Causes of fear & stress regarding Anatomy in selected private medical colleges in Dhaka

Introduction

BackgroundWorldwide medical colleges are responsible for making sure that medical students have adequate knowledge & skills before taking professional responsibilities. In order to achieve this goals, medical colleges typically use a curriculum of lectures, simulations, supervised practice, mentoring & hands on experience to boost individual skill. Unfortunately some aspects of the training process have unintended negative consequence on students’ physical & mental health. At present there are 20 public medical colleges & 54 private medical colleges in Bangladesh1.Anatomy is taught in first year of medical curriculum. It enhances the knowledge of human body & helps to understand various functions of different body parts . Anatomy practical dissection is one of the most hardest part & core component of anatomy. Students get their first experience of dissecting human body in the practical classes which brings with them a special set of problems2.

Majority expressed negative experience & highly stressful condition in practical classes .These practical classes are not fruitful if used plastic models . Working with dead body whether through active dissection or by examination of resected specimens are potential stressor in anatomy3. Pass rate in anatomy is also lower than other two basic subjects physiology & biochemistry4. 32% of Bangladeshi medical students are suffering from academic stress . Many complain of insomnia, nightmare, depression, learning impairment. This is a significant emotional challenge for students5.

Problem statement• In 1st year of medical life, medical students are taught in the basic medical

sciences which include anatomy, biochemistry and physiology. The speculation that students’ pass rate is lower in anatomy than in biochemistry and physiology4 . One of the Nigerian studies reveals only 54.7% passed anatomy9.The practical cadaveric dissection is usually the first in a long series of encounters with death, and these experiences, because they are infrequent outside of medical life, often are seen as unpleasant or frightening11.

• A study in Nigeria4 showed that students avoided practical class due to implicated overcrowding(55.2%),bad cadaver(12.3%),laziness (10.0%), and poor environment, formalin odour, absence of demonstrators etc . Majority of the respondents (42.8%) considered gross anatomy the most difficult, followed by embryology(20.9%) and histology(12.9%).18.9% respondents rated them equal in difficulty. Most of the respondents believed that large volume of work, lack of teaching aids, bad teaching methods and fear of the subject , academic stress influence the performance of students in anatomy examinations4.

Problem statement cont.• At present there are 54 private medical colleges in Bangladesh1.A

study among Bangladeshi medical students shows 65% of them was admitted into medical college by their own wish.26% of them felt unhappy & 32% was in constant stress . Medical students experience a relatively high level of personal distress with adverse consequences on academic performance ,competency , professionalism & health5.

• Our goal is to examine the students’ interpretation of the problems they encounter as they study anatomy– the backbone of medical practice. To identify the students’ problems, we looked into the various methods they employ in their study of anatomy and the problems they encounter. Their responses will help in the diagnosis of their problems as a veritable tool to making useful suggestions towards a lasting solution to the problems4 .

Review of literature• A study of Medical university of Nigeria done by Emmanuel AE,Justus N &

two others among 300 medical students of first year of which 51.2% was female,81.1% are of 21-30 yrs age shows 90% of them devoted more time in anatomy than other subjects,42.8% considered gross anatomy most difficult,76% suggests anatomy practical dissection classes with A-V aid will help them to learn & perform well in exam,53.2% said preparatory time for anatomy should be extended,55,2% said overcrowding is a major cause of aversion for practical class leading to inadequate exposure,12.3% said cadaver used are bad,40.3% complained of bad odors of formalin & lack of trained instructor,65.2% of them studied in groups to cope the situation4.

• A study by Veronika B,Hermann J & Erich K in Germany among 155 medical students reveals 50% was anxious during practical classes,58.7% had recurrent thought about death,33% reported sickness after 1st encounter with cadaver with headache,lightheadedness,4.3% complained of stressful negative emotions6.

• Another Nigerian study done in Jos university by Al s,FJ Shimwen,F Shinku & 3 others shows 51.6% of medical students faced dizziness in practical room,27% of them had lost their appetite after dissection.47.6% used relaxation therapy for coping the stress,71.4% tried to focus on the task & others used rationalized thinking, discussion with fellow students7.

• Imola S,Emma B,Zsuzsa G conducted a study in 4 medical university on Hungary among 733 students & found that the source of stress & fear regarding anatomy were study workload, examination, time shortage, practical dissection, parents/friends related stress, financial stress & future career related stress. Reactions after the dissection class were dream ,flashback, thoughts, fear when alone, turned inwards, doubt fitness about medical profession & no effect. Coping strategies used by them were treating cadaver as objects/dummy/plastic models, think it as just flesh & bones, pay attention to the pathology, go through this to learn, concentrate on the task, acceptance of death as a part of life, discussing, trying to avoid looking to the face & eyes of cadaver, humor with friends.33.4% of them had recurrent thought of cavader,23.7% had flashbacks.87% had the strategy of going through this for learning. Women react more sensibly than men8.

• One more study’s findings in Nigeria by Emmanuel N,Emmanuel O & Udechukwu F shows pass rate in anatomy was 54.7% in UNEC & 41.24% in UNIPORT9.

• Mishra P,D Sheersagar,Dharmendar M conducted a study in Nagpur, India & found 74% of 1st year students found anatomy practical class unclean & smelly,6,6% called it horrifying & depressing,1.3% fainted at first encounter,76% said teacher was not available for demonstration10.

• A study among Bangladeshi medical students by Eliza Omar Eva,Md Zakirul Islam & others shows 65% of them was admitted into medical college by their own wish.26% of them felt unhappy & 32% was in constant stress5.

Justification• Medical profession is considered as a noble profession. Knowledge of

basic subjects should be sound for further studies .There are several causal factors that influence negative impact on performance of Anatomy among undergraduate medical students. There are a number of studies on factors including fear, anxiety, stress among undergraduate medical students but very few studies conducted in Pakistan, India, Hungary on factors including fear, anxiety, stress etc. that constrain Anatomy learning in dissection room as well as in classroom.

• At present there are 54 private medical colleges in Bangladesh1.Several studies have been done on the causes of stress among medical students but very few studies have been done on fear and stress regarding Anatomy in Bangladesh perspective.

• The aim of the study is to identify the problems stumble upon by students in the study of Anatomy and suggest ways of improving their performance in the subject4.

Operational definition Stress: Medically, stress is when a person feels threatened by or under pressure from a particular situation and their body reacts accordingly5.

• Fear: According to Webster dictionary,be afraid of (someone or something) as likely to be dangerous, painful, or threatening.

• Causes of stress & fear :Time pressure,workload,having multiple roles,emotional issues,practical classes,large syllabus with sub-branches,examinations etc.

Anatomy: According to Webster dictionary , the branch of science concerned with the bodily structure of humans, animals, and other living organisms, especially as revealed by dissection and the separation of parts.

Private medical college: Medical colleges under private sector

List of variables1.Variable related to causes of stress and fear: Study load , large syllabus , many sub-branches of subjects, inefficient practical classes,lack of trained teachers, exam, viva ,time constraints,finanacial issue,family & friends issues and others.

2.Variables related to coping mechanism: Avoid dissection,sharing with friends & family,group study,relaxation therapy,watch TV,self counselling,say prayers,taking rest,listening to songs,net surfing,reading story books,playing games,doing social work,travelling,meditation ,focussing,rationalization,discussion etc.

3.Varibles related to academic performance:Resident with parents or hostel,previous medium of study Bengali or English,completed months in medical college,most difficult subject,study style,time allocation for each subject,marks in item,card & terms.

4.Variables related to socio-demographic characteristics:Age in completed years, sex, monthly family income , marital status.

Research question• What are the causes of fear & stress regarding anatomy

in selected private medical colleges in Dhaka?

Objectives• General : To find out the causes of fear & stress regarding

anatomy in selected private medical colleges in Dhaka.

• Specific: 1. To find out the causes of fear among the respondents. 2. To identify the causes of stress among the respondents. 3. To explore the mechanism of coping for stress & fear among the respondents. 4. To find the academic performance & socio-demographic characteristics of the respondents.

MethedologyStudy area: Selected private medical colleges in Dhaka.

Study period & duration: From October 2016-December 2016.

Study population: 1st year students of selected private medical colleges in Dhaka.

Study design:Descriptive cross sectional study.

Sample size:Sample size,n = z2pq/d2

Here,p=% of stress among Bangladeshi medical students=32%=0.32 5

q= 1-p=0.68z=1.96 at 95% of CI d=Level of error=5%=0.05

So, n= {(1.96)2x0.32x0.68}/(0.05)2=334.4

Sampling technique: ►Multistage sampling is done.

►First all private medical colleges in Dhaka are listed according to Dhaka north & south . Two medical colleges from each municipalities are selected by simple random sampling by lottery.

►Total sample size is divided by four , result is 83.5 approx 84.So there will be 84 students from each medical college.

►In medical college the list of 1st year MBBS medical college students who are present at the time of data collection will be collected. This is the sampling frame. Among them 84 students will be selected by using simple random sampling by random number of table.

Selection criteria:►Includes all 1st year MBBS students present at the time of data collection.►Excludes students who are absent , have ongoing professional exams , ill that unable to participate in interview.

Data collection method:1.by semi-structured pre tested self administered questionnaire2. The Medical Students Stressor Questionnaire (MSSQ) :to identify the source of stress.The items on MSSQ represent 40 events that have been identified to be the most probable source of stress in medical students. Respondents will be requested to assess each event in them during the recent weeks by choosing from five responses: ‘causing no stress at all’, ‘causing mild stresses, ‘causing moderate stress’, ‘causing high stress’ and ‘causing severe stress’. The MSSQ is scored by assigning a value of 0–4 for each of the respective responses. A response of ‘causing no stress at all’ would be scored as 0 and a response of ‘causing severe stresses’ scored as 4(13) .

Data management

Data analysis

Time Frame

1stwk

2ndwk

3rd

wk4th

wk1st

wk2nd

wk3rd

wk4th

wk1st

wk2nd

wk3rd

wk4th

wkTopic selection

Literature review

Proposal defense

Questionnaire developmentData collection

Data entry

Data analysis

Report writing

Final defense

October November December

Ethical consideration• We are doing this study for academic purpose.

• Approval is taken from ERC (Ethical Review Committee) of SUB (State University of Bangladesh).

• Permission from the concerned authority- the principals of four private medical colleges will be taken.

• Informed verbal consent of the respondents will be taken.

• Privacy & confidentiality of data will be kept preserved.

• Respondent has every right to withdraw from the procedure at any time of data collection.

References1. List of medical college.www.bmdc.org.bd.www.bmdc.org.bd/recognized-medical-colleges/accesed 19 Nov 20162. I sander,E Birkas,Z Gyorffy.The effects of dissection room experiences & related coping strategies among Hungarian medical students.BMC Med Educ.2015;15:www.ncbi.nlm.nih..gov/pmc/articles/PMC4409727/.published 11 April 2015.accessed 21 Nov 2016.3. F Javadria,M Hashemitabar et al.How to decrease the emotional impact of cadaver dissection in medical students.Pakistan journal of medical sciences.2006;22(2):www.pjms.com.pk/issues/aprjun06/article/sc1.html.published April-June 2006.accessed 21 Nov 2016. 4.Emmanuel A,Justus N,Oylogu F etal.Factor that affect medical students’ performance in anatomy in the university of Nigeria.OJM.2010;1-4:www.ajo/journals/ojm published 2010.accessed 26 Nov 20165. Eliza Omar Eva,Md Zakirul Islam,Abu Sayed Md Mosaddek,Md Faizur Rahman,Rini Juliet Rozario etal.Prevalence of stress among medical students.Biomed central.bmcresnotes.biomedcentral.com/articles/10.1186/s13104-015-1295-5published 22 July 2015.accessed 21 Nov 2016.

6. Veronika B,Hermann J,Erich K.Psychological stress in 1st year medical students in response to dissection of a human corpse.BMC medical education.2012;29(1):www.ncbi.nlm.gov/pmc/articles/PMC3296105/published 2012.accessed 26 Nov 2016.7. Al Shuguba,FJ Shimwen,YM Usman etal.Attitude of Jos university medical students to their initial encounter with cadavers in diisecting room.Journal of experimental & clinical anatomy.2015;14(2):101-104.www.jecajournal.org/article.asp?issn=1596-2393;year=2015;volume=14;issue=2,spage=101;epage=104;aulast=Shugaba published 2015.accessed 16 Nov 2016.8. Imola S,Emma B,Zsuzsa G.The effects of dissection room experiences & related coping strategies among hungarian medical students.BMC medical education.2015;15:www.ncbi.nlm.nih.gov/PMC/articles/PMC4409727/ published 11 Apr 2015.accessed 21 Nov 2016.9. Justus N Eze,Oyiogu FN Ozoemena,Emmanuel A Esom,Udechukwu F Ezepue.Performance of students in anatomy in 2nd MBBS exam in some Nigerian universities.Orient journal of Medicine.2006;18(1):www.ajol-info/index.php/ojm/article/view/29099 published 2006.acessed 26 Nov 2016.10. Mishra Purvi,DD Sheersagar,Dharmendra Mishra.Attitude of 1st year medical students towards dissecction.J cont Med A Dent.April 2015;3(1):http://dxdoi.org/10.18049/jcmed/319 published 2015.acessed 26 Nov 2016

11. Finkelstein P, Mathers L. Post-Traumatic stress among medical students in the Anatomy Dissection Laboratory.Clinical Anatomy.3rd.California:Wiley-Liss Inc;1990:220.12.Patel Bhaskar,Jagdeep Jadav,Ajay Parmer,Bharat Tridvedi.Attitude of medical students to cadever dissection in Ahmedabad city.IJCRR.2012;4(22):54-58.13. Eva E O,Islam M Z,Mosaddek A S M,Rahman M F,Rozario R J,Iftekhar A F M H,Ahmed T S,Jahan I,Abubakar A R,Dali W P E W,Razzaque M S,Habib R B,Haque M. Prevalence of stress among medical students; a comparative study between public and private medical schools in Bangladesh. BMC Reseach notes.2015;8:327.

Thank you