stress and debt Stress, debt and undergraduate medical student performance Sarah Ross,1 Jennifer Cleland2 & Mary Joan Macleod1 INTRODUCTION Against the background of current debate over university funding and widening access, we aimed to examine the relationships between student debt, mental health and academic performance. METHODS We carried out an electronic survey of all medical undergraduate students at the University of Aberdeen during May–June 2004. The questionnaire contained items about demographics, debt, income and stress. Students were also asked for consent to access their examination results, which were correlated with their answers. Statistical analyses of the relationships between debt, performance and stress were performed. performance. Students who worry about money have higher debts and perform less well than their peers in degree examinations. Some students in this subgroup were also identified by the GHQ and may have mental health problems. The relationships between debt, mental health and performance in undergraduate medical students are complex but need to be appreciated by medical education policy makers. KEYWORDS stress, psychological ⁄ *aetiology ⁄ economics; students, medical ⁄ *psychology; *educational status; financing, personal; education, medical, undergraduate ⁄ *economics; income; mental health; Scotland; humans. Medical Education 2006; 40: 584–589 RESULTS The median total outstanding debt was £7300 (interquartile range 2000–14 762.50). Students from lower socioeconomic backgrounds and postgraduate students had higher debts. There was no direct correlation between debt, class ranking or General Health Questionnaire (GHQ) score; however, a subgroup of 125 students (37.7%), who said that worrying about money affected their studies, did have higher debt and were ranked lower in their classes. Some of these students were also cases on the GHQ-12. Overall, however, cases on the GHQ had lower levels of debt and lower class ranking, suggesting that financial worries are only 1 cause of mental health difficulties. DISCUSSION Students’ perceptions of their own levels of debt rather than level of debt per se relates to 1 Department of Medicine and Therapeutics, University of Aberdeen, Aberdeen, UK 2 Department of General Practice and Primary Care, University of Aberdeen, Aberdeen, UK Correspondence: Sarah Ross, Department of Medicine and Therapeutics, University of Aberdeen, Medical School, Foresterhill, Aberdeen AB25 2ZD, UK. Tel: 00 44 1224 553015; Fax: 00 44 1224 554878; E-mail: s.ross@abdn.ac.uk 584 doi:10.1111/j.1365-2929.2006.02448.x INTRODUCTION Debt accrued by university students during their studies has been the source of recent debate and controversy in the UK. Proposals for variable university tuition fees have reopened the debate about how higher education should be funded and how much students should contribute.1 The widening of participation by recruiting graduates from other disciplines or from lower socioeconomic backgrounds is now a major policy strand in higher education. Debt for medical students is greater than for other students. Students with parents from lower socioeconomic classes are already under-represented in medicine; they underestimate their own chances of getting a place and staying the course, and see the costs of study as constraining their choices.2 This has implications for equity of access. It is important to identify and understand the impact of debt on student mental health and performance Blackwell Publishing Ltd 2006. MEDICAL EDUCATION 2006; 40: 584–589 585 Overview What is already known on this subject Medical student debt is substantial and higher than in other disciplines. No evidence is available about the effect of debts on psychological health or performance in medical school. What this study adds Students from lower socioeconomic backgrounds and postgraduate students have higher debts. There is no direct correlation between debt, GHQ score and performance. Students who perceive debt to be a problem have larger debts and are ranked lower in their classes. Suggestions for further research More precise identification of the relationships between financial worry, psychological health and student performance is needed. Investigation into coping with stressors would be helpful as this may aid the development of systems to identify and support struggling students. because it may have implications for student support and guidance.3,4 The current literature, while quantifying debt levels, does not specifically examine the possible relationships between stress, performance and debt. We aimed to elicit current levels of debt amongst medical students at the University of Aberdeen, Scotland and investigate the relationships between debt level and stress, and debt level and performance in routine course assessments. METHODS We carried out an electronic survey of all medical undergraduate students at the University of Aberdeen during May–June 2004. The responses from direct entry (Year 4) students newly arrived from Malaysia were excluded from the current analysis. Questions about basic demographics, debt and income were modified from the British Medical Association (BMA) Medical Students Committee survey questions.5 The General Health Questionnaire (GHQ-12) was added to assess general mental health status.6 The GHQ screens for psychological distress or non-psychotic psychiatric disorders, particularly depression and social dysfunction. Additional questions were asked about the relationship of stress to financial concerns and about levels of smoking and alcohol consumption. The survey was piloted with 15 Year 4 students to check for clarity and readability. The survey was posted on the student portal and students were informed by e-mail. This allowed students to respond in their own time and in privacy. Participation was entirely voluntary. The questionnaire was not anonymous; students were asked for their student identity number to allow for correlation with examination results. Students were specifically asked for consent to access to their examination results. Responses were kept to prescribed options where possible. Free text answers mostly dealt with monetary information. Where a range of money was given, the average value was used. If no answer was given, it was assumed to be zero. Some answers were in currency other than British pounds and were converted to pounds using the exchange rate on 1 July 2004. If a numerical answer was required and text was given, this was not analysed (e.g. Question: How much money do your parents give you? Answer: ÔCover rent and feesÕ). Socioeconomic class was derived from parental occupation, which was categorised using the Registrar General’s scale.7 If categorisation was not possible, responses were excluded from analysis. The GHQ was coded according to the instructions.8 A score ‡ 4 was considered to represent a ÔcaseÕ (which indicates the possibility of mental illness). Marks from degree examinations for the last academic year were noted for every student from the university files. Ranking was used to give each student a rank in his or her year, relative to the whole year rather than just responders. This allowed for analysis between different years. Statistical analysis was performed using SPSS. Basic descriptive statistics were employed. T-tests examined mean levels of normally distributed data between 2 Blackwell Publishing Ltd 2006. MEDICAL EDUCATION 2006; 40: 584–589 586 stress and debt groups. Mann–Whitney U-tests and the Kruskal– Wallis test were used to examine median levels of skewed data. Partial correlations (Pearson’s) were used to assess the linear relationship between 2 factors after controlling for the effect of year. In the correlation analysis, any skewed variables were logarithmically transformed. RESULTS There were 352 responses from a total student population of approximately 900. There was no significant difference between the class ranking of responders and non-responders (mean difference 3.81; 95% CI ) 3.29–10.92, P ¼ 0.29). After direct entry students (n ¼ 18) had been excluded, we found that 136 responders were male (41%) and 196 female (59%) (2 students did not give their gender). This gave a total of 334 students. Female students had significantly higher class ranking than male students (mean difference 27.57; 95% CI 16.24– 38.89, P < 0.001). Student characteristics are shown in Table 1. Table 1 Student characteristics Characteristic n ( %) Year of medical school Year 1 Year 2 Year 3 Year 4 Year 5 Unknown 41 75 57 87 72 2 (12.3) (22.5) (17.1) (26.2) (21.7) (0.6) Country of home Scotland UK (excluding Scotland) Overseas 191 (57.2) 122 (36.5) 21 (6.3) Socioeconomic class I II IIIN IIIM IV Uncodable 128 129 15 30 5 27 (38.3) (38.6) (4.5) (9.0) (1.5) (8.1) 87 192 34 11 3 (26.2) (57.8) (10.2) (3.3) (0.9) Current residence Own flat Privately rented flat University accommodation Parental home Partner’s home A total of 56 students (16.8%) had a prior university degree; 63 (18.9%) were interested in taking or had taken an intercalated degree. Of those who would not choose or had not chosen an intercalated degree, 50 already had a first degree, 71 could not afford it and 179 were not interested (some gave more than 1 reason). In all, 173 students (51.8%) had paid tuition fees at some point during the course. A total of 250 students (75.3%) received some financial support from their parents; 148 (59.2%) of these felt that this caused excessive financial stress to their family. A total of 33 students (9.9%) said that they received money from investments. Another 34 (10.2%) were paid rent. A total of 54 (16.2%) were paying a mortgage. Nineteen (5.7%) students said that they were living with a partner who had an income. Five (1.5%) students had a dependent. A total of 34 students (10.2%) said that they had applied to a hardship fund for financial help. Of these, 15 (4.5%) received some assistance. In all, 287 students (86.2%) reported drinking alcohol. Of these, 116 (34.7%) thought they drank more than was healthy. Median units per week were 15 (interquartile range [IQR] 8–25) for men and 7.75 (IQR 4–12) for women. The highest reported intake was 50 units per week. A total of 26 female students (16.3%) and 39 male students (34.2%) drank more than the recommended maximum. A total of 17 students admitted to smoking. Debt The median total outstanding debt was £7300 (IQR 2000–14 762.50). A total of 264 students (79.0%) had a student loan. The median student loan debt was £6000 (IQR 1300–12 000). A total of 179 students (53.6%) had an overdraft (median ¼ £200, IQR 0–1500). Fewer students (77 [22.4%]) had credit card debts (although the highest debt was £6000) or bank loans (52 [15.6%]). Gender had no significant association with debt. The level of debt was significantly correlated with year of medical school (Kruskall)Wallis test v2 ¼ 79.08, d.f. ¼ 4, P < 0.001) (Table 2). Students who already had a degree had higher debts (P < 0.001). Students with parental homes outside the UK had the lowest debt levels, and students from areas of Blackwell Publishing Ltd 2006. MEDICAL EDUCATION 2006; 40: 584–589 587 Table 2 Breakdown of debt owed by year Table 4 Perceived percentage of stress due to money Year Total debt Median Interquartile range Percentage Students n (%) 1 2 3 4 5 £ £ £ £ £ (0–4080) (1400–8000) (3805–12 000) (2361.50–15 050) (8381.25–20 662.50) 0% 1–25% 26–50% 51–75% 75–99% 100% No answer 60 141 71 40 13 4 5 2000 3400 9000 9000 16 000 (18.0) (42.2) (21.3) (12.0) (3.9) (1.2) (1.5) Table 3 Parental home and debt owed Parental home Total debt Median Interquartile range Table 5 Sources of stress Scotland Rest of UK Outside UK £ 5800 £ 9700 £ 300 (1580–12 500) (4500–16 000) (0–2167.25) Source Students n (%) Coursework Money Relationships Family Job Other 261 221 113 106 60 65 (78.1) (66.2) (33.8) (31.7) (18.0) (19.5) the UK other than Scotland had the highest (Table 3). Socioeconomic class was also related to level of debt owed (Kruskall)Wallis test v2 ¼ 10.27, d.f. ¼ 4, P ¼ 0.04), with students from lower socioeconomic backgrounds having higher levels of debt. Income A total of 103 students (30.8%) had a term-time job working a median of 11.5 (IQR 8–16) hours per week for an average pay per hour of £6.54 (SD 4.40). Students with term-time jobs had similar debts and class rankings to those without term-time jobs (P ¼ 0.15; P ¼ 0.60). The number of hours worked made no difference to debt or to performance. Performance and debt No significant relationship was found between total debt owed and performance as measured by class ranking. This null effect remained after adjusting for gender, parental home and year of medical school. Having a previous degree was not related to class rank (P ¼ 0.11). Forty-two per cent of students reported that stress about money contributed to up to a quarter of their stress. Nearly 16% stated that stress about money made up greater than 50% of their overall stress (Table 4). A total of 125 students (37.4%) thought that worrying about money affected their studies. A substantial number thought about money on a daily basis (19.2%), with only 3% never worrying about it. Sources of stress are detailed in Table 5; only coursework was considered to be a greater source of worry than debt. There were no significant differences in thinking that money worry affects performance by gender or socioeconomic class. Students who reported that worrying about money affected their performance had higher outstanding debt (P ¼ 0.01) and tended to be ranked lower than those who did not hold this belief (mean difference 11.57, P ¼ 0.05). Students who had already taken a degree were more likely to say that money worries affected their performance (v2 ¼ 4.38, P ¼ 0.04). There was no significant association between worrying about money and drinking more than the recommended maximum. The General Health Questionnaire A total of 95 students (28.4%) scored ‡ 4 on the GHQ-12 and were therefore considered cases. Blackwell Publishing Ltd 2006. MEDICAL EDUCATION 2006; 40: 584–589 588 stress and debt The proportion of GHQ-12 cases was similar in males and females (v2 ¼ 0.004, P ¼ 0.95). Students with Scottish backgrounds had lower GHQ scores than other students (Kruskall)Wallis test v2 ¼ 10.65, d.f. ¼ 2, P ¼ 0.01). Socioeconomic class did not make a significant difference to GHQ score (v2 ¼ 1.38, d.f. ¼ 4, P ¼ 0.85). There was a significant relationship between GHQ score (> 4) and lower class ranking (mean difference ) 15.14; 95% CI ) 28.01 to ) 2.28, P ¼ 0.02). Students who had high scores on the GHQ-12 had lower debts (P ¼ 0.04). There was a significant relationship between ÔcasenessÕ (GHQ) and thinking that worrying about money affects performance (v2 ¼ 22.63, P < 0.001); 55 students worried about money and were cases on the GHQ, suggesting only some crossover between the groups. Having a term-time job did not make a significant difference to GHQ score. DISCUSSION The amount of student debt was comparable with that found in the BMA survey,5 with a similar median level of debt in Year 5. Debt was related to location of parental home, parental social class, previous higher education and length of time in medical school. It was not related to income. The major difference between students from Scotland and those from elsewhere in the UK concerned the payment of tuition fees by the latter. We found no direct relationship between amount of debt and stress or debt and poor performance. While this was reassuring, we identified that students’ perceptions of their own levels of debt did relate to performance. Students who worried about money had higher debts and performed less well than their peers in degree examinations. Some of these students were also highlighted by the GHQ-12 as having mental health problems. This implies that a proportion of students may be under-performing and suffering adverse mental health because of debt. Medical students have been thought to have more university-related concerns and stresses than personal stresses by some researchers,9 while others have suggested that personal issues are more important.10 In our study, money and coursework were rated as the most significant causes of stress by students. Interestingly, a substantial proportion of students whose parents helped them financially reported that this put their family under excessive financial pressure. It may be that worry or stress associated with debt impact more widely than just on the individual student. As far as we know, this is the first study to have correlated medical student debt with a validated measure of stress and academic performance. A potential weakness of this study is its response rate (approximately 40%). This is similar to that found in previous studies11 and respondents were representative in terms of gender and class mark. However, we do not know if, for example, only students with certain levels of debt respond to such surveys. The limited response rate may have been due to the fact that students were asked for their student identification numbers and this raised concerns about confidentiality. The survey went out just before the examination period and it is possible that we may have achieved higher response rates at less stressful times of the academic year. In addition, the upcoming examinations may have inflated general levels of stress. Not all students who reported worrying about their finances reached ÔcasenessÕ (i.e. scores that indicate psychological distress) on the GHQ. A different instrument may be more sensitive or it may be that some students who worry are affected by the worries without showing signs of mental illness. Further research is required to identify the exact relationship between financial worry, psychological health and student performance. It may be that coping responses (the ways in which potential stressors are appraised and tackled and how these are evaluated by the individual)12 are the critical factors in predicting difficulties. Further investigation of the relationships between coping with stressors, including debt, would be helpful as this may aid the development of systems to identify and support struggling students. Researchers may also wish to examine the longterm impact of perception of debt and how this relates to the doctor’s psychological health and his or her ability to provide patients with the best possible care. If the perception of debt impacts on the performance of doctors, this may be an issue to investigate when assessing their fitness to practise. Our results also indicate that government policy should take account of the potential adverse psychological effects and impact on performance of debt in all undergraduate medical students. If worry about Blackwell Publishing Ltd 2006. MEDICAL EDUCATION 2006; 40: 584–589 589 debt contributes to poorer performance, perhaps even failure in later years of undergraduate medicine, having fewer student support grants and higher fees may be counterproductive. These factors are known to deter prospective medical students, particularly graduates and those from lower socioeconomic backgrounds2 from considering medicine as a career. While additional support is not the whole solution,13 given that these groups are targets for recruitment, the provision of sufficient support and encouragement before and after entry to medical school should be a fundamental component of government policy. REFERENCES 1 2 3 4 CONCLUSION Sayer et al. identified that the key points for supporting students with academic difficulties involve the identification of reasons, particularly those that are non-academic, for poor performance.10 This relatively small survey has provided useful information on the relationships between psychological distress ⁄ stress, debt and performance in undergraduate medical students. This information may underpin effective student support systems: faculty staff and senior teaching staff must facilitate discussion not just of levels of debt, but of students’ perceptions of their debt. Further investigation of the relationship between coping with stressors, including debt, would be helpful as this may aid the development of systems to identify struggling students and intervene on their behalf. If worry about debt is contributing to poorer performance, perhaps even failure, bringing in a system with fewer student support grants and higher fees may be counterproductive, given the need for more doctors and the substantial cost of training undergraduates. Contributors: MJM conceived the original idea for the study. All authors were involved in the design of the study and the questionnaire. SR carried out the data collection and analysis and drafted the paper. All authors revised the paper. Acknowledgements: the authors thank the medical students at the University of Aberdeen for contributing to the study, Amanda Lee for advice on statistics, and Mark Deakin and John Lemon for creating the electronic version of the questionnaire. Funding: none. Conflicts of interest: none. Ethical approval: the authors received notification from the Scientific Advisor of NHS Grampian Research Ethics Committee 2 that the initial questionnaire was considered to be audit of the service and that ethical permission was therefore not required. 5 6 7 8 9 10 11 12 13 Department of Education. Higher Education Act 2004. London: Stationery Office 2004. Greenhalgh T, Seyan K, Boynton PM. ÔNot a university typeÕ: focus group study of social class, ethnic and sex differences in school pupils’ perceptions about medical school. BMJ 2004;328:1541–4. General Medical Council. Tomorrow’s Doctors: Recommendations on Undergraduate Medical Education. London: GMC 2003. http://www.gmc-uk.org/med_ed/ default.htm. [Accessed 14 September 2004.] Higher Education Quality Assessment Agency. Subject Review: Medicine. 2000. http://www.qaa.ac.uk/ revreps/subjrev/subjrev_subj_index.asp?subjID=21. [Accessed 14 September 2004.] British Medical Association. Survey of Medical Students’ Finances 2002 ⁄ 03. http://www.bma.org.uk/ap.nsf/ Content/medfin0203. [Accessed 14 September 2004.] Goldberg D. The General Health Questionnaire. Windsor, UK: NFER-Nelson 1978. Office of Population Censuses and Surveys. Registrar General’s Standard Occupational Classification. Vol. 3. London: HMSO 1991. Goldberg DP, Williams P. A User’s Guide to the General Health Questionnaire. Windsor, UK: NFER-Nelson 1988. Moffat KJ, Macconnachie A, Ross S, Morrison JM. First year medical student stress and coping in a problembased learning curriculum. Med Educ 2004;38:482–91. Sayer M, Chaput De Saintonge M, Evans D, Wood D. Support for students with academic difficulties. Med Educ 2002;36:643–50. Whitacker AA. Use of the Internet for Pharmacy Practice Research: an Exploratory Methodological Study. Presented at the 6th Health Services Research and Pharmacy Practice Conferences, Robert Gordon’s University, Aberdeen, UK, 13)14 April 2000. Lazarus RS, Folkman S. Stress, Appraisal and Coping. New York: Springer 1984. Hilton S, Lewis K. Opening the doors to medicine. BMJ 2004;328:1508–9. SUPPLEMENTARY MATERIAL The following supplementary material is available for this article online: Questionnaire S1. Medical Student Debt Questionnaire, University of Aberdeen, UK This material is available as part of the online article from http://www.blackwell-synergy.com Received 9 December 2004; editorial comments to authors 7 April 2005, 5 July 2005; accepted for publication 22 November 2005 Blackwell Publishing Ltd 2006. MEDICAL EDUCATION 2006; 40: 584–589