Understanding the psychosocial and physical work environment in a Singapore medical school.

Abstract

This study aims to understand the physical and psychosocial work environment, expectations and the perceived levels of stress encountered of medical students in Singapore.
A cross-sectional study employing a self-administered work environment questionnaire was applied over a one-week period to the entire 2003/2004 medical school cohort (1,069 students, response rate 85 percent) from the first to fifth (final) years at the National University of Singapore.
3.3 percent had at least one needlestick injury within the academic year. The majority (especially the clinical students) also had musculoskeletal complaints (neck and back mainly) within the last three months. Using the General Health Questionnaire, it was found that 49.6 percent encountered significant stress and 64.6 percent reported that more than 60 percent of their total life stress was due to medical school. The most important psychosocial stressors were: too much work and difficulty in coping. The clinical students were particularly concerned about being good medical students and doctors. The reasons for choosing Medicine as a career and social health (health, study and sleep habits) were also studied.
The health risks of a medical student are primarily psychosocial in nature. The biggest challenges are work demands, maintaining a work-life balance and managing the psychosocial work environment.

Full text

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Singapore Med J 2007; 48 (2) : 166
O r i g i n a l A r t i c l e
ABSTRACT
Introduction: This study aims to understand
the physical and
environment, expectations
per ceived levels of stress encountered of
medical students in Singapore.
psychosocial work
the and
Methods: A cross-sectional study employing
a self-administered
questionnaire was applied over a one-week
period to the entire 2003/2004 medical
school cohort (1,069 students, response rate
85 percent) from the fi rst to fi fth (fi nal) years
at the National University of Singapore.
work environment
Results: 3.3 percent had at least one
needlestick injury within the academic
year. The majority (especially the clinical
students) also had
com plaints (neck and back mainly) within
the last three months. Using the General
Health Questionnaire, it was found that
49.6 percent encountered signifi cant stress
and 64.6 percent reported that more than
60 percent of their total life stress was due
to medical school. The most important
psychosocial stressors were: too much work
and diffi culty in coping. The clinical students
were particularly concerned about being
good medical students and doctors. The
reasons for choosing Medicine as a career
and social health (health, study and sleep
habits) were also studied.
musculoskeletal
Conclusion: The health risks of a medical
student are primarily psychosocial in nature.
The biggest challenges are work demands,
maintaining a work-life balance and managing
the psychosocial work environment.
Keywords: medical students, musculoskeletal
complaints, needlestick injury, physical work
environment, psychosocial health, stress
Singapore Med J 2007; 48(2):166–171
INTRODUCTION
It is often said that undergraduate medical schools offer
one of the most stressful courses within the university
of any country, and the health of medical students has
sometimes been neglected. Students are exposed to
various psychosocial and physical hazards. At the time of
this study, Singapore had only one medical school, the
Yong Loo Lin School of Medicine, which has a fi ve-year
undergraduate programme. The fi rst two years are largely
pre-clinical years are with grounding in basic human
sciences such as anatomy, physiology and biochemistry;
and the later clinical years are where students have clinical
rotations through the healthcare facilities, i.e. hospitals
and polyclinics. There is also an annual programme quota,
and a selection process is required. Graduates undergo a
one-year training as a House Offi cer before obtaining
their full medical licence as a Medical Offi cer.
A number of foreign medical schools have written
about the psychological stressors of medical students. In
Singapore, there has only been a published study done
on 135 fi rst-year medical undergraduates comparing their
stress levels with that of fi rst-year law undergraduates.(1)
Even less is known of the physical hazards encountered.
As the medical school evolves and studies how best to
improve the curriculum to produce even better doctors,
it becomes even more necessary to fully appreciate the
physical and psychosocial work environment, and lifestyle
habits of our medical students. This cross-sectional
study aims to profi le the physical and psychosocial
work environment of our undergraduate medical
students, and strives to understand the perceived stress
among the medical undergraduates, their psychosocial
work environment, healthy lifestyle habits and general
well-being.
METHODS
The questionnaire was divided into “physical health” and
“psychosocial health” sections. The “physical health”
portion comprised questions pertaining to the prevalence
of needlestick injuries (within the academic year – last
eight months) and musculoskeletal complaints occuring
Understanding the psychosocial
and physical work environment in a
Singapore medical school
Chan G C T, Koh D
Department of
Community,
Occupational and
Family Medicine,
Yong Loo Lin
School Of Medicine,
National University
of Singapore,
Block MD3,
16 Medical Drive,
Singapore 117597
Chan G C T, MBBS,
MMed, FAMS
Adjunct Assistant
Professor
Head, Performance
Maximisation
Branch, Navy
Medical Service
Koh D, MBBS, PhD,
FFOM
Professor and Head
Correspondence to:
Dr Gregory Chan
Tel: (65) 6750 5544
Fax: (65) 6750 5610
Email: gregchan@
nus.edu.sg

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Singapore Med J 2007; 48 (2) : 167
during the course of work. Needlestick injuries were
defi ned as injuries from handling needles/syringes only.
Prevalence over a three-month period was used for
musculoskeletal complaints and positive responses were
taken as those which were encountered daily or frequently
(more than three times per week).
The “psychosocial health” section utilised the
General Health Questionnaire (GHQ-12) to evaluate
stress levels.(2-4) It used 12 questions to assess the general
levels of happiness, anxiety, depression, stress and sleep
disturbance. One point was awarded for a “less than
usual” or “much less than usual” response while no point
was given for a “more than usual” or “same as usual”
response. A GHQ score of 4 or more (out of a maximum of
12) is used to identify potentially stressed respondents.
Psychosocial work environmental factors were drawn
from the experiences of other medical school surveys as
well as from members of the research group.(5-8) These
were subjective responses and they were ranked according
to a positive response. We also included a section on the
reasons for choosing Medicine as a career and how they
had changed throughout medical school, so as to better
understand the changing expectations of our medical
students (if any).(9,10) As a measure of psychosocial
outcome, we also asked questions about their social
health, including health, study and sleep habits.
The questionnaire was self-administered and
anonymous, and further refi ned after conducting a pilot
survey among 30 members of the project group. The
survey was conducted intensively over a one-week period
from February 27 to March 4, 2004. All undergraduate
medical students (fi rst to fi fth year) from the 2003/2004
cohort were included, less foreign exchange students,
third-year students from Community Health Project
Group 6 which conducted the study, and transfer students
who enrolled after the start of academic year 2003/2004.
Data was analysed using the Statistical Package for Social
Sciences version 12.0 (SPSS Inc, Chicago, IL, USA).
RESULTS
While we had initially compared data between the
different years, the analysis was found to be more
meaningful most of the time when compared between
the pre-clinical and clinical years. There was also little
difference in gender and ethnic comparisons for the
various work environmental exposures and outcomes.
We used the Singapore National Health Survey, 1998 as
a means of comparison to the general population, for the
analysis of healthy lifestyle habits.(11)
Despite the short survey period, we were able to
garner 909 (out of 1,069 eligible students) responses or
85.0% response rate (Table I). Additional demographical
information were: age ranged from 17 to 25 years, with
age between the years being one year apart; gender
– males 60%, females 40%; and doctor-parents – none
93%, one doctor-parent 5%, both doctor-parents 2%.
There were a total of 30 (3.3%) respondents who
indicated that they had suffered from a needlestick injury
in their current academic year (eight months at time of
survey). The incidence was highest among fourth year
students (15), compared with fi rst year students (0), as
they did not handle needles/syringes (Table II). 28 of the
students had a single needlestick injury, while two had a
needlestick injury on two separate occasions. None had
three or more injuries. Most needlestick injuries occurred
Table II. Distribution of needlestick injuries by year
of study.
Year of study12345
Number of needle-
stick injuries (%)
0
2
(0.9)
8
(5.3)
15
(9.0)
5
(3.2)
Table IV. Prevalence over a three-month period of
musculoskeletal complaints.
Affected area
Three-month prevalence n (%)
Pre-clinicalClinical
Upper back and neck258 (59.6)340 (71.8)
Lower back218 (50.8) 338 (71.6)
Shoulders and arms 194 (44.8) 268 (56.3)
Wrists and hands 152 (35.1) 210 (44.1)
Lower limbs 185 (42.7) 324 (67.9)
Table I. Response rates among the medical students.
Year of study Response rate
Year 189.1% (212/238)
Year 2 97.8% (221/226)
Year 377.6% (152/196)
Year 479.1% (167/211)
Year 5 79.3% (157/198)
Pre-clinical 93.3% (433/464)
Clinical 78.7% (476/605)
Total 85.0% (909/1069)
Table III. Causes of needlestick injuries.
Cause of needlestick injury Prevalence (%)
Venepuncture11 (36.7)
Uncapping 8 (26.7)
Recapping2 (6.7)
Stray needles 2 (6.7)
Others 7 (23.2)
Total30 (100)

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Singapore Med J 2007; 48 (2) : 168
during the venepuncture process and uncapping of needles
(Table III). Only nine students claimed to have reported
their injury to the hospital, 15 admitted to not making any
report, and the rest did not respond to the question.
The three-month prevalence of musculoskeletal
complaints is shown in Table IV. The most frequent
complaints involved aches and pains in the neck/upper
back and the lower back. The other areas were less
affected. However, the clinical students had a higher
prevalence of musculoskeletal complaints than pre-
clinical students (statistically signifi cant, p < 0.05). It
was noted that clinical students also needed to “maintain
uncomfortable postures” (85.1% versus 64.4%) and
“stand to the point of discomfort” (94.1% versus 40.4%)
more frequently than pre-clinical students.
Based on a GHQ score of 4 and above, 49.6% (451)
of medical students appeared to be stressed, where
clinical students were slightly more highly stressed
(52.5%) compared with pre-clinical students (46.7%).
The comparisons between year of study are shown in
Fig. 1a. When asked about the perception of work stress
in medical school, 64.6% felt that it contributed to more
than 60% of their total life stress, and of this group,
46.8% said it contributed to more than 80% (Fig. 1b).
The median perceived levels ranged from 70% to 77.5%.
There was no signifi cant difference between the pre-clinical
and clinical students. Table V shows the main factors
associated with work stress (GHQ-12) for pre-clinical and
clinical students.
There was no statistical signifi cance when the above
factors were compared between the two groups. However,
25.6% (233) of respondents (41.2% in clinical versus
8.1% in pre-clinical students) claimed to have been
subjected to some form of public scolding or humiliation
Table V. Correlation of work stressors and stress among pre-clinical and clinical students.
Pre-clinical students Clinical students
Cannot cope with amount I have to study (0.421)Cannot cope with amount I have to study (0.367)
Lack of time for personal activities (0.414) Course is too diffi cult for me (0.320)
Stressed by having to get good grades (0.347)Lack of time for personal activities (0.306)
Do not have time to complete my work (0.329) Lack confi dence to be successful doctor (0.302)
Afraid of failing/repeating course (0.315)Lack confi dence to perform well as medical student (0.287)
Table VI. Reasons for choosing Medicine as a career and staying in Medicine.
Reasons for choosing MedicineProportion of students (%)Reasons for staying in MedicineProportion of students (%)
Save lives55.0Save lives 56.1
Out of interest53.9Out of interest53.4
Job stability27.5 Job stability32.5
Not interested in any other courses 22.9Not interested in any other courses 27.5
Childhood ambition 19.8Childhood ambition 19.0
Fig.1a GHQ stress level (≥ 4) among medical students.
Fig. 1b Proportion of life stress attributable to medical school.
by tutors, and 26.1% (237) claimed unfair grading during
tests/examinations.
The main reasons for choosing Medicine as a career

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Singapore Med J 2007; 48 (2) : 169
before coming into medical school and how they had
changed since then (up to three choices were allowed) are
listed in Table VI. When asked if they “regretted choosing
medical school”, only 8.7% agreed/strongly agreed, and
74.7% said that they would choose Medicine again if they
were given another opportunity.
There were 14 (1.5%) current smokers, and more
males (2.2%) than females (0.5%) smoked. This is far
below the national average of 18% prevalence (based on
the Singapore National Health Survey, 1998).(11) There
was no correlation with GHQ-12 scores (Spearman’s
correlation coeffi cient was 0.04). Clinical students were
also six times as likely as pre-clinical students to smoke.
Regular alcohol consumption was defi ned as having
a drink four or more times a week, and 7.7% met this
criterion. There was no difference between clinical or pre-
clinical students but more males than females drank. This
was slightly lower than the national average. There was
no correlation with GHQ-12 scores. Overall, 21% of the
students exercised regularly (at least three times per week
of 20 minutes’ duration each), 50% exercised occasionally,
and 29% do not exercise at all. The proportion of male
and female students who participated in regular exercise
(26.4% and 13.1%) was similar to the national average
for that age group (25.1% and 11.3%).
The frequency distribution of study habits is shown
in Fig. 2a. The median number of hours spent studying
outside school hours was 4.0 hours. 48.6% studied up to
three hours per day, 33.1% between three and seven hours,
and 18.2% more than seven hours a day. More females
(27.6%) studied more than seven hours a day compared
with their male counterparts (20.3%). 71.0% of students
had insuffi cient sleep (defi ned as at least seven hours of
sleep daily). The frequency distribution between the years
is shown in Figs. 2b–2c, and more Years 2 and 5 students
had more sleep than the others.
DISCUSSION
A limitation of this study was that it was conducted as
part of a community health project by third-year medical
students on students within the same medical school.
The questionnaire was designed to obtain descriptive
statistics and there was no available validated instrument
to meet all our objectives. Wherever possible, validated
instruments were incorporated, such as the GHQ-12 (for
psychological well-being).(2-4) Most of the other sections,
like sources of stress, reasons for going to medical
school and needlestick injuries, were self-developed
and structured to be as direct as possible. It was also not
possible to narrow down the specifi c causes for stress,
especially whether the stress was a culmination of the
medical school environment or due to individual factors
(such as the imposition by self to over-achieve). There
was also the possibility of bias in the form of response
Fig. 2a Frequency distribution of study habits among medical
students.
Fig. 2b Medical students with suffi cient sleep.
Fig. 2c Hours of sleep in medical students.

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Singapore Med J 2007; 48 (2) : 170
bias (over-reporting or exaggerated response of ill-health
by the students). The study was also conducted near to the
end of the academic semester when examinations were
looming. As such, the results may need to be interpreted
conservatively. Nevertheless, the results have provided
useful information about the working environment of our
medical students.
The current prevalence of needlestick injuries has
decreased signifi cantly. In a similar study done in third-year
medical students in our medical school in 1993, 35.1% of
third-year students sustained at least one needlestick injury
in that academic year.(12) This is attributed to the greater
awareness and proper training in the handling of sharp
instruments within the medical curriculum. Back then,
the teaching of venepuncture was informal and occurred
within the wards. These fi gures also compare favourably
with published data from other medical schools such as
Birmingham, UK (14.6%, year 2000) and Malaysia (14.1%,
year 2003).(13,14) The current defi ciency perhaps lies in the
notifi cation process, as 50% of the affl icted indicated that
they did not report their needlestick incident.
Musculoskeletal complaints, particularly those of the
neck and lower back, were signifi cant among medical
students, especially among those in the clinical years. This
was probably attributed to the long hours spent standing
and walking within the wards with patients, looking for
appropriate cases, following the ward rounds and bedside
tutorial sessions. This was aggravated by prolonged
sitting during studying, especially if there was prolonged
fl exion of the neck while reading. There were no other
available studies of medical students for comparison.
Fortunately, such complaints are likely to be transient and
diminish during the holiday periods. It would also help if
the students were able to get regular exercises and learn to
take rest breaks at work.
The undergraduate medical course is inherently
a “stressful” one, not just because of the need to learn
copious amounts of new information, but the constant
requirement to interact with patients and translate
clinical knowledge into practice. It is not enough to just
make the right diagnosis, the medical student also has
to communicate well to patients and other healthcare
professionals as part of the management process. The
use of information technology adds another dimension
to modern medicine. Medical training pedagogy involves
the use of electronic presentations and typed case reports.
Thus work demands are high in medical studies, and
this was the highest ranked stressor among the medical
students. Another factor that apparently contributes
to stress is that of personal expectations and peer
competition. This is especially so in pre-clinical students
who consistently highlighted that their biggest stressors
were the fear of failing and repeating their course as well
as having to get good grades. This is less so in the clinical
students whose focus is probably on passing the course
and being good doctors, rather than just good grades.
The clinical students have also highlighted their
insecurities in a system that primarily utilises academic
grades in assessing good medical students and doctors.
It is at this phase that they begin to question whether just
clearing examinations would make them good enough
medical practitioners. There is no perfect assessment
framework in this particular area at this juncture for
undergraduate medical students, and a mentorship or
coaching programme could be helpful in this exceptional
instance. It is here also that the students are exposed to
clinical tutors from different disciplines and hospitals.
It is important for these tutors not only to teach, but to
adopt the optimal teaching methods, to avoid student
perception of tutoring as a form of public humiliation
and discrimination.
In the management of expectations and the
effectiveness of our selection of students into the medical
course, it is encouraging to note that the majority of
students chose Medicine because they wanted to “save
lives” and were “interested in the course”. Only a handful
of students expressed regret in taking up the course.
This is in contrast to a number of other medical studies
in the past where students felt that a medical career was
associated with a poor quality of life and regret.(15) A
recent study among 16 US medical schools showed these
results: among senior medical students, 42% reported
having experienced harassment and 84% belittlement
during medical school. These types of abuse were caused
by other students (11% and 32% experienced harassment
or belittlement, respectively); residents (27% and 71%),
pre-clinical professors (9% and 29%), clinical professors
(21% and 63%), and patients (25% and 43%).(16) Affected
students were signifi cantly more likely to be stressed,
depressed, suicidal, to drink alcohol or to binge drink,
and to state that their faculty did not care about medical
students. Although our survey results in this aspect were
not as comprehensive, they do suggest that our perceived
“ill-treatment” is lower (and less severe) than that of US
medical schools. We wanted to understand whether there
were any unhealthy lifestyle habits as a consequence of
work stress. There was no association with smoking,
alcohol intake or lack of exercise. The prevalence of
smokers and drinkers was also much lower than the
national average. What we noted was that students spent
relatively long hours studying and hence, had shorter
sleeping hours.
In conclusion, there are certain health hazards during
the course of work of a medical student, and these are not
that much different from those of the working healthcare
worker. The main challenges of medical school appear to
be the work demands, maintaining a work-life balance,
and managing the psychosocial environment. It is