Stress and Clinical Reasoning in Medical Students

Overview

Solving a problem in ambulatory setting may contain peripheral stress due to socio-evaluative stressors (patient's expectations about explanations) and task contingent stress due to time pressure, the necessity to take into account patient's mood, to deal with uncertainty of their own data collection and with complex clinical situations. In France, excepted for family medicine, undergraduate medical students and residents are currently not trained to perform consultations and are never exposed to ambulatory patients during training. The investigators postulate that this lack of practice may generate a significant state of stress during the first consultations and consequently modify or even impair clinical reasoning. The primary objective of this study is to compare subjective and physiological levels of acute stress in ambulatory versus hospitalization setting in medical students confronted to a real patient with a diagnostic problem. Measures: The French version of the Anxiety Spielberger test is administered just before and after each problem solving session. Cortisol salivary samples are taken before and after each problem solving session. Salivary cortisol levels have been shown to be correlated to stressful situations and some personality traits but with some difference according to gender. Cognitive appraisal (threat/challenge) is assessed before and after the tasks by the ratio of primary appraisal to secondary appraisal according to Tomaka et al.

Participants and Method: Year 6 medical students who attend a one-month full-time course in an Internal Medicine Department are eligible. Since no consultations in the ambulatory setting are currently structured for medical students, the following adjustments have been done within the internal medicine consultation department, with the approval of the department director: * the consultation duration has been increased (1 hour instead of 30 minutes) * during the first 30 minutes, consultation is performed by the participant * during the following 30 minutes, the patient is examined by his/her own physician. * The consent of the patient has been obtained by phone (prior to the consultation).