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Int J Med Educ. 2019 Apr 2;10:68-74. doi: 10.5116/ijme.5c94.9391.

Stress among medical students during clinical courses: a longitudinal study using contextual activity sampling system.

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Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
Department of Health Sciences. The Swedish Red Cross University College, Huddinge, Sweden.
Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.



To investigate medical students' experiences of stress and other emotions related to their professional roles, as defined by the CanMEDS framework, by using the Contextual Activity Sampling System (CASS).


Ninety-eight medical students agreed to participate of whom 74 completed this longitudinal cohort study. Data was collected between 6th and 8th term via CASS methodology: A questionnaire was e-mailed to the participants every 3rd week(21questionnaires/measurements) during clinical rotations and scientific project work term. Emotions were measured by a 7-point Likert scale (e.g., maximum stress = 7). Answers were registered through mobile technology. We used a linear mixed-model regression approach to study the association between stress over time in relation to socio-demographic and learning activities related to CanMEDS roles.


Participants completed 1390 questionnaires. Mean stress level over all time points was 3.6. Stress was reported as highest during the scientific project term. Learning activities related to 'Communicator,' 'Collaborator,' 'Scholar,' 'Manager' and 'Professional' were associated with increased stress, e.g. 'Scholar' increased stress with 0.5 points (t(1339)=3.91, p<0.001). A reduced level of stress was associated with 'Health Advocate' of 0.39 points (t(1338)=-2.15, p=0.03). No association between perceived stress and demographic factors, such as gender or age was found.


An association between different learning activities related to CanMEDS Roles and feelings of stress were noted. The CASS methodology was found to be useful when observing learning experiences and might support educational development by identifying course activities linked to stress.


canmeds; cass; contextual activity sampling system; medical students; stress

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