The educational environment includes several factors that contribute to learning, such as classes, other learning activities, teachers, and social relationships. The learning environment includes what is perceived or experienced by students and teachers,1–3 and it stands out as a factor that can exacerbate or mitigate stress among medical students.4 Evidence indicates that levels of psychological distress in medical students are higher than in their age-matched peers.4–8 One reason may be that medical students need to deal with suffering and death.9,10 Another reason could be the verbal, emotional, and physical abuse some students receive from faculty and resident physicians.4,11,12 Finally, lack of time, competitiveness, poorly prepared teachers, and an excess of required and/or personal activities can also negatively influence educational environment.13
Reactions to stressful situations or environments are different for each person; they depend on the individual’s current levels of stress, his or her values, culture, and the availability of social and economic support.14–17 How medical students respond to stressful stimuli is important because their response affects their academic performance and well-being during training, as well as their future practice.18–20 A maladaptive reaction can be associated with decreased well-being and quality of life (QoL).21–23
Previous researchers have examined the association between educational environment and QoL among medical residents,24 but, to our knowledge, none has yet examined this association among medical students. In this report, therefore, we present the association between Brazilian medical students’ perceptions of QoL and of their educational environment using the Dundee Ready Education Environment Measure (DREEM)25; the World Health Organization Quality of Life Assessment, abbreviated version (WHOQOL-BREF)26; and a global QoL self-assessment. We hypothesized that a more negative perception of the educational environment would be associated with lower QoL scores.
Study design and sample
We conducted this investigation, designed to evaluate QoL and educational environ ment, as part of a multicenter study involving 22 Brazilian medical schools.
The research ethics committee of the School of Medicine of the University of São Paulo, as well as the institutional review boards of all the participating institutions, approved this study.
When we collected the data for this study (August 2011–August 2012), Brazil had 153 medical schools with at least one graduating class, constituting approximately 86,000 medical students at different levels across all six years of training in Brazil. We defined our sample size (n = 1,152) to enable an effect size of 0.165 between two groups of the same size, with 80% power at a .05 significance level. Later, we increased the sample to 1,650 students to account for a 30% loss of participants. We randomly selected at least 60 students from each of 22 medical schools (the participating medical schools provided the lists of students). Next, we stratified them into clusters by gender and program year (i.e., five males and five females per each of the six program years), using a computer-generated list of random numbers.27
We invited the selected students to participate in the study, contacting them through e-mail and social media. If a student did not respond, we randomly selected another student from the same cluster. Participation was voluntary, and we did not offer any compensation or incentive. We guaranteed both confidentiality and anonymity, and participating students completed a consent form.
We collected data from August 2011 to August 2012. Selected students received a link to access an electronic survey platform, which we designed specifically for the study. Besides the data collected through formal, validated instruments (described below), we also collected sociodemographic data: age, sex, location and type (public or private) of medical school, and information on financial support and housing. Location and type of medical school are important in Brazil because these data provide insight into socioeconomic and other forms of diversity.
Students had 10 days to complete the survey. Once they submitted it, they received feedback on their scores. Specifically, they received their score for each domain of each questionnaire and information about the meaning of each result. We also provided students with the opportunity to contact any of the coordinating researchers for guidance or emotional support.
DREEM is a 50-item questionnaire that evaluates respondents’ perceptions of their educational environment.25 DREEM is divided into five domains: students’ perceptions of learning, students’ perceptions of teachers, students’ academic self-perceptions, students’ perceptions of the atmosphere, and students’ social self-perceptions. Answers are given on a five-point Likert scale (4 = strongly agree; 0 = strongly disagree). Higher scores correspond to more positive perceptions of the educational environment, though some items are reverse-scored. We used the McAleer and Roff score descriptors as a guide for interpreting the domain and item results.28 This questionnaire was translated to Brazilian Portuguese and validated.29
WHOQOL-BREF is a short form of a longer tool to measure QoL that consists of 26 items divided into 4 domains: physical health, psychological health, social relationships, and environment.26 Answers are given on a five-point Likert-type scale. Scores in each domain are transformed into a scale from 0 (worst QoL) to, for ease of comparison, 100 (best QoL).26 This questionnaire was translated to Brazilian Portuguese and validated.30
The QoL self-assessment consists of two global questions that evaluate students’ perceptions regarding their overall QoL and QoL related to medical school (MSQoL). The items are (1) “Rate your overall quality of life on a scale of 0 to 10” and (2) “Rate your quality of life in medical school on a scale of 0 to 10,” where 10 = highest quality and 0 = no quality.
We performed analyses, using the Cronbach α to examine the reliability of the data.
We considered age, WHOQOL domain scores, DREEM domain scores, and total DREEM scores to be continuous variables. We classified participants’ educational environment perceptions according to their DREEM total score as follows:
- very poor (score 0 to 50),
- having many problems (51 to 100),
- more positive than negative (101 to 150), or
- excellent (151 to 200).
Because the number of individuals with a very poor perception of their learning environment was very small (n = 8), we grouped these students with those who perceived the environment as “having many problems” for analysis.
We also categorized participants according to their DREEM total scores in quartiles, obtaining the following distribution:
- First quartile: 18 to 100 points;
- Second quartile: 101 to 119;
- Third quartile: 120 to 138; and
- Fourth quartile: 139 to 191.
We also used quartiles to categorize overall QoL and MSQoL. For both variables, we grouped individuals in the second and third quartiles together because they had similar scores. For overall QoL we had the following distribution:
- First quartile: 2 to 6 points;
- Second/third quartiles: 7 or 8 points;
- Fourth quartile: 9 or 10 points.
For MSQoL we had the following distribution:
- First quartile: 0 to 5 points;
- Second/third quartile: 6 or 7 points;
- Fourth quartile: 8 to 10 points.
We stratified the periods of medical school into three levels of two years each, according to the most widely used classification in Brazilian schools: basic sciences (first and second years), clinical sciences (third and fourth years), and clerkships (fifth and sixth years).
We presented categorical variables as proportions, and quantitative variables as means (and standard deviations [SDs]). We used chi-square tests and Kruskal–Wallis tests whenever applicable.
We analyzed the results of each of the five DREEM domains separately by MSQoL and overall QoL scores (i.e., in quartiles). We performed chi-square trend tests for proportions across groups defined by overall QoL and MSQoL quartiles. To analyze individual DREEM questionnaire items, we calculated the frequency of participants who responded that they perceived the situation described in each item positively (≥ 3 points). We presented the items with a pronounced difference between first and fourth quartile groups (defined as a frequency ratio ≥ 1.5) based on the distribution of MSQoL scores.
We used multinomial regression models (crude and adjusted for age, sex, year of medical school, school location, and public/private status) to study the association between measurements of QoL perceptions and DREEM total scores by quartiles. As the measurements of QoL perceptions yield different ranges, we used standardized scores (i.e., the individual score minus the mean score for the sample, divided by the SD) to allow for better comparisons. We have presented the odds ratios (ORs) for one SD increase in each measurement of QoL perception.
We performed all statistical analyses using R software version 3.1.1 (Vienna, Austria).
Of 1,650 randomly selected students, 1,350 (81.8%) agreed to participate and completed the study, 274 (16.6%) declined to participate, 13 (0.8%) did not complete the questionnaires, and 13 (0.8%) were excluded for technical reasons (e.g., problems with the online platform). The main reason students gave for declining was lack of time. Participants’ ages ranged from 17 to 40 years. We show characteristics of the study sample in Table 1.
The results of the reliability analyses performed using the Cronbach α coefficient demonstrated that the data were highly reliable, with α values between 0.66 and 0.94 for all domains of the questionnaires (data not shown).
The mean total DREEM score (not shown) was 119.4 (SD 27.1). We detected a small significant difference in total DREEM scores for male (121.0 [SD = 27.2]) and female (118.0 [SD = 27.0]) students (P = .05). These scores revealed that, overall, the students’ perceptions of the educational environment were more positive than negative.
In bivariate analyses (Table 1), higher total DREEM scores (analyzed by quartiles) were associated with younger ages (P < .001), higher proportions of individuals in the first or second year of medical school (P for trend = .001), and lower proportions of individuals in the fifth or sixth year (P for trend < .001) of medical school. The proportion of women also tended to decrease as overall DREEM score increased, with borderline significance (P for trend = .051). The MsQoL scores were significantly lower than the scores for overall QoL (P < .001).
Regarding the measurements of QoL (Table 2), groups with higher total DREEM scores were associated with higher (more positive) perceptions of QoL (P < .001 for all comparisons). Mean overall QoL scores were higher than MSQoL scores (mean difference, 1.35; 95% confidence interval [CI] 1.28–1.43; P < .001), and this difference (P for trend < .001) was higher in individuals with lower DREEM scores. Our analysis of DREEM scores by domains per the distribution of overall QoL and MSQoL scores in quartiles (Table 2) showed that for all DREEM domain scores, higher scores were associated with higher overall QoL and MSQoL scores (P < .001 for all comparisons).
When we compared the students from different phases of medical school, we found significantly lower individual DREEM item scores (P < .05) in all domains among students in their later years of study (not shown). The items with the lowest scores for students in their clerkship include, from the social domain, 3 (“There is a good support system for students who get stressed”) and 4 (“I am too tired to enjoy this course”); from the academic self-perceptions domain, 22 (“I feel I am being well prepared for my profession”) and 27 (“I am able to memorize all I need”); from the learning domain, 20 (“The teaching is well focused”), 7 (“The teaching is often stimulating”), and 48 (“The teaching is too teacher centered”); and from the teachers domain, 29 (“The teachers are good at providing feedback to students”).
We show the association of self-rated MSQoL and DREEM questionnaire items in Table 3. In this table, we show DREEM questionnaire items with pronounced differences (defined as a frequency ratio ≥ 1.5) between the frequency of individuals with a positive perception of their educational environment (i.e., scored two to four points in each DREEM item) in the first MSQoL quartile group and individuals with a positive perception of their educational environment in the fourth MSQoL quartile group.
Table 4 shows the results of multinomial regression models for the association between standardized QoL scores and DREEM total quartile groups. For all QoL measurements, we observed significant dose–response patterns, with higher DREEM quartile scores associated with better QoL. The influence of DREEM scores seemed to be higher on MSQoL scores compared with overall QoL scores, as point OR estimates were higher for the association with MSQoL. For the association with specific WHOQOL domains, the highest ORs for the association with DREEM scores were found for the psychological health domain (OR 4.70, 95% CI = 3.80–5.81).
Controlling for age, sex, year of medical school, and two main variables that influence medical schools’ profiles in Brazil (location and public or private financing) did not alter the results significantly.
Our data—from 1,350 students from 22 Brazilian medical schools—reveal consistent associations between students’ more positive perception of their educational environment and their more positive perception of their QoL. We found that students’ perception of their educational environment is more closely associated with their MSQoL scores than with overall QoL scores. We also found that the psychological domain of the WHOQOL questionnaire was more related to students’ perception of their educational environment in full-adjusted models than the other WHOQOL domains.
Our findings of medical students’ perceptions of their educational environment are similar to those reported in other studies. Studies made in medical schools in the United Kingdom, Australia, and Sweden have reported higher total DREEM scores than our study (above 130),31–34 whereas studies from other countries, such as Iran, India, Kuwait, Sri Lanka, and Brazil, including our study, have reported DREEM scores up to 130.3,35–40 It might be difficult to compare and explain these differences because students from different regions may have different environment perceptions due to their educational background, values, and culture, and the medical schools analyzed also may follow different types of curricula (traditional or with active learning methods).
Our study also shows that Brazilian students report a more positive perception of their educational environment during their first and second years of medical school than they do during the final four years. These results are consistent with those of other studies.3,36,41–45 In analyzing the DREEM items, we observed several factors that seem to exacerbate stress during the clerkship years. Students in this phase reported that they can really notice or feel the lack of a good support program, are too tired to enjoy their studies, and have trouble memorizing all the material. Clerkship students also perceive that the teaching is not cohesive, not focused, not stimulating, not student centered, and not developing their confidence. These students also indicated that their teachers do not give appropriate feedback, which we find especially worrying in a clinical setting that demands frequent feedback.
Lower scores in the clerkship years could also be explained by the fact that in this phase students have a greater workload and more responsibilities. In addition, the clinical work during clerkship may produce more stress in trainees and faculty, which may contribute to moral crises and emotional abuse.4,5,12 Moreover, throughout their earlier years of medical school, trainees may have developed a more critical view of their teachers, educational activities, and methods.13,42 Another cause of the more negative perceptions of QoL and of the learning environment during the last two years of medical school might be the admission exams for medical residency that clerkship students take. In Brazil, these exams are very competitive because of the high demand for a limited number of positions.
We observed a nonsignificant trend for more negative perceptions of the educational environment among female students in our study. This trend is consistent with the findings described in other studies, which report no, or only minor, gender differences.35,40,43–46 Many studies, however, show that female students face greater difficulties in medical school. They have higher rates of depression, worse well-being and QoL, and higher levels of academic stress.5,23,47,48 Studies showed that female students seek support services more often than their male colleagues.49
Students’ perceptions of their MSQoL were worse than their perceptions of their overall QoL. Both higher overall QoL and higher MSQoL scores were positively associated with higher total DREEM scores, as well as with scores for each of the DREEM domains. Notably, however, the difference between overall QoL score and MSQoL score was even more pronounced for individuals who have more negative perceptions of the educational environment (Table 3). These results suggest that perceptions of the educational environment have a greater effect on perceptions of MSQoL than overall QoL.
Our analysis of individual DREEM items, compared across students with more positive and less positive perceptions of their QOL, revealed four items in the social self-perceptions domain with striking differences (Table 3). These items ask students about how good their social life is, whether they are too tired to enjoy their studies, whether they are bored in their courses, and whether they feel lonely. Our data suggest the importance of a social life (i.e., support from family and friends) in having and maintaining a positive perception of QoL. Other studies have also shown that medical students’ life satisfaction is related to the presence of strong social ties and robust social support.50,51
Students with a better perception of their QoL also reported more positive perceptions of items belonging to the learning and teachers domains (related to educational methods, course organization, atmosphere, focus of learning, and memorization). Some authors suggest that providing professional development (which empowers teachers with new educational practices), limiting the number of judgmental formative assessments, and making psychosocial counseling available could lead to decreased stress among students and decreased work pressure among faculty.39 In fact, previous investigators have found that well-designed assessments, skilled faculty, and pedagogically sound classes are all related to the increase in the perception of QoL in medical students.13
Students with a better perception of their QoL more heavily endorsed the item “enjoyment outweighs the stress of studying medicine.” This result is consistent with those reported in a previous qualitative study in which most students declared that, although their perception of the MSQoL was worse than that of their overall QoL, they believed that sacrifices during medical school were necessary to attain their goal of becoming a doctor.13
We found differences in the responses to all the DREEM items between the students in the fourth quartile and in the first of the MSQoL questionnaire—with one exception. This exception is number 3, “There is a good support system for students who get stressed.” Our respondents’ negative answer—the perception that support is minimal or lacking—for this item aligns with data reported in multiple previous studies.36,37,39,42,44 This consistency across studies seems to align with anecdotal evidence that many medical schools offer no formal support systems for students, and/or that the support system that is available does not meet students’ needs. In addition, item number 25, “The teaching overemphasizes factual learning,” showed an inverse trend; for this item, the students whose perceptions of the educational environment were worse had higher QoL scores. This reverse relationship could be related to the interpretation of this item in the Brazilian Portuguese version of the questionnaire. Some students may consider factual learning (memorization) to be a positive attribute. In contrast, many students believe that learning facts is not positive because they prefer active learning.
In our study, the associations between perceptions of QoL and DREEM scores were independent of age, sex, and year of medical school. Our data show that more negative perceptions of the educational environment may be associated with a decrease in medical students’ perception of their QoL. Dealing with stress and adversities in medical school can be easier for some students, such as those in the fourth quartile group of our study. This group included, compared with the other three groups, a higher number of young students, a higher number of students enrolled in the first and second years of medical school, and the same proportion of male and female students. Perhaps these students had a support system, personal characteristics, or emotional competencies that might explain their positive perceptions of their QoL and educational environment. Medical schools have little or no control over many aspects of each individual student’s social life or emotional and personal characteristics; however, they do have the power to change the educational environment, such as including content about QoL and well-being in the curriculum, providing protected areas to study, and offering programs to support students who face difficulties related to the process of becoming a doctor.13,22,52–54
In addition, when we observed the relationship between the standardized scores of the WHOQOL-BREF domains and total DREEM scores (Table 4), we found the strongest association between higher total DREEM scores and the psychological health domain of the WHOQOL-BREF. Importantly, medical students may be especially vulnerable to more negative perceptions of the components covered in this domain (e.g., body image and appearance, “negative feelings,” self-esteem, concentration); other studies have also shown that medical students score low on the psychological health domain of WHOQOL-BREF.47,55
Some educators believe that students must undergo some “stressful” experiences in medical training and must learn how to deal with them.21 We agree with this idea, provided that students receive adequate supervision and support. Many studies have shown that excessive stressful experiences affect learning and personal development both during medical school and in future practice.4,18–21,27 The challenge is to plan the curriculum to offer experiences which lead to personal and professional growth while supporting social, physical, and mental health.
This study has important strengths. We randomly selected our sample to reduce response bias. The participation of 22 medical schools, collectively representing different curricula and every region of Brazil, allows us to generalize our results to medical students throughout the country. Compared with most published studies using DREEM, our study has a large sample. We have used validated measures that allow us to make additional cross-cultural comparisons. We have also employed an original design, allowing us to examine the associations of medical students’ perceptions of their QoL and perceptions of their educational environment in a way that, to our knowledge, has not been done previously.
Our study also has some limitations. The main limitation is its cross-sectional design, which prevents us from making causal inferences. Second, we cannot directly generalize our results to other countries. However, given that our data are from a large number of students from 22 extremely heterogeneous and geographically dispersed medical schools distributed throughout a very large country, our findings are not likely due to a single, specific educational scenario. Third, we cannot exclude the possibility that the characteristics other than educational environment, such as location of, type of (public or private), and educational methods adopted at each medical school may be associated with students’ perceptions of QoL, which could affect our results. However, controlling for two main variables that influence medical schools’ profiles in Brazil (location and public or private financing) did not alter the results significantly. We believe that future longitudinal studies that include different countries would answer some of these questions.
We found a positive association between QoL measures and DREEM scores. This association had a dose–response effect, independent of age, sex, and year of medical school. The results strengthen the idea that educational environment may impact students’ perceptions of their QoL. Medical educators retain the responsibility to improve the educational environment of medical schools by planning the curriculum to offer experiences that lead to personal and professional growth while supporting social, physical, and mental health.
Acknowledgments: The authors would like to thank the following associate researchers—all members of the VERAS Collaborative Research Group—for their hard work recruiting students: Alicia Navarro Souza (Universidade Federal do Rio de Janeiro), Ana Carolina Faedrich dos Santos (Universidade Federal de Ciências da Saúde de Porto Alegre [UFCSPA]), Benedita Andrade Leal de Abreu (Universidade Estadual do Piauí), Cleane Toscano S. Bezerra (Faculdade de Ciências Médicas da Paraíba [FCMPB]), Cleidilene Ramos Magalhães (UFCSPA), Derly Streit (Faculdade de Medicina de Petrópolis), Emilia Perez (FCMPB), Emirene M.T. Navarro da Cruz (Faculdade de Medicina de São José do Rio Preto), Eugenio Paes Campos (Centro Universitário Serra dos Órgãos), Itágores Hoffman (Universidade Federal de Tocantins [UFT]), Ivan Antonello (Pontifícia Universidade Católica do Rio Grande do Sul), Katia Burle dos Santos Guimarães (Faculdade de Medicina de Marília), Luís Fernando Tófoli (Universidade Federal do Ceará), Maria Amélia Dias Pereira (Universidade Federal de Goiás), Maria Cristina Lima (Universidade Estadual Paulista [UNESP]), Maria Luísa Carvalho Soliani (Escola Bahiana de Medicina e Saúde Pública), Nilson Rodrigues da Silva (Faculdade de Medicina do ABC [FMABC]), Olívia Maria Veloso Costa Coutinho (UFT), Raitany Almeida (Universidade Federal de Rondônia), Sérgio Baldassin (FMABC), and Vera Lúcia Garcia (UNESP).
The authors would also like to thank the participating students for their willingness to complete the questionnaires.
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