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Stress Management in Medical Education: A Review of the Literature

Shauna L. Shapiro, MA, Daniel E. Shapiro, PhD, and Gary E. R. Schwartz, PhD
ABSTRACT Purpose. To review systematically clinical studies providing empirical data on stress-management programs in medical training. Method. The authors searched Medline and PSYCHINFO from 1966 to 1999. Studies were included if they evaluated stress-management programs for medical trainees (medical students, interns, or residents); reported empirical data; and had been conducted at allopathic medical schools. Results. Although the search yielded over 600 articles discussing the importance of addressing the stress of medical education, only 24 studies reported intervention programs, and only six of those used rigorous scientic method. Results revealed that medical trainees participating in stress-management programs demonstrated (1) improved immunologic functioning, (2) decreases in depression and anxiety, (3) increased spirituality and empathy, (4) enhanced knowledge of alternative therapies for future referrals, (5) improved knowledge of the effects of stress, (6) greater use of positive coping skills, and (7) the ability to resolve role conicts. Despite these promising results, the studies had many limitations. Conclusion. The following considerations should be incorporated into future research: (1) rigorous study design, including randomization and control (comparison) groups, (2) measurement of moderator variables to determine which intervention works best for whom, (3) specicity of outcome measures, and (4) follow-up assessment, including effectiveness of future patient care. Acad. Med. 2000;75:748759.

Medical education has deleterious consequences. Trainees (students, interns, and residents) suffer high levels of stress, which lead to alcohol and drug abuse,1 interpersonal relationship difculties,2 depression and anxiety,3,4 and even suicide.5 Medical students have mean anxiety scores one standard deviation above those of non-patients, and their depression levels increase sig-

Ms. Shapiro is a doctoral student in clinical psychology, University of Arizona, Tucson. Dr. Shapiro is assistant professor, Departments of Psychiatry and Integrative Medicine, University of Arizona College of Medicine. Dr. Schwartz is professor of psychology, neurology, psychiatry, and medicine, University of Arizona. Correspondence and requests for reprints should be addressed to Ms. Shapiro, University of Arizona Department of Psychology, Tucson, AZ 85721; e-mail: shapiros@u.arizona.edu.

nicantly throughout the rst year of medical school.6 Stress may also harm trainees professional effectiveness: it decreases attention,7 reduces concentration,8 impinges on decision-making skills,9,10 and reduces trainees abilities to establish strong physicianpatient relationships.11 To address these problems, programs have been changed in a variety of ways, including reducing the work week,12 instituting curricular reforms (e.g., smaller classes, less rote memorization), and providing psychological services such as couples counseling, child care services, social activities, support groups, and stress-reduction programs.13 A decade ago, after a comprehensive literature review of stress in medical education, Buttereld concluded that the body of literature on effective interven-

tions needs to be expanded. 14 Unfortunately, this recommendation has not been followed. Despite numerous articles that decry the negative consequences of stress and call for intervention and change, few have studied the specic effects of stress-management interventions in medical education, and even fewer have provided empirical data. Although there is a large literature on stress management in general, its specic application to medical education has been largely unexplored. To ll this gap, in this article we review the literature on stress-management programs in medical education; specically, programs providing trainees with coping techniques (such as meditation, hypnosis, imagery, and muscle relaxation), education regarding the psychological and physiological effects

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of stress, afliation with peers and opportunities for emotional expression (support groups), and intensied relationships with faculty. We then discuss implications for the integration of stress management in medical training and make suggestions for future research. LITERATURE REVIEW While the literature is replete with papers discussing stress reduction or describing specic programs, we found only 24 studies that reported data. Table 1 provides a three-part matrix describing these 24 studies across eight categories: participants, randomization, control groups, structure of intervention, content of intervention, follow-up, outcome measures, and results. Part I contains the six rigorously designed studies, Part II has the one study that violated randomization, and the remaining 18 studies comprise Part III. As can be seen in the table, the studies looked at a heterogeneous group of programs that blended a variety of interventions and means of delivery. Of the 24 studies, only seven used control groups or attempted to randomize participants. This diversity and lack of consistent method makes drawing rm conclusions difcult. Below we discuss each column of the matrix, highlighting key points and issues and discussing implications for future directions. We begin our review of the results by addressing the question, Are stress-management programs in medical education effective? We then rene our analysis by examining three aspects of the studies: (1) participants and methods, (2) interventions, and (3) outcome measures. RESULTS

trainees who responded in all studies were in favor of the programs being offered regularly or integrated into the curriculum. Authors reported that participating trainees demonstrated improved immunologic functioning15,16; decreases in depression and anxiety15,17; increases in spirituality and empathy17; enhanced knowledge of alternative therapies for future referrals18; improved knowledge about stress19; improved sensitivity toward themselves,20 their peers,20,21 and their patients20; reduced perceptions of isolation20; greater use of positive coping skills and less use of negative coping skills22; and resolution of professional role conicts.21 Only four studies reviewed found no difference between experimental and control groups on standardized measures of psychological functioning, immune functioning, or health at post-assessment.15,19,23,24 However, of these four only one conducted any follow-up assessment, and this one did nd a significant positive change in the intervention group compared to the control group. Trainee achievement, as assessed by examination performance, was consistently not correlated with participation in stress-reduction programs. Follow-up Although all of the studies reported results based on assessments immediately after the interventions, only four20,2426 assessed trainees beyond the end of the intervention. Of these, three reassessed participants a few months later and one assessed subjects one year later. While follow-ups supported the effectiveness of the interventions, the durations of stress-management effects for the majority of programs remain unclear. Participants

of the studies allowed participants in different years of training to participate in the same programs. The other half focused on single years of training, most commonly the rst year of medical school or residency. Because of the heterogeneity of the programs described, it is difcult to draw conclusions about how these inclusion decisions inuenced outcomes. Most of the studies based their conclusions on small samples. The majority of the studies had samples under 30; the smallest had six participants.26 Such small sample sizes made it difcult to nd statistically meaningful results, make generalizations, and rule out type II errors (incorrectly concluding that an intervention is not effective). Finally, studies varied in their recruitment of participants. Most stress-management programs recruited volunteers, but they may not have reached those trainees most in need. As noted by Reuben,27 severely impaired residents are least likely to use support systems such as groups, mental health counselors, or faculty mentors. Other stress-management programs made attendance mandatory.28 This was more common in programs for residents than in programs for medical students. A minority of participants in the mandatory programs resented the requirement; one study found that some residents felt that attending a support group indicated decreased competence.28 Future research should compare the results of mandatory and volunteer interventions. In addition, given Reubens observation, it may be particularly important to screen and then target those trainees found to be most impaired, as they appear to be the least likely to volunteer. Randomization Only seven of the studies1517,2224,28 randomly assigned participants, and only one of those28 used stratied sampling to ensure that equal numbers of different participants, in that case rst-, sec-

The 24 studiesthe earliest one published in 1969, the latest in 1998 showed that the stress-management programs were helpful psychologically and/or physiologically, and virtually all

Fifteen of the studies focused on medical students, one included both residents and medical students, and the remaining eight focused on residents. Half

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Table 1
A Review of the Literature on Stress Management in Medical Education, 1969 to 1998 No. of Participants Part I: Rigorously designed studies Shapiro et al.17 78 rst- and second-year med students (advanced premed students) Matched for gender, race, and premed vs. med student status 36 intervention; 36 wait-list control Elective course; 7 weekly 2-hour sessions. Up to 20 students. Sessions led by mindfulnessbased stress-reduction teacher. 14 weekly 90-minute training sessions led by psychiatrists experienced in clinical hypnosis. 15 minutes daily selfhypnosis practice. Mindfulness-based stress reduction. Meditation, body scan, yoga, discussions. None Standardized psychological measurements Reduced psychological distress, depression state and trait anxiety, and increased empathy and spirituality. Results replicated in control group. Experimental group had less distress and anxiety. No difference in immune function. For experimental group, quality of hypnosis practice predicted number of natural killer cells and natural killer activity. No difference in exam scores. Hypnosis group improved on all health variables, waking group improved on some, and passive group worsened in mood. Type of Control Structure of Intervention Content and Techniques Outcome Measures

Randomization

Follow-up

Results

Whitehouse et al.15 35 rst-year med students

Yes

21 intervention; 14 wait-list control

Self-hypnosis training, discussion of experiences

None

Standard psychological inventories and immunologic measures

Palan and Chandwani22

56 med students

Randomized by most recent exam score and hypnotizability

20 hypnosis group; 17 waking group; 19 passive-relaxation control group

All attended 9 weekly sessions and had 20 minutes of daily home practice.

Hypnosis: suggestions during hypnotism for improving study habits. Also taught self-hypnosis. Waking: received same suggestions while awake. Passive group: light reading. Discussions of stress, progressive relaxation, physical exercise, deep muscle relaxation, time management, autogenic relaxation, test anxiety, visual imagery, systematic desensitization, type-A behavior, stress in medical profession.

None

Exam scores; non-standardized inventory assessing 8 health variables

Nathan et al.23 (rst study)

96 rst-year med students

Yes

50 intervention; 46 control

Intervention started with large class then broke into smaller groups. 8 weekly sessions lasting 50 minutes. (25-minute lecture, 25-minute smallgroup discussion. Control group had unstructured time.)

None

Standardized inventories with acceptable validity and reliability

No measurable effect on grades, health, or psychological variables.

Nathan et al.23 (second study) Yes 49 large group; 54 small groups (7 or 8 each) Compared large group with small groups. All had 8 weekly 50-minutes sessions (25-minute lecture, 25-minute discussion). 10 35- to 45-minute sessions over 21/2 weeks, including hypnosis and led by clinical psychologist. Sessions provided overview of hypnosis, self-hypnosis practice, progressive relaxation, autogenic training, and imagery exercises. At end of sessions facilitator made hypnotic suggestions for greater relaxation and improved study habits. None Standardized psychological measures, baseline health report, frequency of relaxation practice and immunologic measures Sessions focused on teaching subjects to change maladaptive cognitions, and to practice meditation and progressive muscle relaxation. 10 weeks post-intervention Esteem or depression Control group increased in anxiety, obsessive compulsive symptoms, and distress. No difference in academic performance or sleep quality. Within hypnosis group, more practice was correlated with improved immune function. Intervention group reported increased skills in coping with school-related stress. Same as above. None Standardized Inventories with acceptable validity and reliability No signicant difference

103 rst-year med students

Kiecolt-Glaser et al.16

34 med students

Yes

17 intervention; 17 wait list control

Holtzworth-Munroe et al.24

40 rst- and second-year med students

Yes

20 intervention, 20 no-treatment control

6 weekly 1-hour sessions led by a doctoral student in clinical psychology.

Part II: One study that violated randomization Control group composed of students who called after intervention groups were lled 14 intervention; 14 wait-list control 6 60- to 90-minute sessions over 3 weeks. Sessions, coordinated by clinical psychologist and psychologist trainees, had three parts: didactic, discussion, and descriptions of homework practice. Discussion of stress, relaxation training, cognitive modication skills, time management, self talk. None Standardized inventories with acceptance validity and reliability; one non-standard inventory Knowledge about stress improved. No difference in standardized scales; control group worsened in Jenkins Hard Driving Scale.

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Kelly et al.19

48: 65% rstyear; 12% second-year; 3% fourth-year; 20% residents or nurses

Continued on next page

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Table 1 (Continued)
No. of Participants Part III: Remaining Studies Klamen25 60 rst-year med students No No 3 weekly 2-hour stress-management workshops. Social support and relaxation training, communication skills and burnout prevention, discussion of stress and coping. Groups, discussed role expectations, relationships with peers and supervisors, coping with anxiety, and emotional issues. Focus of group leader was on physicianpatient relationship, feelings generated in response to cases, role demands. Variety of patient issues discussed, including depression, somatization, and loneliness. Leader used discussion of group dynamics, parallel process, genogram analysis, and didactics. 2-day encounter groups that used sociometric analysis, time structure forms, interactional analysis, and selfappraisal. None No standardized measure; subjective rating of helpfulness of stress management No standardized inventory, students responded to questions about coping and value of intervention No standardized measure 100% of students reported helpfulness of course. Type of Control Structure of Intervention Content and Techniques Outcome Measures

Randomization

Follow-up

Results

Kahn and Addison13

7 residents

No

No

39 75-minute unstructured sessions throughout academic year. Process group led by family physician and clinical psychologist. Balint groups: 55% met weekly, 30% met bimonthly, remainder met less often. Majority met for two years or longer. Most had 5 to 10 participants. All had leaders who were either family practice MDs, psychiatrists, or psychologists. Groups included family practice rst-, second-, third-year residents or mixed groups. Health care simulations of team roles with mock patient data, structured encounter groups in which interpersonal processes were noted and discussed, and unstructured encounter groups.

None

100% felt group was valuable; reported decreases in negative coping and increases in positive coping. Highly endorsed: Provides support for residents; Helps resolve professional role conict; and Determines effect of doctors personality on illness.

Brock and Stock34

381 family pracNot applicable tice residents. 19% had Balint groups, 11% had had seminars in the past, and 19% expressed interest in starting them

Not applicable

Not applicable

Johnson et al.1

15 rst-year med students

No

No

None

Participants selfrated pre/post intervention on 30 items, including personal responsibility, cooperation on tasks, communication, problem solving and decision making, and personal growth

Signicant improvement on all items from pre- to postintervention. Means and other data unreported.

Franco et al.35 No No Informal support groups (7 students each) led by member of deans staff. Discussion of curriculum, professional identity, and socioeconomic pressures. None No standardized inventory; students answered question: Should program be continued? 80% felt the program should be continued through the rst year of med school. 42% felt program should be continued through fourth year. 75% of respondents felt system provided adequate psychological support, 80% had attended at least one support meeting, roughly 33% had attended 5 or more. 1 respondent felt groups not helpful. Of interns, 67% had attended at least 1 meeting with faculty sponsor.

150 rst-year med students

Reuben et al.27 No Article looked at support group meetings, described as more focused on topics than emotions. Content dictated by faculty, residents, and occasional guest speakers. Topics included: anger at nature of training system, appropriate emergency care of patients, methods of communicating with private physicians, and proposals to reduce burden on on-call physicians. None Undescribed, unvalidated questionnaire sent to all residents; percentage of respondents to those queries not reported None Anonymous (not parametric) questionnaire Addressed stress experience due to high expectations, lack of control, and dependence/independence issues. None No standardized measure; yearend questionnaire No Comprehensive system initiated after residents suicide: (1) mass communication (hospital newsletters, grand rounds, etc.) validating stresses of internship; (2) faculty sponsor system for rst-year residents; (3) individual counseling of residents by authors; (4) network of mental health professionals for individual treatment; and (5) weekly support meetings. Group met weekly for Social group. free lunch, led by clinical psychologist. 36 weekly 1-hour stress-discussion groups facilitated by MDs. Median number of participants was 5.

Total program supported 250 residents from various disciplines; 54 answered questionnaire

Weiner48 No No

Internsnumber not reported

Participants endorsed usefulness of group. 90% enjoyed group sessions. 55% felt group helped them deal with stress.

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Ziegler et al.49 No NO

Internsnumber not reported

Continued on next page

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Table 1 (Continued)
No. of Participants Blitch et al.
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Randomization Yes; stratied to equal numbers of each year in each group No

Type of Control

Structure of Intervention 10 residents randomized to each of 3 groups.

Content and Techniques Mandatory facilitated interpersonal groups met for 8 weekly sessions with one feedback session. Sessions lasted between 1 and 2.5 hours during regular duty time. Groups discussed various topics, including frustration with residency, positive aspects of training, personal issues such as conicts between role demands and private life, anxiety about life after residency, and feelings that contradict images of professionalism. 4 general themes of the group: response to training experiences, identity and career decisions, personal and life crisis, and gender stereotypes. Interns discussed work stress and feelings of depression, anxiety, anger, and helplessness.

Follow-up None

Outcome Measures Residents completed questionnaires: (1) rated goals of group; (2) Modied Interpersonal Relationship Scale; and (3) informal written feedback Co-leaders asked all participants 11 questions; unvalidated inventory

Results Groups considered a valuable supplement to behavioral science curriculum.

30 rst-, second-, and third-year family practice residents

Strahilevitz et al.32

33 pediatrics residents

No

No

Designed to address pediatrics residents feelings of isolation. 3 groups met over lunch, facilitated by pediatricians and one psychiatrist. Groups scheduled to last 8 weeks but two continued beyond 8 weeks.

None

80% felt groups helped them get to know peers, realize others have similar experiences, develop better working relationships, and express emotions. All felt support groups had place in training. 75% attendance rate.

Webster and Robinowitz26

6 second-year med students

No

No

Elective course meeting 1 to 1.5 hours rst semester, and 2 to 2.5 hours during remainder of study (30 months). Two co-leaders. 10 weekly 90-minute support-group sessions

10-month follow-up

Yalom Inventory and ve other rating scales measuring gains from group

Participants reported improved intra- and interpersonal relations.

Siegel and Donnelly50

7 pediatrics interns

No

No

None

No standardized measure; forms asked whether students valued the group

5 returned evaluations, all reporting valuable experience.

Soskis18 No No standardized measure; students asked what they might continue studying after study and what they would recommend for patients 40% considered continuing religious meditation; 69%, yoga; 88%, transcendental meditation. 79% to 88% would recommend techniques for patients. Most provided positive feedback. Some disliked the experience. Essays completed by medical students No One-semester elective course entitled Mediation and Healing led by professional teachers. Readings, lectures, None demonstrations, and supervised practice in four techniques: selfhypnosis, Western religious meditation, yoga, and transcendental meditation. Groups discussed career issues, authority issues, peer relationships, problems in relationships, emotional support. None

42 rst- and second-year med students

Golden and Rosen31

Med students: 3 years of 4-year program reported: 25, 30, and 136

Participants volunteered for group; nature of assignment to groups unreported

Yes, rst year had 13 subjects arbitrarily assigned to experimental group with 12 selected as controls

Most groups met weekly for 2 hours or more. For rst two years, group leaders had experience in small-group dynamics. Most third-year group leaders had no training in smallgroup leadership or psychiatric or psychological training. Weekly 1- to 2-hour informal discussion groups met for 1 year, led by two female faculty each. Insight-oriented support groups. Frequently focused on interpersonal issues between group members. Other foci included conicts between female and medical identities, isolation, perfectionism. Unstructured group sessions allowed emotional expression and interpersonal exploration. None Students completed goals sheet before joining groups; at end of academic year, answered 12 statements on 4-point scale including importance and helpfulness of groups Mailed evaluation one month before end of year. Group seminars met weekly for 90 minutes, met for 1 trimester. Used discussions and role playing. No Questionnaire: Modied Yaloms Q-sort

Hilberman et al.21 No No

17 rst-year and 1 second-year female med students

Participants satised with groups, reported getting closer to classmates and understanding problems of professional women.

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Dasdef et al.20 No No

47 med students, mostly fourthyear

Between 4 and 6 voluntary facilitated unstructured group sessions lasting between 1.5 and 2.5 hours.

Improved sensitivity, reduced isolation, increased capacity for intimacy.

Cadden et al.52 No No

42 volunteer rstyear med students

No standardized measure

65% found it interesting and helpful, 21% generally helpful, 15% waste of time. No difference in academic performances between participants and non-participants.

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ond-, and third-year family practice residents, would be included in each group. One study19 described a procedure that actively violated randomization: students were recruited on a rstcomerst-served basis, with those who called earlier being assigned to the experimental group and those who called later (who may have been less organized), to the control group. The rest of the studies did not describe how participants were assigned to groups. Control Groups With eight exceptions,1517,19,2224,29 the studies reported did not use control groups. Most studies used pre/post designs, comparing baseline and post-intervention ratings. Unfortunately, there is ample evidence that stress levels uctuate considerably during training. Medical students report experiencing considerably more stress during examination periods, and interns and residents report varying levels of stress depending on assigned rotations, on-call schedules, or time off. Given these factors, it is likely that pre/post designs are vulnerable to these uctuations. An example illustrates this problem. Shapiro and colleagues17 reported no change in state anxiety levels (a measure of current anxiety, as opposed to trait anxiety, which measures characteristics or general anxiety) for the experimental group from before to after the intervention. However, signicant differences in state anxiety were found between groups (experimental and control) after the intervention. The post-intervention assessment coincided with the examination period, suggesting that the stress-management intervention had buffered students against the negative effects of examination stress. If the study had not included a control group, the intervention would have erroneously appeared ineffective. In some cases not using control groups is understandable. Researchers have to balance the value of informa-

tion gleaned from control groups against the possible negative consequences for medical trainees enrolled in wait-list controls, inert control groups, or comparison groups suspected to be less effective than the experimental groups. Of those who did use control groups, ve used wait-list control groups,1517,19,29 two compared interventions,22,23 and one had a no-treatment control group.24 Intervention Structure of the intervention. The majority of the programs used a group structure where trainees met with peers or with leaders. Interventions varied in the amounts of time required of participants, from two consecutive intensive days30 to weekly hour-long meetings throughout the academic year.13 Participants tended to meet from one to two hours. The optimal duration for interventions, both in frequency and duration of meetings, is unknown. No study systematically examined what length or intensity of intervention was most effective. Considering the demands already made on trainees time, many of the programs required only modest additional time commitments. However, this also meant that only a few programs provided long-term support. Controlled empirical research needs to determine what length of intervention is most benecial, considering the trainees rigorous time commitments. Paradoxically, stress-management programs may initially elicit greater levels of stress.22 Therefore, a costbenet analysis should be performed to determine what intensity is most effective both short- and long-term. The facilitators of the interventions varied in terms of training, background, and experience level. In selecting group leaders, one should consider a few issues. On the one hand, group leaders with training experiences similar to those of the participants will be familiar

with their specic stresses and struggles.32 On the other hand, effective group facilitation is not a simple task33 and should be conducted by those with professional training, such as social workers, psychologists, and psychiatrists.34 Another problem with using facilitators with similar experiences is that many have dual relationships with the participants. For example, in some cases the leaders of groups had grading responsibility for the participants,35,36 a clear violation of basic support-group theory. Further, some stress-management interventions are based on specialized training and the facilitator must be an expert in order to effectively teach the stress-management skills (e.g., hypnosis or meditation). As a result, researchers frequently had to choose between selecting facilitators who had training similar to that of the participants, those who had training in group leadership, or those who had specialized training. Content of the intervention. No gold standard exists for the content of stress-reduction programs for medical trainees. As in stress-management programs offered in other workplaces,37 content varied considerably. Our review revealed that a wide variety of interventions were included under the umbrella of stress reduction; e.g., directed and non-directed support groups, relaxation training (including meditation and hypnosis), time-management and coping skills, mindfulness-based stress reduction, and mentoring programs. The groups also varied in the degrees to which they encouraged emotional expression, incorporated personal as well as professional issues, and focused on technique versus discussion. Outcome Measures The most common outcome measure used in the studies was the trainees evaluations of the stress-management programs. The trainees almost universally found the programs helpful and in

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many cases urged researchers to integrate the programs into the curriculum. Most medical schools rely heavily on students evaluations when making teaching assignments and rotation selections. Although students evaluations are vital as an outcome measure, more objective measures (e.g., behavioral and physiologic measures) are needed to provide more comprehensive assessment of outcomes. Unfortunately, systematic evaluation of other outcomes was scarce. Only seven studies used standardized measures. Most researchers relied on non-standardized inventories they had constructed themselves. The problems with non-standardized measures are well known to behavioral scientists and are not discussed here. Future researchers might focus on a number of outcomes that have yet to be examined. For example, what is the inuence of stress-management programs on physicianpatient communication? How does stress management for physician trainees inuence patient outcomes? Do programs with stress-management interventions have less trainee dropout? We believe one unintended and unfortunate side effect of medical training is that it produces physicians who believe that self-denial is valuable and necessary and that living under stress is normal. Until physicians recognize the signicant health impact stress has on them and the importance of modeling healthy behaviors (including relative stress-free living) for their patients, it is unlikely that the skills learned in a stress-management program will be incorporated into their professional and personal lives. Stress Assessment One reason that most of the studies did not use validated measures is that there is no gold standard for assessment of stress management. Researchers studying stress tend to rely on checklists that

ask respondents to report the number of symptoms they are experiencing or the severity of events they have experienced. The most widely employed include the Unpleasant Events Schedule,38 the Hassles Scale,39 the Assessment of Daily Experiences Questionnaire,40 the Inventory of Small Life Events,41 and the Daily Stress Inventory.42 However, the checklist approach has many limitations. Clearly, all self-report instruments are open to response biases, social desirability, and unconscious (repressive) coping.43 Even more problematic, none of these instruments was designed to apply to medical trainees, who experience not only predictable and general pressures, such as interpersonal stressors, economic problems, fatigue, and condence decits,44 but also stressors specic to medicine, such as 24-hour schedules and issues of life and death. The particular demands of medical training merit measurement by a tool sensitive and specic to this population. One direction may be to develop a medical education stress inventory. Although self-report measures of stress are important, examination of physiologic measures of stress should supplement them to validate the effectiveness of the stress-management techniques. According to Cambell and Fiske,45 multi-trait, multi-method assessment is the most sophisticated and accurate research design. The following are common physiologic measures cited in the literature46,47: electroencephalagram (EEG), electrocardiogram (EKG), blood pressure (baseline and return to baseline), cortisol levels, measures of immune functioning, nger-pulse transit time (FPTT), ear-pulse transit time (EPTT) (see Cacioppo and Tassinary47 for a more complete description of these measures). One of the more common criticisms of these forms of assessment is that they may not generalize outside of the laboratory. This important question deserves attention, and measures have been or are being developed (e.g., ambulatory

blood pressure monitor) to address it. Other potential limitations include cost, confounding variables, and time. Despite possible concerns, physiologic measures of stress give another relevant piece of the picture by providing an objective comparison with trainees subjective self-reports. This is especially important in light of past studies of repression in which physiologic arousal was objectively measured even though participants did not self-report arousal.43 Further, these physiologic measures are often markers of future physiologic pathology. Finally, although the negative consequences of stress include decreased attention and concentration, poor decision-making ability, alcohol and drug abuse, depression and anxiety, relationship difculties, and even suicide, few of these variables have been assessed as outcome measures of stress-management programs for medical trainees. Future research must include outcome measures that will determine whether the stress-management program is able to buffer against these potential negative consequences of stress. CONCLUSIONS AND IMPLICATIONS FOR FUTURE RESEARCH The purpose of this article is to review the literature on stress management and medical education. Of the 24 studies reviewed, the vast majority supported the effectiveness of interventions designed to reduce the stress of medical education and training. In almost all cases (where measured) the participants found the programs useful. Unfortunately, a lack of careful control in most studies, few validated outcome measures, and heterogeneous interventions make drawing rm conclusions beyond this premature. Despite continued calls for research on stress-management programs in medical education, there have been few carefully conducted trials. In our search, we found over 600 articles discussing

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the importance of addressing the stress of medical training. Common themes described by authors of these articles suggest that the reigning paradigm in medical education emphasizes performance under stress, competition, and self-denial. Unfortunately, only 24 of these articles reported empirically assessed intervention programs, and only six of these1517,2224 used rigorous scientic method. This discrepancy illustrates that there is much work to be done. Although some may feel that the obvious conclusion is to implement stress-management programs immediately without future research, there are still many unanswered questions. It is unclear which types of stress-management programs are most effective (e.g., meditation versus support group). While it is encouraging that researchers are exploring many approaches, it is difcult to make comparisons among diverse treatments. Interventions have varied in treatment modality (e.g., individual versus group), in format (e.g., structured versus unstructured), and in therapeutic techniques (e.g., hypnosis versus meditation). Further research is needed to disentangle research designs and explore which components of a complex array of interventions are most effective. It is also unclear what duration and frequency are necessary to produce results. Precise comparison of interventions of differing durations and frequencies must be made to determine the most efcient and effective stress-management programs for medical trainees. Further, although a variety of interventions have proven effective, sensitivity to medical trainees in general, and individual differences in particular, is necessary. Future research must accurately determine which interventions work best for whom by assessing moderator variables. Based on our review, the following considerations should be incorporated into future research: (1) rigorous design,

including randomization and control (comparison) groups; (2) precise study of varying durations and frequencies of interventions (e.g., two-day intervention versus eight-week intervention); (3) measurement of moderator variables to determine which interventions work best for whom; (4) specicity of outcome measures; and (5) follow-up assessment, including effectiveness of future patient care. This review has described the widespread interest in stress-management programs, the promising start made by those already implemented, and the great unexplored territory that must be charted if these interventions are to efciently and effectively succeed in the twin goals of beneting physicians and their patients and establishing a sound scientic base for future research.
The authors acknowledge and thank all of the pioneering researchers who have contributed to the eld of stress management in medical education. They also thank Benedict Freedman for his insightful editorial comments and Heather Rist for her help in creating Table 1.

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