Medical education is globally acknowledged as one of the most challenging and stressful academic pursuits [1]. The extensive curriculum, high academic expectations, constant exposure to human suffering, and concerns about future career prospects create a high-pressure environment that predisposes students to significant psychological distress [2]. While stress is an inherent part of this training, excessive and unmanaged stress can have deleterious consequences, including burnout, depression, anxiety, substance abuse, and impaired academic performance [3, 4].

Among the various stressors encountered in medical school, examinations are consistently identified as the most potent source of acute stress [5]. These high-stakes assessments determine academic progression and future career paths, leading to intense periods of pressure characterized by sleep deprivation, social isolation, and performance anxiety. The physiological and psychological responses to this examination stress can directly interfere with cognitive functions such as memory consolidation and recall, paradoxically hindering the very performance students strive for [6].

In response to stress, individuals employ a range of cognitive and behavioral strategies known as coping mechanisms. These can be broadly categorized as adaptive (e.g., problem-solving, seeking support) or maladaptive (e.g., avoidance, self-blame, substance use) [7]. The choice of coping strategy is a critical determinant of an individual's ability to navigate stressful situations successfully. The development of adaptive coping skills is essential for long-term psychological resilience, not only during medical training but also throughout a demanding medical career [8].

Numerous studies have investigated stress among medical students. Research from India reported that over 73% of students had perceived stress, with academic factors being the primary cause [9]. A systematic review of studies in Arab countries found a pooled stress prevalence of 40%, again highlighting academic pressures [10]. However, many of these studies assess general stress levels over a semester or year. There is a specific gap in the literature focusing on the acute stress experienced in the immediate run-up to professional examinations and the specific coping mechanisms activated during this critical period. Furthermore, it is plausible that the nature of stressors and the coping resources available may differ between students in the pre-clinical (foundational sciences) and clinical (patient-facing) phases of their training.

Therefore, this study was designed to provide a focused assessment of stress levels and the specific coping strategies employed by MBBS students during the intense period just before their professional examinations. The primary objectives were to quantify the prevalence of high stress and to identify the most commonly used coping mechanisms. A secondary objective was to explore potential differences in stress and coping based on the academic year (pre-clinical vs. clinical) and gender.

The study population comprised all undergraduate MBBS students from the first to the final year. For this exploratory study, a sample size of 100 students was targeted. A non-probability convenience sampling technique was employed to recruit participants from the college library and student common rooms, where students were typically found studying during the pre-examination period.

Inclusion and Exclusion Criteria

All MBBS students who were scheduled to appear for the upcoming professional examinations and who provided voluntary written informed consent were included. Students who were undergoing treatment for a pre-diagnosed psychiatric illness or who submitted incomplete questionnaires were excluded from the final analysis.

Data Collection Tools and Procedure

Ethical clearance was obtained from the Institutional Ethics Committee prior to the commencement of the study. Participants were approached by the investigators, and the nature and purpose of the study were explained. They were assured of the anonymity and confidentiality of their responses.

Data were collected using a self-administered questionnaire, which consisted of three parts:

1. Sociodemographic Profile: This section collected basic information such as age, gender, and year of study. The year of study was categorized as 'Pre-clinical' (1st and 2nd year) or 'Clinical' (3rd year and above).
2. Perceived Stress Scale (PSS-10): This is a widely used and validated 10-item instrument for measuring the perception of stress. Respondents rate the frequency of certain feelings and thoughts over the past month on a 5-point Likert scale (0=never to 4=very often). Total scores range from 0 to 40, with higher scores indicating higher perceived stress. Scores were categorized as low (0–13), moderate (14–26), or high (27–40) stress.
3. Brief COPE Inventory: This 28-item scale assesses a broad range of coping responses. It consists of 14 subscales, each with two items (e.g., active coping, planning, seeking emotional support, denial, self-blame). Respondents rate how often they use each coping strategy when faced with stress on a 4-point scale (1=I haven't been doing this at all, to 4=I've been doing this a lot). For analysis, the strategies were grouped into problem-focused, emotion-focused, and dysfunctional coping categories.

Statistical Analysis

The collected data were coded and entered into Microsoft Excel, then analyzed using the Statistical Package for the Social Sciences (SPSS) version 26.0. Descriptive statistics such as mean, standard deviation (SD), frequencies, and percentages were used to summarize the data. The Independent Samples t-test was used to compare the mean PSS scores between pre-clinical and clinical students, and between males and females. The Chi-square test was used to determine the association between categorical variables, such as the use of specific coping strategies and the student groups. A p-value of less than 0.05 was considered statistically significant

A total of 100 medical students participated in the study. The sociodemographic profile of the participants is presented in Table 1. The mean age of the students was 21.1 ± 2.3 years. The sample consisted of 55 males (55.0%) and 45 females (45.0%). The cohort was nearly evenly split between pre-clinical (n=52) and clinical (n=48) years of study.

Table 1: Sociodemographic Characteristics of Study Participants (N=100)

The assessment of perceived stress is detailed in Table 2. The overall mean PSS-10 score was 24.8 ± 5.6. Based on the score categorization, a vast majority of students (79.0%) were experiencing high levels of stress. A statistically significant difference was found in the mean stress scores between academic years, with clinical students reporting higher stress levels than pre-clinical students (26.3 ± 4.9 vs. 23.3 ± 5.8; p=0.018). No significant difference was observed in mean stress scores between male and female students (p=0.412).

Table 2: Perceived Stress Levels Among Medical Students

Table 3 summarizes the use of various coping mechanisms as reported by the students. Adaptive strategies were widely used, with planning (85%), active coping (83%), and acceptance (76%) being the most common. Among maladaptive strategies, self-blame was notably high (52%), followed by behavioral disengagement (35%) and denial (28%). A significant gender difference was observed in the use of "seeking emotional support," with female students reporting its use more frequently than male students (70% vs. 45%; p=0.021). No other significant gender-based differences were found in the coping strategies listed.

Table 3: Frequency of Coping Mechanisms Used by Students and Comparison by Gender

This study provides a focused snapshot of the immense psychological pressure faced by medical students during their examination period. The primary finding is the exceptionally high prevalence of stress, with nearly four out of five students reporting stress levels in the severe range. This is substantially higher than the prevalence reported in studies assessing general stress over a semester [9, 10], which confirms that examinations are indeed a period of acute psychological crisis for this population. Such high levels of stress are a major concern, as they are strongly linked to an increased risk of mental health disorders and academic burnout [3, 11].

A key finding of our research is the significant difference in stress levels between students in pre-clinical and clinical years. The higher stress reported by senior, clinical-year students may be multifactorial. While pre-clinical years are demanding due to the vast volume of foundational knowledge, the clinical years add the complexities of patient care, ethical dilemmas, and a more direct fear of the consequences of failure, which could be perceived as more immediate and tangible [12]. This suggests that while all students need support, tailored interventions may be required for senior students who face a different spectrum of stressors.

The analysis of coping mechanisms revealed a dualistic approach among students. On one hand, the high reported use of adaptive, problem-focused strategies such as planning and active coping is encouraging. It indicates that students are actively trying to manage their academic load and prepare for exams in a structured manner [7]. This proactive engagement is a hallmark of resilience. However, this positive finding is overshadowed by the alarmingly high prevalence of maladaptive coping. More than half of the students engaged in self-blame, a cognitive distortion that is strongly associated with depression and anxiety [13]. Furthermore, over a third reported behavioral disengagement (giving up), which is counterproductive to academic success. This co-existence of adaptive and maladaptive strategies suggests that while students know what to do, the overwhelming pressure of exams may push them towards dysfunctional coping patterns.

The gender-based difference in seeking emotional support is consistent with a large body of literature on coping, which often shows that females are more likely to utilize social support networks as an emotion-focused coping strategy [14, 15]. This can be a highly adaptive mechanism, as social support is a powerful buffer against the negative effects of stress.

The implications of these findings are significant for medical educators and administrators. The high stress levels are not just an individual student's problem but an institutional issue that warrants a systemic response. This could include curriculum reforms to reduce information overload, implementing formative assessments to lower the stakes of final exams, and creating protected time for relaxation and hobbies. Furthermore, the prevalence of maladaptive coping highlights the need for proactive skill-building workshops on stress management, cognitive-behavioral techniques to challenge self-blame, and mindfulness-based stress reduction [8]. Simply providing access to counseling is not enough; a culture of wellness must be actively fostered.

This study has several limitations. Its cross-sectional design prevents us from drawing causal inferences. The use of a convenience sample from a single institution may limit the generalizability of the results. The data were self-reported and could be subject to social desirability or recall bias. Finally, we did not measure baseline stress levels outside the examination period, which would have provided a clearer picture of the acute increase in stress

The period preceding professional examinations is a time of severe psychological distress for the vast majority of medical students, with those in their clinical years being particularly vulnerable. Students are caught in a difficult position, employing constructive, problem-focused strategies while simultaneously resorting to harmful, maladaptive coping mechanisms like self-blame. This dichotomy highlights a critical need for support. Medical institutions have an ethical responsibility to move beyond a curriculum focused solely on academic excellence and to integrate robust, evidence-based wellness and resilience training. By equipping students with healthier coping skills, we can not only mitigate the immediate distress associated with exams but also help shape more resilient and mentally healthy physicians for the future.

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