences in mental health measures have been
identified among medical students and doctors [3,15],
and females constitute an increasing proportion of the
total student population. Despite this, few studies have
explored gender differences in students' response to
interventions. Further, most studies have used qualitative
* Correspondence: Mari.email@example.com
1 Department of Clinical Medicine, Section for Psychiatry, University of Bergen,
N-5020 Bergen, Norway
Holm et al. BMC Medical Education 2010, 10:23
Page 2 of 8
self-reports, and few present quantitative data using vali-
dated instruments . In addition, it has been suggested
that voluntary recruitment may not reach all of those who
need help . To the best of our knowledge, no con-
trolled studies have been published that have investigated
the effect of mandatory group interventions for medical
Stress levels among medical students at different uni-
versities have been investigated using instruments focus-
ing on the stressors within medical education [3,18]. The
Perceived Medical School Stress (PMSS) scale is an exam-
ple of such an instrument, which addresses and measures
stress factors specifically related to medical school . It
consists of stressor items such as perceived threat, feel-
ings of anonymity and isolation, and worries about
schoolwork and competence. Lack of time for social
activities and recreation, and worries about finances and
accommodation are also included. In Norwegian medical
students, a high level of perceived stress during medical
school predicts undergraduate and postgraduate mental
health problems that may require treatment [5,20]. Anxi-
ety and depression in medical students have been
assessed using a variety of instruments [6,21,22]. In Nor-
way, various versions of the Symptom Check List (SCL-
90) have been widely used to measure anxiety and
depression  in the general population, in clinical
groups and medical students [6,24,25]. A short version of
this measure was used to capture general mental distress
in our sample, and to identify if the intervention influ-
enced such health problems.
With this background in mind, a group intervention
aimed at preventing mental health problems among med-
ical students was developed and carried out at the Uni-
versity of Bergen, Norway. The objective of the study was
to compare a full class of students receiving specific inter-
ventions with another group that received no interven-
tion. We investigated the course of perceived stress and
general distress in the two groups over time to detect any
possible short-term effects of the intervention.
Participants and procedures
Two subsequent classes of third-year medical students at
the University of Bergen, Norway participated in this
quasi-experimental study. Medical students in Bergen
follow a "traditional" curriculum, with two years of pre-
clinical studies, followed by four years of clinical training.
Problem-based learning is not a part of the curriculum.
The intervention took place in the initial months of the
students' clinical training. The intervention group (n =
129) enrolled at the university in 2001, and a second
group (n = 152) enrolled in 2002, acted as the control
group. Both groups were assessed twice. The intervention
group was assessed before (T1), and three months after
end of intervention (T2), while the control group was
assessed at the same points in time. The medical curricu-
lum was identical for both groups.
The intervention was mandatory, but the participants
could choose between two types of intervention. One
option was self-development groups based on the model
of therapy groups. The meetings focused on the students'
positive resources and personal lives, and aimed at
enhancing the participant's self esteem and personal
insight. Another part of the programme involved identi-
fying typical patterns of relationships that restricted their
full capacity to relate to other people. The self-develop-
ment group sessions were led by psychiatrists trained in
group analytic treatment. Alternatively, the students
could attend discussion groups where different topics rel-
evant to medical studies and their later practice as doc-
tors were discussed. Examples of issues discussed in these
groups were: how to handle stress at work, balancing pro-
fessional and private life, how to handle and communi-
cate with difficult patients, and how to "break bad news"
to patients and their relatives. Topics were selected by the
students from a prepared list, or suggested by the stu-
dents themselves. The discussion groups were lead by
experienced general practitioners. The students were
divided into groups of 8-10 participants. The format
comprised 12 weekly group sessions, each lasting 90 min-
Participating in self-development or discussion groups
was a mandatory part of the curriculum for medical stu-
dents, similar to other mandatory courses at the Medical
Faculty of the University of Bergen. However, to partici-
pate in the study concerning mental health was voluntary
for all of the students, both in the intervention and con-
trol group. All students who chose to participate in the
study signed a form of consent together with the first
questionnaire. This form was sent together with an infor-
mation letter describing the content, purpose and time
dimension of the study. The letter also stated that the stu-
dents would remain anonymous throughout and after the
study. The same information was given orally in class for
both groups. The questionnaires and information about
the study were distributed by mail, with a postal reminder
Informed consent was obtained from 83.3% (234/281)
of the students. Altogether, 75.6% (177/234) of those who
consented to participate responded on all items on both
occasions (T1 and T2). This constituted 63.0% (177/281)
of the original sample. There were no statistically signifi-
cant differences in gender or mean age between the self-
development, discussion, and control groups.
The three groups' personality traits were also compared
using the questionnaire Basic Character Inventory (BCI).
BCI includes 27 items and capture Eysenck's Giant three
personality trait dimensions: neuroticism, extraversion,
Holm et al. BMC Medical Education 2010, 10:23
Page 3 of 8
and conscientiousness (low psychoticism) [7,26]. There
were no statistically significant differences in distribution
for the three traits between the self-development, discus-
sion and control groups.
Ethical approval was obtained from the Regional Com-
mittee for Medical Research Ethics and the Norwegian
Social Science Data Service, which are the authority of
research ethics in Norway.
The programme was an integrated part of the curricu-
lum and did not interfere with exams or holidays. Atten-
dance was mandatory, but the students had the
opportunity to be absent from two of the twelve group
sessions, in case of sickness or other unplanned inci-
dences. The leader of each group kept a list of attendance.
During the intervention period, group leaders held
meetings to exchange experiences and discuss possible
problems that may have occurred in the groups. For
example, two students were advised to seek psychiatric
treatment after such discussions among the leaders. The
group leader meetings were administered and led by co-
author K. I. S (Table 1).
Measures of distress
Perceived Medical School Stress
The level of perceived stress among students was mea-
sured using the Perceived Medical School Stress (PMSS)
questionnaire , with minor adaptations to reflect the
situation of Norwegian students , see Additional file 1.
The PMSS questionnaire has shown a concurrent validity
to symptoms of anxiety and depression among medical
students , and a predictive validity on mental health
problems in need of treatment four years after graduation
from medical school .
Each of the 13 items has a five-point Likert scale, rang-
ing from "strongly disagree = 0" to "strongly agree = 4".
We used the total score of the items to indicate the level
of stress among the students, where a high score indi-
cated a high level of perceived stress. In the current study,
the Cronbach's alpha coefficient for the entire group was
0.79 at T1. The 13 items of the PMSS scale were subjected
to a principal component analysis with varimax rotation,
including a scree plot evaluation. This confirmed three
factors, in accordance with previously reported research
: "Medical school is cold and threatening", "Worries
about work and competence", and "Worries about finance
General mental distress
The five-item edition (SCL-5) of the Hopkins Symptom
Check List (SCL-90) was used to measure symptoms of
mental distress among the students. The SCL-5 scale was
developed and validated by Tambs and Moum to find
anxiety and depressive symptoms [24,27], and it has pre-
viously been used among Norwegian medical students
. The questionnaire asks how much a person has been
bothered by each of five specific symptoms over the past
fourteen days. The symptoms listed are "Feeling fearful",
"Nervousness or shakiness inside", "Feeling hopeless
about the future", "Feeling blue" and "Worrying too much
about things". Each item is rated on a five-point scale,
from "not at all = 0" to "very much = 4". The mean item
score indicated the level of mental distress. Cronbach's
alpha coefficient for the entire group was 0.88 at T1.
Changes in scores over the observation period
To measure changes in perceived stress over the observa-
tion period, we computed a variable for the difference in
PMSS scores between the two observation points: PMSS-
Difference = the PMSS score at T2 minus the PMSS score
at T1. A similar variable was calculated to show changes
in SCL-5 distress from T1 to T2 (SCL-5-Difference).
Group intervention dummy variables
To study the effect of the two different interventions in
the linear regression analysis, we computed two dummy
variables to capture the effect of the three-category group
variable. We used the control group as a reference, and
Table 1: Age and gender of the medical students
Discussion groupControl groupTotal
(n = 54)
(n = 50)
(n = 111)
(n = 215)
(n = 35)
(n = 26)
(n = 69)
(n = 130)
(n = 20)
(n = 25)
(n = 44)
(n = 89)
Gender and mean age (SD) before the intervention for medical students participating in the self-development group, discussion group, and
the control group. The number of subjects vary for age (n = 215) and gender (n = 219) due to missing data. No differences were found
between the groups according to the chi-squared test with a significance level set at 5%.
Holm et al. BMC Medical Education 2010, 10:23
Page 4 of 8
named the dummy variables self-development group and
discussion group respectively.
The data were analysed using the SPSS statistical soft-
ware package v15.0. The chi-squared test was applied to
test for significant gender differences between the
groups. One-way analysis of variance (ANOVA) was used
to compare the mean age and mean sum of scores at T1
between the groups, and Tukey and Scheffé corrections
were applied to the post-hoc tests. Student's paired t-test
was applied to test for changes in PMSS mean sum score
and SCL-5 mean item score from T1 to T2. Furthermore,
the changes in PMSS and SCL-5 scores between T1 and
T2 were tested using the mean of linear regression mod-
els. The significance level was set at 5% (95% confidence
intervals) for all analyses.
The mean scores for PMSS and SCL-5 before (T1), and
after (T2) the intervention and the change scores
between T1 and T2 are shown in Table 2. No significant
mean score differences were found between the groups at
T1. The intervention group showed a significant reduc-
tion in mean total scores for PMSS (20.58 vs. 18.95, t =
2.61, P = 0.01). No such decline in PMSS was found for
the control group over the similar period (19.26 vs.
19.94). When the two intervention groups were analysed
separately, only the self-development group showed a sig-
nificant decrease in mean total scores for PMSS (21.72 vs.
19.72, t = 2.30, P = 0.03). There was no such decline in
SCL-5 over the observation period. Figure 1 shows the
PMSS scores before, and three months after the interven-
tion for the three groups. We studied age, gender, inter-
vention and the group intervention dummies as
predictors of PMSS-Difference in the sample (Table 3).
Unadjusted predictors of PMSS-Difference in a bivariate
regression were: intervention, β = -2.31 (-3.85 to -0.76), P
< 0.01, age, β = 0.27 (0.03 to 0.51), P = 0.03, and self-
development group, β = -2.13 (-3.90 to -0.36), P = 0.02. In
the first adjusted multiple regression analysis we tested
the effect of the intervention versus the control group
when adjusted for age and sex. The intervention was a
significant predictor, β = -1.93 (-3.47 to -0.38), P = 0.02.
In the second multiple regression analysis, we included
group intervention dummies in order to test for any dif-
ferences between the intervention groups. Self-develop-
ment group was the only significant predictor with the
control group as the reference, β = -2.18 (-4.03 to -0.33), P
= 0.02. There was a trend in our results showing male stu-
dents in the self-development groups having a greater
decrease in PMSS score than their male peers in the dis-
cussion and control groups did, but there was no interac-
tion between gender and the self-development group.
This means that there were no significant gender differ-
ences concerning the effect of the self-development
The most important finding of this study was that the
intervention was a significant and independent predictor
of the decrease in PMSS over the observation period.
When we tested the effects of each of the intervention
groups, only the self-development group was a significant
predictor of the reduction in PMSS. However, we found
no effect of the intervention on general mental distress,
as measured by the SCL-5 score. This suggests that the
intervention affected the specific stress related to medical
school, rather than general mental distress. The interven-
tion, and in particular the self-development programme,
reduced the specific factors related to attending medical
school and negative attitudes towards medical training.
Examples of such stressors that the PMSS seems to cap-
ture include: lack of thriving in the study situation, a
sense of opposition towards teachers and the curriculum,
a feeling of being controlled too much, of having too little
space for personal interests, and not being seen as an
Two recent papers have studied the effects of self-
selected interventions among medical students. Both Fin-
kelstein et al and Rosensweig et al report benefi-
cial effects on mental health from a voluntary stress
reduction class. The participating students had higher
initial scores on mental health parameters than their
peers who did not seek help and no gender differences
were reported [12,13]. We believe that our mandatory
intervention design may be important. In planning the
study, we assumed that some students would not partici-
pate voluntarily in a group intervention that had elements
of psychotherapy, and that this would particularly apply
to male students. This assumption was however not sup-
ported in our data. Nevertheless, the importance of a stu-
dent's opportunity to choose between the two different
types of group should not be underestimated.
In a qualitative evaluation carried out among the stu-
dents at the last meeting of the group sessions, the dis-
cussion groups were generally evaluated as being more
popular. From this, we may have expected this type of
group to be more effective than the self-development
groups were . However, in contrast, the self-develop-
ment groups seem to be more effective. Why might this
The self-development groups may have given the stu-
dents an experience of being seen as individuals, and that
their personal recourses were acknowledged as valuable
in becoming a good physician. Some of the students said
that they experienced an openness about personal prob-
lems that was a new experience at medical school. They
also mentioned that building a network among their
Holm et al. BMC Medical Education 2010, 10:23
Page 5 of 8
peers was valuable, as the group members became closer
to each other and could share problems. Thus, they had a
feeling of a safety net that would help them solve new
problems. They also thought it would be easier for them
to talk to colleagues about personal or professional prob-
lems, and this lowered the threshold for them to seek
professional help in the future. They simply learned that
it was acceptable to have problems, since their peers had
disclosed problems of their own. The participation in the
groups may have helped the students to tolerate insecu-
rity and ambiguity, a common aspect of all medical prac-
tice. This is consistent with reports from previous self-
Figure 1 Perceived Medical School Stress (PMSS) score before and after the intervention. Total Perceived Medical School Stress (PMSS) score
before and three months after the intervention for participants of the self-development and discussion group. Corresponding time periods for the
control group. Change was significant for the self-development group in paired samples t-tests. P < 0.05.
Table 2: Changes in Perceived Medical School Stress (PMSS) and Symptom Check list (SCL-5) score over the period
Self-development group (n = 47)Discussion group (n = 39)Control group
(PMSS n = 93, SCL-5 n = 94)
T1 T2 T1 T2 T1T2
* Changes were significant in paired samples t-tests. P < 0.05. Mean sum scores and mean change scores for Perceived Medical School Stress
(PMSS) n = 179, and mean item score and mean change scores for Symptom Check list (SCL-5), n = 180, for students responding at both T1
and T2. The 95% confidence interval for the mean and difference is given in parentheses.
Holm et al. BMC Medical Education 2010, 10:23
Page 6 of 8
development groups of volunteer female medical stu-
dents at the University of Bergen .
Similar comments were also made by students of the
discussion groups. The leaders of the discussion groups
reported a high level of personal involvement from the
students, and that the group discussion often dealt with
private and personal issues . This in spite of the more
rigid and preset structure of the meetings.
An important and specific part of the self-development
groups was learning about relational patterns from their
past, which hindered a more flexible attitude towards
peers, teachers, and patients. This may contribute to a
more robust and sustainable effect of the self-develop-
ment groups than that of the more "external reality based"
discussion groups. But this remains to be investigated by
longer term follow- up of our cohort.
Since the students themselves chose which particular
group intervention to join, even though participating in a
group was mandatory, it seems that this self-selection
was especially successful for those who chose the self-
development groups. These students may have had high
levels of insight into the type of help they needed.
Another factor of great importance for the positive out-
come is the specific qualifications of the group leaders of
the self-development group. This factor may restrict the
practical applicability of the programme in other medical
schools, since such highly qualified psychiatrists with
group-analytical training are not easy to recruit.
High levels of PMSS have been found to predict mental
health problems that require treatment, and hence, the
PMSS score may represent a vulnerability measure [5,20].
Stress may affect academic performance negatively ,
and increase the chances of developing depression [6,19].
However, only long-term follow-ups will show whether
these initial results are stable throughout and following
graduate school, implying improved mental health, and
improved management of the specific stressors involved
in medical practice.
The evaluation after the groups had ended showed that
most students appreciated the groups, even though they
were mandatory . On the other hand, some students
said that they lacked interest in the groups, and that they
were not motivated to participate because of the manda-
tory requirement. The students showed ambivalent atti-
tudes towards making the group programme a
mandatory part of the curriculum on a permanent basis.
Although neither of the two interventions was defined as
treatment, students who participated in the groups said
that one positive aspect of making them mandatory
would be that teachers could pick out students who
needed to seek professional help. The self-development
and discussion groups have previously been voluntary for
medical students in Bergen. At that time, however, only
half of the students participated in the voluntary groups,
and these were mostly female students .
The intervention and design applied in this study has
several strengths and limitations. The prospective design
with pre-post intervention measures and a control group
are major strengths. The mandatory intervention and
that the group leaders kept track of any student absent
ensured a good compliance, and that we reached all stu-
dents in need of help. To our knowledge, few studies have
evaluated this type of mandatory intervention pro-
gramme using a control group. The instruments applied
have also been validated for the Norwegian population.
One important limitation of our study is the lack of a ran-
domized, controlled trial design. The intervention groups
and the control group were from two different student
Table 3: Predictors for changes in PMSS scores among students at T2. N = 177 in the multivariate analysis
Bivariate analyses Multivariate analysis
Crude β 95% CIP value Adjusted β95% CI P value
Age (n = 177)0.27 0.03, 0.510.030.22 -0.02, 0.470.07
Gender (male = 1)
(n = 179)
0.13 -1.48, 1.730.880.25 -1.33, 1.820.76
Self-development group (n = 179)-2.13 -3.90, -0.360.02-2.18 -4.03, -0.330.02
(n = 179)
-0.96-2.87, 0.95 0.32 -1.62 -3.59, 0.350.11
Holm et al. BMC Medical Education 2010, 10:23
Page 7 of 8
classes and were assessed during two different calendar
years. It is possible that the pressures on the intervention
and control groups have been different, so also the moti-
vation to participate in the study. This design implies a
risk of a confounding cohort effect. There were however
no known changes in the curriculum from the one year to
the other. Further, there were no significant differences in
general mental distress and medical school stress at base-
line between the two cohorts. Though, it is a weakness of
our study that it was not conducted according to the
design of a randomized controlled trial, and as a conse-
quence we should be cautious to make too firm conclu-
sions. The positive effects of such group interventions
should be further explored with a randomized, controlled
trial design. In our study a randomization would not have
given the students the opportunity to choose between the
two different types of groups. This would have forced
unmotivated students to participate in self-development
groups, and perhaps hindered the group process. On the
other hand, even without randomization, any mandatory
intervention runs the risk that unmotivated students may
be included. Responses from both leaders and students
confirmed that this was the case in some groups. This
might have reduced the positive effects of the interven-
tion of the present study. It may also be a limitation that
the study was based on self-report measures. This may
lead to less reliable reporting of mental distress, for
example, an underreporting of such distress.
This is one of the first controlled group intervention
studies to show an effect on stress among a whole class of
medical students. The self-selected self-development
intervention may beneficially affect students' perception
of specific stressors related to medical school. The effects
of such group interventions should however be studied in
other samples of medical undergraduates, and preferably
with a randomized, controlled trial design.
The authors declare that they have no competing interests.
MH drafted the manuscript and performed the statistical analyses. RT contrib-
uted to the interpretation and the analyses of the data, and revised the manu-
script. KIS participated in the conception and design of the study and revised
the manuscript. BH participated in the conception and design of the study and
helped to draft and revised the manuscript. All authors approved the final
This research received grants from the Norwegian Medical Association. We are
grateful to Associate Professor Magne Thoresen from Department of Biostatis-
tics, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo
for statistical assistance, and Eva Biringer, MD PhD, Leader of Section of Mental
Health Research, Division of Psychiatry, Helse Fonna HF for her contributions in
the data collection phase. Thanks also to Professor Anders Lund, Department
of Clinical Medicine, Section for Psychiatry, University of Bergen, and Psychia-
trist in private practice Anne Margrethe Tveit for their enthusiasm and support.
We are also grateful to project secretary Henriette Muri for practical help.
Finally, we will thank all the medical students and dedicated group leaders
who took part in this project.
1Department of Clinical Medicine, Section for Psychiatry, University of Bergen,
N-5020 Bergen, Norway, 2Department of Behavioural Sciences in Medicine,
Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, N-
0317 Oslo, Norway and 3Division of Psychiatry, Helse Bergen HF, N-5021
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Additional file 1 Perceived Medical School Stress Questionnaire
Received: 24 March 2009 Accepted: 16 March 2010
Published: 16 March 2010
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Cite this article as: Holm et al., Self-development groups reduce medical
school stress: a controlled intervention study BMC Medical Education 2010,