Stress responses in medical students in ambulatory and in-hospital patient consultations

Med Educ. 2011 Jul;45(7):678-87. doi: 10.1111/j.1365-2923.2011.03935.x.


Context: Little is known about health professionals' responses to acute stressors encountered in the clinical environment. The goal of this study was to measure the subjective and physiological stress responses of medical students to consultations in familiar (in-hospital) and unfamiliar (ambulatory) settings. We hypothesised that: (i) providing a consultation in an unfamiliar setting would result in increased stress responses in medical students, and (ii) some differences in stress responses according to gender might become apparent.

Methods: A quantitative cross-over study was conducted over a 6-month period. Participating students were invited to provide consultations to patients in an ambulatory setting. In order to provide a control condition, each student was required to conduct a similar consultation (without reporting back to the patient) with an in-hospital patient during his or her rotation in internal medicine. Pre- and post-consultation subjective and physiological responses were measured using a visual analogue scale (VAS), the State-Trait Anxiety Inventory (STAI), a cognitive appraisal scale and salivary cortisol levels.

Results: All of the subjective and physiological stress responses were greater in the ambulatory setting than the in-hospital setting. There was an effect of gender on the responses. Women showed greater pre-consultation subjective stress levels in the ambulatory setting, whereas men exhibited greater physiological stress levels in the ambulatory setting. No correlations were observed between subjective and cortisol responses.

Conclusions: Ambulatory consultations are more stressful for medical students than consultations carried out in the more familiar in-hospital setting. Further studies should be conducted to investigate the nature of the stressors in this particular environment, to explore the possible explanations for a gender effect, and to explore the effects of these stress responses on students' diagnostic skills.

MeSH terms

  • Cross-Over Studies
  • Education, Medical, Undergraduate
  • Female
  • Hospitalization
  • Humans
  • Hydrocortisone / metabolism
  • Male
  • Medical History Taking
  • Outpatient Clinics, Hospital
  • Physician-Patient Relations*
  • Saliva / metabolism
  • Stress, Physiological / physiology*
  • Stress, Psychological / etiology*
  • Stress, Psychological / physiopathology
  • Students, Medical / psychology*


  • Hydrocortisone