Dear Sir,

I read the article ‘Understanding Singaporean medical students’ stress and coping’ by Wu et al(1) with great interest and would like to congratulate the authors for a well-designed, unique, yet important study on stress among medical students. However, I would like to highlight the following points about the article.

First, while the authors made a novel attempt to employ the critical incident analysis(2) tool in their study, they did not justify their decision not to use well-validated and widely used measures such as the General Health Questionnaire, Perceived Stress Scale, and Brief COPE tool.(3,4) Furthermore, methodological and executional details of the survey are lacking. The authors demonstrated, for instance, that problem-focused coping was more frequently reported among responders in comparison to emotion-focused coping.(1) However, this finding could, in part, be due to the interviewing technique itself, where instructions to interviewees focused on what they ‘did’, hence potentially instigating ‘behavioural’ answers as opposed to ‘emotional’ ones. Next, the use of terms such as ‘coping’ and ‘stress’ during the interview may lead to biases in response.(2) It is, however, unclear whether such techniques were considered or adhered to by the authors.

Second, the authors have made a few misleading statements in their manuscript. For instance, the authors stated that “We found that students experienced examination stress, which affirms prior data, but our respondents also described stress arising from relationships, which has not been previously reported.” However, Moss et al(5) demonstrated that relationships with senior staff were perceived by students as stressful and anxiety-inducing. Firth et al(6) published in the BMJ, showing that students’ relationships with consultants were particularly stressful when humiliated in front of their peers. Hence, it is not entirely true that stress among medical students arising from relationships has not been reported before.

The authors also concluded from their study that there was a cultural influence on coping behaviours. However, no comparative analysis was performed across different cultural groups in their study to justify such a conclusion, understandably so since the majority of respondents were of Asian background. Furthermore, the small sample size precluded logistic regression analysis to determine if results varied across cultures.

Nonetheless, the study serves as an important springboard for future research to be conducted. There are various gaps that the study has not addressed. For instance, it would be interesting to compare the nature and impact of stress, as well as stress coping itself, between undergraduate and postgraduate medical students in Singapore. Although compressing five years’ worth of medical curriculum into a four-year programme for postgraduate candidates may seem stressful, one may hypothesise that they are better equipped to handle stress given their increased maturity and age.(7) Next, the authors have not performed subgroup analysis by the year of study, as previous studies have shown correlations between year of study and stress findings.(4,7,8) This is important because students in pre-clinical and clinical years may face and cope with stress differently.

In summary, Wu et al should be commended for their efforts in addressing a pertinent issue among medical students in Singapore. However, the findings should be interpreted in the context of known limitations, and future research should be conducted to address these gaps.

Yours sincerely,

Editor’s note: The authors, Wu et al, have declined to respond to the above letter.

Wu L, Farquhar J, Ma J, Vidyarthi AR.Understanding Singaporean medical students' stress and coping. Singapore Med J. 2018;59:172-6.
O'Driscoll MP, Cooper CL.A critical incident analysis of stress-coping behaviours at work. Stress Med. 1996;12:123-8.
Anuradha R, Dutta R, Raja JD, Sivaprakasam P, Patil AB.Stress and stressors among medical undergraduate students: a cross-sectional study in a private medical college in Tamil Nadu. Indian J Community Med. 2017;42:222-5.
Zvauya R, Oyebode F, Day EJ, Thomas CP, Jones LA.A comparison of stress levels, coping styles and psychological morbidity between graduate-entry and traditional undergraduate medical students dang the first 2 years at a UK medical school. BMC Res Notes. 2017;10:93.
Moss F, McManus IC.The anxieties of new clinical students. Med Educ. 1992;26:17-20.
Firth J.Levels and sources of stress in medical students. Br Med J (Clin Res Ed). 1986;292:1177-80.
Casey D, Thomas S, Hocking DR, Kemp-Casey A.Graduate-entry medical students: older and wiser but not less distressed. Australas Psychiatry. 2016;24:88-92.
Datar MC, Shetty JV, Naphade NM.Stress and coping styles in postgraduate medical students: a medical college-based study. Indian J Soc Psychiatry. 2017;33:370-4.