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
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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
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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
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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.
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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
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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
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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.
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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