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Stress responses in medical students in ambulatory and in-hospital patient consultations: Pottier P, Hardouin JB, Dejoie T, Bonnaud A, Le Loupp AG, Planchon B, LeBlanc V. Medical Education 2011; 45:678-687.


Reviewed by Susan Bannister

What was the study question?
Do medical students experience more stress when conducting a consultation in an ambulatory setting (deemed to be a less familiar setting) than in an in-patient setting (deemed to be a more familiar setting)?

How was the study done?
Students' subjective (how anxious were they) and physiological (cortisol levels) stress responses were measured before and after in-patient and out-patient consultations. The study had a prospective, cross-over design. It is important to note that this study was conducted in France because important differences between the two settings are present: 1) students rarely perform out-patient (ambulatory) consultations, 2) out-patient consultations require students to determine a diagnosis and come up with a management plan, 3) out-patient consultations must be completed in 30 minutes. In contrast, in-patient consultations require neither a diagnosis nor a plan, are not time-limited, and are familiar to the students.

What were the results?
All of the subjective and physiological stress responses were greater in the out-patient setting compared to the in-patient setting. There were 30 women and 29 men who participated in the study and there were some differences between these groups. Women experienced a greater pre-consultation subjective (anxious) stress response in the out-patient setting than did the men, while the men demonstrated a greater physiological (cortisol) stress response in the out-patient setting than did the women.

What are the implications of these findings?
When we understand the context of medical education in France, the important finding in this study is not that out-patient consultations are more stressful that in-patient consultations. Rather, these data demonstrate that students exhibit more subjective and physiological stress when asked to do more in less time in an unfamiliar setting. This authors wonder about the potential impact of stress on clinical reasoning. A second interesting finding of this study is that the students' stress responses were higher before the out-patient consultations than after them, indicating that the source of stress may have been the anticipation of the consultation rather than the consultation itself. This finding reminds us of the need to carefully prepare students for their clinical encounters.

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