Original Article
A Systematic Review of Stress-Management
Programs for Medical Students
Malan T. Shiralkar, Toi B. Harris, M.D., Florence F. Eddins-Folensbee, M.D.
John H. Coverdale, M.D., M.Ed., FRANZCP
Objective: Because medical students experience a considerable
amount of stress during training, academic leaders have recog-
nized the importance of developing stress-management programs
for medical students. The authors set out to identify all controlled
trials of stress-management interventions and determine the efcacy
of those interventions.
Method: The authors searched the published English-language
articles on PsycINFO and PubMed, using a combination of
the following search terms: stress-management, distress, burnout,
coping, medical student, wellness. Both randomized, controlled
trials and controlled, non-randomized trials of stress-management
programs were selected and critically appraised.
Results: A total of 13 randomized, controlled trials or controlled,
non-randomized trials were identied. Interventions included self-
hypnosis, meditation, mindfulness-based stress-reduction, feedback
on various health habits, educational discussion, changes in the
length and type of curriculum, and changes in the grading system.
Only one study was identied to be of very high quality, although
several had described group differences at baseline, used blinding,
had good follow-up, and used validated assessment tools. There
was a wide heterogeneity of outcome measures used. Interventions
that were supported by a reduction in stress and anxiety in
medical students included mindfulness-based stress-reduction or
meditation techniques, self-hypnosis, and pass/fail grading.
Conclusions: Signicant opportunities to advance educational
research in this eld exist by developing more high-quality studies
with particular attention to randomization techniques and
standardizing outcome measures.
Academic Psychiatry 2013; 37:158164
Received January 4, 2012; revised September 25, 2012; accepted October
16, 2012. From Baylor College of Medicine, Houston, TX (MTS); the Dept.
of Psychiatry & Pediatrics, Baylor College of Medicine, Houston, TX
(TBH, JHC); and University of Texas Health Science Center at San Antonio
(FFE-F). Send correspondence to Malan T. Shiralkar; e-mail: shiralka@
bcm.edu
Copyright 2013 Academic Psychiatry
158 http://ap.psychiatryonline.org
M edical students experience an immense amount of
stress during training, and the Liaison Committee
of Medical Education (LCME) standard on this issue is an-
other impetus for the creation and study of wellness pro-
grams for medical students (1). Studies have shown that
there is a higher prevalence of psychological distress
among medical students than in the general population
and age-matched peers (2, 3). The implications for psycho-
logical distress of medical students include lowered aca-
demic performance (4), increased professional misconduct
(5), decreased empathy (6), increased substance abuse (7
9), and suicide (10). Medical students often avoid seeking
help because they believe it might affect their future career
plans or fear that they will be seen as weak by others (11).
Given the high rates of distress among medical students, it is
imperative that efcacious health-promoting interventions
are offered for all students in order to limit distress. Accord-
ing to the standards of best-evidence medical education (12,
13), medical school educators and administrators should take
account of published information on stress-management
programs in order to guide the development of efcacious
stress-management programs at individual medical schools.
There is a great variety in the types of health-promotion
programs currently offered, including self-development
groups (14), yoga interventions (15), mindfulness and life-
style programs (1620), self-hypnosis (21), small group
stress-management programs (22), time management pro-
grams (23), reective writing sessions (24, 25), curriculum
changes (2628), grading changes (2931), and educa-
tional electives (32). Although there has been one notable
systematic review of stress-management programs for
medical students (33), this review has not been updated,
nor did it identify any search terms used. Moreover, this
review had wide inclusion criteria that included not only
medical students, but residents, nurses, and premedical
students.
Academic Psychiatry, 37:3, May-June 2013

Because of the dearth of systematic reviews on this wide
array of interventions for reducing medical student dis-
tress, the aims of this review are to identify all randomized
controlled trials and controlled non randomized trials for
stress-management programs, to identify the efcacy of
these interventions for reducing distress, and to identify
the strengths and weaknesses of the available studies con-
cerning allopathic and osteopathic medical students alone.
We aim to describe how stress-management programs were
incorporated into the medical education curriculum for
medical students and their impact on psychological dis-
tress, if any, by comparing intervention-group ndings with
comparison-group ndings.
Method
We used standard methodologies (34) for conducting
systematic reviews, searching PsycINFO and PubMed
databases for peer-reviewed articles reporting on primary
studies of stress-management programs integrated into
allopathic and osteopathic medical schools for medical
students. Also, we performed directed searches of primary
publications referenced in other articles, including review
articles. The search was conducted over a 22-month period
(February 2010November 2011). Combinations of the
following key words were used: stress management, dis-
tress, burnout, coping, medical student, and wellness.
Inclusion criteria included English-language articles pub-
lished after 1995 and the use of a separate control or com-
parison group in the research design. The authors arbitrarily
started at 1995. The major reason for exclusion was the
absence of a control group; other reasons for exclusion in-
cluded those programs aimed to decrease substance abuse or
increase professionalism and programs conducted within
residency training. We focused the review on medical
school programs so that these programs could serve as
a model for the development of medical school stress-
management programs.
After initial searches, the team met regularly to discuss
potentially relevant articles and whether these articles met
the inclusion criteria. All articles that met the inclusion
criteria were read by all team members. Articles were scored
on criteria for establishing validity of a study, using and
extending the standards developed by the Criteria from the
Evidence-Based Medicine Working Group (35). These
items included the presence of randomization, adequacy of
methods of concealment, randomization, whether differ-
ences at baseline were identied, the presence of blinding,
follow-up and intention to treat, and validity and reliability
Academic Psychiatry, 37:3, May-June 2013
SHIRALKAR ET AL.
of outcome measures used. Each item was dichotomously
scored by three members of the team (JC, TH, FE), with
a maximum score of 7 points. Any differences in ratings
were resolved by consensus. Two members (TH and MS)
checked for reliability and validity of psychometric scales
for those publications that did not make note of it.
These included the Brief Symptom Inventory, Prole of
Mood States, UCLA Loneliness Scale, Hopkins Symptom
Checklist, and the Perceived Stress Scale. In presenting the
results of the individual papers, we only comment on sim-
ilarities or differences that were identied as being of im-
portance between experimental and comparison groups. If
sufcient data were available, the numbers needed to teach
(NNT) or the numbers needed to harm (NNH) were
calculated.
Results
Our initial search yielded 735 primary articles. All
abstracts were scanned, and the abstracts of articles per-
taining to distress in medical students were read. Also,
a secondary screening was done, in which the reference lists
of these articles were read, to include articles that may not
have shown up on the primary search. Furthermore, other
articles relevant to managing stress in allied health students
or physicians were identied, and their reference sections
were searched for any articles pertaining to medical stu-
dents. Our search of the databases plus our additional
searches yielded 13 articles that met our inclusion criteria.
These included ve randomized, controlled trials (RCTs;
17, 20, 21, 25, 32) and eight controlled, non-randomized
trials (CNRTs; 18, 19, 2631). As shown in Table 1, eight of
the studies examined one medical school year class; one
study included premedical students and rst- and second-
year medical students, and three studies included two med-
ical school class years. Interventions included self-hypnosis
(21), changes in the length and type of preclinical curricu-
lum (19, 2628), meditation (17), feedback on various
health habits (32), educational discussion groups on self-
care (32), classes focusing on mindbody medicine (19),
mindfulness-based stress-reduction (18, 20), reective
writing seminars (25), and changes in basic sciences cur-
riculum grading (2931). All of the studies aimed to de-
crease medical students emotional distress; however, one
study also addressed the effects of the intervention on health
habits (32); a second study examined the effects of the in-
tervention on immune system reactivity (21); and a third
study examined the effects of the intervention on United
States Medical Licensing Examination (USMLE) scores,
http://ap.psychiatryonline.org 159
STRESS MANAGEMENT FOR MEDICAL STUDENTS

TABLE 1. Characteristics of RCTs (Randomized, Controlled Trials) and CNRTs (Controlled, Non-Randomized Trials)
of Medical School Stress-Management Programs

Experimental
Study and Control Training Assessment
Study Type Subjects Level Methods and Tools Intervention Outcomes
Whitehouse RCT 21 / 14 1st-year POMS, BSI, UCLA Self-hypnosis versus (2) no between-group immune
et al., Loneliness Scale, controls differences; (+) experimental
199621 blood immune group reported signicantly less
measures distress at exam time
Guthrie CNRT 204 / 100 1st year MBI, GHQ, Stress 2- versus 3-year (+) lower stress levels with a longer
et al., Incident Record preclinical curriculum curriculum
199726
Shapiro RCT 37 / 41 Premedical Hopkins Symptoms Meditation-based stress (+) experimental group reported
et al., and 1st Checklist, STAI-1, reduction versus wait- signicantly reduced
199817 and 2nd Empathy Construct list control depression, anxiety, and overall
years Rating, INSPIRIT psychological distress
Ball and RCT 23 / 29 1st year BDI-II, MEQL, Self-care (lecture, (+) self-care intervention favored
Bax, Epworth Sleepiness discussion, over written feedback in
200232 Scale, Health Habits education) versus proportion of students changing
Survey, AUDIT educational written health habits
feedback
Rosenzweig CNRT 190 / 162 2nd year POMS Mindfulness-based (+) experimental group reported
et al., stress-reduction signicantly greater
200318 versus control improvement in mood
Kiessling CNRT 59 / 96 1st year Perceived Stress and Reformed track (+) reformed-track subjects felt
et al., Support (problem-based signicantly more supported
200427 small-group teaching)
versus traditional
track (lecture and
seminar)
Austenfeld RCT 24 / 24 / 24 3rd year emotional approach, Writing about emotions (2) no signicant between-group
et al., coping, affect, (EMO) versus writing differences in psychological and
200625 physical symptoms, about goals (BPS) physical health
medical care versus control
utilization, essay
ratings
Rohe et al., CNRT 41 / 40 First 2 years PSS, POMS, PCS, TAI, 5-interval grading (+) signicantly less perceived
200631 USMLE Step 1 system versus Pass/ stress and greater group
Fail grading system cohesion with Pass/Fail grading
during rst 2 years of system; (2) no signicant
medical education differences in mood, test-taking
anxiety, or USMLE Step 1 scores
Finkelstein CNRT 30 / 46 2nd year SCL-90 Anxiety 10-session elective on (2) no signicant between-group
et al., subscale, POMS, mindbody differences in anxiety, mood
200719 2-Item Depression medicine states, and perceived stress
Index, PSMS
Bloodgood CNRT 141 / 140 First 2 years Academic 5-interval grading (+) signicant increase in well-
et al., performance in basic system versus Pass/ being and satisfaction with the
200929 sciences and Fail grading system quality of medical education
clerkships, USMLE during rst 2 years of and personal lives with Pass/Gail
Step 1 and 2, medical education grading; (2) no signicant
DGWBS differences in academic
performance, USMLE Step 1
and 2 scores
Dare et al., CNRT 136 / 132 Final (6th) PSS Shortened academic (2) no between-group differences
200928 year year (47 versus 42 in stress levels
weeks)
Reed et al., CNRT 491 / 701 First 2 years PSS, MBI, MOSSF-8 3-interval grading (2) signicant decrease in stress,
201130 system versus Pass/ burnout, and serious thoughts
Fail grading system of dropping out of medical
school with Pass/Fail system
continued

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 SHIRALKAR ET AL.

TABLE 1. Characteristics of RCTs and CNRTs of Medical School Stress-Management Programs (cont'd)

Experimental
Study and Control Training Assessment
Study Type Subjects Level Methods and Tools Intervention Outcomes
Warnecke RCT 31 / 34 Final 2 years PSS, DASS Guided CD of (+) experimental group reported
et al., (4th and mindfulness (daily signicantly reduced stress and
201120 5th) over 8 weeks) versus anxiety scores than controls
usual-care control

POMS: Prole of Mood States; BSI: Brief Symptom Inventory; MBI: Maslach BurnoutInventory; GHQ: General Health Questionnaire; STAI-1: State and
Trait Anxiety-1; INSPIRIT: Index of Core Spiritual Experiences; BDI: Beck Depression Inventory; MEQL: Medical Education Quality of Life Questionnaire;
AUDIT: Alcohol Use and Disorders Identication Test; PSS: Perceived Stress Scale; PCS: Perceived Cohesion Scale; TAI: Test Anxiety Inventory; USMLE:
United States Medical Licensing Examination; SCL-90: Symptom Checklist; PSMS: Perceived Stress of Medical School; DGWBS: Dupuy General Well-
Being Schedule; MOSSF: Medical Outcomes Study, Short Form; DASS: Depression, Anxiety, and Stress Scale.

residency placement, and attendance (29). Assessment meth-
ods were heterogeneous; none used all of the same outcome
measures.
One study (20) scored a full 7 on the validity scale,
whereas the validity assessments of the other RCTs and
CNRTs fell within a narrow range of 3 to 4. All of the studies
had high follow-up rates of at least 70%, used outcome
measures that were identied as valid, and assessed the re-
liability of the outcome measures. Moreover, all studies
except one (27) identied some similarities and differences
between groups at baseline before implementation. Only
one study (20) described a method of concealment of ran-
domization or noted using blind raters. This study was
also the only one that used a power analysis.
There were ve RCTs. The rst RCT (20) was a three-
centered, single-blinded, RCT. The intervention consisted
of an audio compact disc that contained 30 minutes of
spoken, mindfulness-guided practice. Participants were
asked to practice this independently every day for 8 weeks.
Validated measures of stress and anxiety were completed at
baseline and at the end of the trial by both groups of par-
ticipants. A primary outcome of perceived stress was sig-
nicantly lower in the intervention group than the control
group. There were no reported adverse effects of the in-
tervention. An NNT or NNH could not be calculated.
In the second RCT (32), rst-year medical students
completed questionnaires about their health habits. In
this study, the two experimental groups included a self-
awareness intervention of educational written feedback on
scores alone and a self-care intervention that included
a lecture plus a group discussion plus written information
about self-care. The self-awareness group was given in-
dividual written feedback on questionnaire scores as
compared with the norm and their peers. The self-care in-
tervention involved a lecture, written information about
self-care habits, and a group discussion. Although there
were differences in outcomes between the groups in terms of
sleep and exercise habits, the feedback and educational in-
tervention groups did not differ in emotional or academic
adjustment. Also, of the 23 students that participated in the
educational discussion groups, 8 reported changed behav-
iors (improved sleep hygiene and getting therapy for de-
pression), compared with 5 of the 29 students who received
written feedback on their questionnaires. The NNT was
6.21.
In the third RCT (17), we assessed the effects of an
8-week, meditation-based, stress-reduction elective. The
course consisted of seven sessions of 2.5 hours each week,
weekly home practice assignments, and daily journaling.
The exercises were aimed to increase mindful listening
skills and empathy. The intervention group reported sig-
nicantly reduced anxiety, reduced depression, reduced
overall psychological distress, increased empathy, and in-
creased spirituality. In the fourth RCT (21), volunteers at an
incoming medical school class were randomly selected to
receive self-hypnosis training as a means of coping with
stress, as compared with a no-treatment control condition .
The self-hypnosis intervention did not result in any signif-
icant immune changes relative to controls; however, sub-
jects in the self-hypnosis intervention assigned signicantly
lower stress ratings during the exam period than did the
subjects in the no-treatment control condition. In the nal
RCT (25), one group wrote about their most emotional and
traumatic experiences; a second group wrote about their
future as if their personal goals had been achieved, including
how they had overcome at least one obstacle; and a third
control group described everything they had done in the past
24 hours, without expressing emotions or opinions. There
were no signicant between-group differences in depressive
symptoms or physical health reported at 3 months.

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STRESS MANAGEMENT FOR MEDICAL STUDENTS
Two CNRTs addressed the impact of interventions that
included mindfulness on mood and anxiety states. In one
study (18), medical students participated in a 10-week,
mindfulness-based stress-reduction seminar. Their mood
states were compared with controls who participated in
a didactic seminar on complementary medicine. The To-
tal Mood Disturbance was signicantly lower in the in-
tervention group than in the control group. In the second
CNRT (19), 30 rst-year medical student enrollees in an
experimental elective on mindbody medicine were com-
pared with second-year medical students who had not en-
rolled in the elective. At the end of the elective, there were
no signicant differences in mood states, perceived stress,
or anxiety.
One CNRT (27) evaluated a change in curriculum from
a traditional track (TT) to a reformed track (RT). In the TT,
teaching and learning were based on lectures and seminars
organized by individual disciplines. In contrast, teaching
and learning in the RT were problem-based, focused on self-
directed learning in small groups, and supplemented by
seminars and tutorials. In the RT, the emphasis was on
providing interdisciplinary teaching and earlier contact with
patients. Reformed-track students felt signicantly more
supported than TT students. Supports included good con-
tact with fellow students and teachers, high-quality courses,
and a curriculum that fullled students expectations.
Two CNRTs evaluated the length of medical school
curriculum on stress levels. One study (26) compared two
medical schools with different lengths of preclinical cur-
riculum, whereas another study (28) compared 2 nal years,
when 1 year had a shortened curriculum. In the rst study
(26), the 2- versus 3-year preclinical curriculum was asso-
ciated with higher stress levels. Since a greater proportion of
students in this 5-year program (23%) contemplated drop-
ping out, as compared with the 6-year program (15.8%), the
NNH was 13.9. On the Maslach Burnout Inventory, there
were no signicant differences on the Emotional Exhaus-
tion, or the Depersonalization subscales between the two
groups. In the remaining study (28), shortening the nal
academic year from 47 to 42 weeks did not signicantly
alter perceived stress levels.
The nal three CNRTs all examined the relationship of
Pass/Fail grading on student well-being. In the rst study
(31), students who were evaluated on the Pass/Fail grading
system were compared with the previous class of students,
who were evaluated on a ve-interval grading system (A, B,
C, D, F). At the end of the second year of medical school,
students graded with the Pass/Fail system reported feeling
less stress and greater group cohesion than those graded
162 http://ap.psychiatryonline.org
with the ve-interval graded system. Also, there were no
differences in USMLE Step 1 scores between the Pass/Fail
and the ve-interval grading groups. In the second study
(29), two medical school classes, with different grading
systems (Pass/Fail and ve-interval) were compared. Data
from each class showed that the Pass/Fail class felt a sig-
nicant increase in well-being, greater satisfaction with the
quality of their education, and greater satisfaction with their
personal lives. Moreover, there were no differences in ac-
ademic performance, USMLE scores, residency placement,
or attendance between the two classes. In the third study
(30), rst- and second-year medical students were surveyed
at seven different medical schools about stress, burnout, and
quality of life. Students who were graded using three or
more intervals had high levels of stress, emotional exhaus-
tion, and depersonalization than students who were graded
on a Pass/Fail system. Also, students who were graded using
three or more intervals were more likely to consider drop-
ping out of medical school and experience burnout than their
Pass/Fail peers.
Conclusions
We found 13 studies that met the inclusion criteria. These
included ve randomized, controlled trials (RCTs) and eight
controlled, non-randomized trials (CNRTs). Nine of the
studies included one medical school class, whereas four
studies included multiple class years. With the exception of
one study (20), the quality of the studies varied little. Study
strengths included similarities on group differences, good
rates of follow-up, and the use of valid and reliable outcome
measures. Only one study (20) described randomization
methods, concealment of randomization, or methods for
blinding raters. Designing adequate randomization methods
is an especially important standard to achieve in education
research (36). The scarcity of studies meeting this standard
limits the rigor of data, and therefore limits the development
of stress-management programs aimed to promote medical
student wellness.
The available data support the efcacy of some forms
of intervention in promoting health and reducing stress
among medical students. A combination of lectures, dis-
cussion groups, and written educational material is
more efcacious than just providing written feedback on
questionnaire answers (32). Three of the four studies that
included mindfulness-based stress-reduction techniques
reported results supporting those techniques (17, 18, 20).
Self-hypnosis appears to be efcacious in reducing stress
and anxiety in the study setting (21). Also, implementing
Academic Psychiatry, 37:3, May-June 2013

Pass/Fail grading appears to enhance student well-being
(2931). One of the two studies on curriculum length
found higher stress levels associated with a shorter curric-
ulum, although these differences were not reported to be
signicant (26).
One methodological concern was that there was a lack
of consistency of outcome measures across studies. Stan-
dardization of outcome measures across studies constitutes
an important goal for this area of research. Although med-
ical students are well known to experience burnout, only
two studies utilized the Maslach Burnout Inventory (26, 30).
Researchers should consider using the Maslach Burnout
Inventory and the Perceived Medical School Stress Scale
(37) for this area of research. In order to compare inter-
ventions, there is a need for investigators to use consis-
tent and important outcome measures, including outcome
measures on depression and burnout, which are commonly
experienced among medical students. Also, these studies
did not assess the long-term effects of interventions, and
most experimental interventions were conducted at one site,
limiting the generalizability of the data.
There were several limitations to our methods. Although
we conducted several searches and used multiple databases,
we did not conduct a search of the gray (unpublished and
not easily accessible) literature. We also only included
English-language articles that were published after 1995.
Nevertheless, our results suggest that there is a role for
stress-management programs in reducing the psychological
distress of medical students. The small number of controlled
studies and the limitations of the data described above in-
dicate a need for developing rigorously-conducted studies in
this critically important area. Psychiatrists should be at the
forefront of this research.
There is no funding to disclose.
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