Though the causes evolve and change shape over time, the presence of stress throughout medical school is a constant.
For a study published in February in the International Journal of Medical Education, researchers tracked seven classes of U.S. medical students, from one institution, finding and that stress remains consistently moderate across all four years of undergraduate medical education (UME). Notably, the researchers found that at no point in training did the classes of students studied fall into a sustained period of low stress.
What are the biggest stressors across the phases of training? What coping mechanisms can help? The data and insight from a medical student shed light on those questions.
Stress throughout UME
Surveys conducted across two cohorts of medical students found that using the Perceived Stress Scale (PSS)—a widely used instrument consisting of 10 items—average stress levels remained consistently moderate across all four years.
What changes is not how students feel stress, but why. The study’s findings revealed several themes across all four years of medical school “that demonstrated year-specific and general patterns. These themes were academic stress, residency application and the Match process and personal life issues,” wrote the study’s authors.
In terms of academic stress, the study’s authors offered the following breakdown:
- Preclinical trainees (first- and second-year medical students), were most stressed by adjusting to the pace and volume of medical school workload and earning a passing score on Step 1 of the United States Medical Licensing Examination (USMLE).
- Third-year medical students identified performance on core clinical rotations and shelf exams as top stressors.
- Fourth-year medical students listed academic pressure around maximizing Step 2 performance and final rotations as main sources of academic stress.
Across four years of training, the highest stress levels were correlated with exam preparations during the second year of training and the residency-selection process during medical school’s fourth and final year.
Institutional interventions are pivotal to addressing medical student burnout. An AMA STEPS Forward® toolkit—"Medical Student Well-Being: Minimize Burnout and Improve Mental Health Among Medical Students”—outlines eight concrete actions that medical schools and faculty can take to promote student well-being and strengthen mental health.
A medical student perspective
AMA member Sneha Kapil is a fourth-year medical student in Florida. She found that the second half of medical school was more stressful than the first two years. The differences between the third and fourth year, she opined, was that one is physically demanding and the other is mentally stressful.
“For me, rotation year was the most physically stressful year,” she said. “It’s demanding on your time and on your body. You’re working long hours, studying and constantly going.”
With the Match process being a primary focus for fourth-year medical students, the ambiguity surrounding it can be burdensome.
As a fourth-year medical student, “there’s can be anxiety about what the future holds,” said Kapil, who serves as an alternate delegate of the AMA Medical Student Section Governing Council for the 2025–2026 term.
“You’re trying to get interviews, trying to get letters of recommendation,” she added.
In the run up to submitting residency applications, there’s also unique pressure points, Kapil said. Medical students are being assessed for their Medical Student Performance Evaluation (commonly referred to as the dean’s letter) and other aspects of performance measurement that impact one’s residency prospects.
“You’re aware of other people’s perceptions of you,” she said.
What helps medical students cope
To look at how medical students manage stress, the study used a modified version of the COPE Inventory, which assesses more than a dozen strategies used to manage stress such as humor, seeking support and acceptance.
When looking at stress-coping mechanisms, mindset had an impact on how medical students experienced stress. Researchers found that positively framing things—viewing stress and stressors in a productive light—was associated with lower perceived stress. On the other side of the coin, behaviors such as venting and self-blame were linked to higher stress levels for medical students, particularly among fourth-year medical students.
Coping strategies and effective habits for managing stress can vary by individual factors. While stress levels did not significantly differ by gender, male medical students were more likely to use acceptance, humor and positive reframing, particularly in the preclinical years.
Kapil found that spending time outdoors—a strategy that likely aligns with self-distraction among the coping mechanisms measured by the study—was a helpful way to manage stress.
“Getting outside for even a few minutes can be helpful,” she said. “In the hospital, resident and student workspaces don’t often have windows; it can feel like a little box. You walk into the hospital, and it’s dark outside. It’s dark outside when you walk into the hospital and it’s dark outside by the time you leave. Prioritizing time to get sunlight and be outside is so important.”
