The results of the qualitative evaluation are divided into two sections: (1) Perceived stressors, and (2) Starting points for health-promoting interventions. In the following sections, each theme is discussed with relevant quotations (for an overview of the code system, see Table
1).
Stressors
Examinations
As important stressors in the pre-clinical stage, students mentioned factors attributable to the curriculum. At first, the weekly examination rhythm in the main subjects-Anatomy, Biochemistry and Physiology-was criticized. The workload was perceived differently in relation to the different subjects. ‘Before Anatomy, I almost always cried’; ‘So, yes, I found the [Anatomy] intermediate examinations harder, but they had a meaning. I find intermediate examinations in Physiology and Biochemistry just pure harassment because we’ll have to pass the final examinations anyway. And then I ask myself: Why do we have to do this?-The grades awarded have no consequences, except in that they somehow induce stress’.
This perceived pressure was morally elevated by pronouncements from teaching staff, such as: ‘One cannot actually afford, as a medical student, to not know something, because one will finally treat people and could potentially kill them through ignorance!’
In contrast, however, there was a clear sense that these moral elevations could possibly be misguided (‘But, after all, one must somehow stay human and be allowed to err from time to time’).
Overall, the meaning of the escalating pressure was questioned (‘Actually, you only need 60 % to pass the exam’) and it was suspected that the well-being of students is less important for the teaching staff than the standing of their institution in terms of overall performance (‘It is the objective of the Biochemistry staff to constantly score first place in the overall examination results’).
Absence
Very long laboratory hours were frequently mentioned (‘But the laboratories are shorter [in the clinical stage] so they do not last until late. In Biochemistry, one has to stand for 7 or 8 h’). Students felt that they were not allowed to be absent, even when sick (‘I find it somehow unacceptable that in some subjects you have absolutely no allowed absences and in others only 1 or 2 days’; ‘Then, due to one lousy day of absence, you have to add half a year to your course!’).
Such practice in relation to absence was not only perceived as negative in terms of the courses but also for internships.
The ironic statement ‘Medical education should prepare students in advance for the reality that as a doctor one is not allowed to be sick because one must heal the sick. One is somehow no longer a human being’ implies that this strict absence regime is perceived as contradictory to their own professional understanding.
Internal motivation
In addition to external factors, the students are also aware of a strong internal motivation: ‘Every time I go into this laboratory, I think: It’s just a laboratory, it is not your life. It is of micro-minimal importance in relation to your whole life. And then, when I’m standing there, I realize at some point that I am causing myself too much stress, and I think: This test tube is your life at the moment and you have to give everything. It just builds up such pressure!’
Especially in the pre-clinical stage, students lack advice regarding which courses are indispensable and which are more or less optional: ‘During the first semester, I learned Anatomy until complete exhaustion late in the evening. And I really made myself ill because no one said to me: ‘that’s enough now’, or ‘you may learn this and that a little more superficially’.
Lack of prioritization and clinical relevance
Catalogues for learning objectives as an aid to prioritization of learning content and to estimate relevance for examinations are missed: ‘I perceived this as the worst problem in Biochemistry, whereas I also sometimes had the feeling in Pharmacology-that it was exactly the same thing. They have an exact catalogue of learning objectives but then you sit in the exam and they ask something wacky, something no one cares about anyway and that no one needs to know except pharmacology students. Why have I written and learned stacks of notes only to be confronted with that sort of stuff!’
Even during the clinical stage, students feel that many exotic diseases and content are prioritized over what is considered relevant for future clinical practice and everyday life: ‘If I find at the end of a textbook chapter the sentence ‘this disease is very rare’, I feel frustrated.’
First medical exam
The first medical exam was named as a significant stressor during pre-clinical medical education. Statements made by teaching staff which are meant to offer relief to students are perceived as a burden by them: ‘[…] I find the being told that 95 % of students pass the course unhelpful because that means that 5 % do not pass. And I simply think, if you are one of those 5 % then you feel like the greatest deadbeat in the world because actually the vast majority of students pass’.
Compared with the pre-clinical section, the spectrum of stressors is different in the clinical stage. Subjects requiring extensive learning, such as Microbiology and Pharmacology, are still mentioned, but these are perceived as less burdensome and clinically relevant (‘Then it becomes more and more practical. You cannot actually compare the clinical and pre-clinical stages’).
Dissertation and medical responsibility
New challenges in the clinical section are the parallel work on a doctoral thesis and a growing feeling of responsibility in patient care (‘So I’m in my tenth semester. What now stresses me is the thought that it’s now nearing the time when I have to take care of patients on my own. That leads me to worrying about the responsibility rather than focusing on how I pass the exam’). Overall, there is a decreasing feeling of being part of a group and a stronger impression of being alone in the clinical stage.
Starting points for health-promoting interventions
Starting points for health-promoting interventions mentioned by the participants can also be assigned to the levels of the setting and individual behaviour and experience. Naturally, these starting points are closely associated with the aforementioned stressors, but they do not resemble them completely (Table
1).
Prioritization of educational content
The most frequently mentioned starting points for health-promoting interventions on the setting level were related to the curriculum itself. Given the wealth of learning content, participants wished that there was a prioritization of this content and proposed the creation of learning objective catalogues, especially in the most extensive pre-clinical subjects such as Biochemistry and Anatomy, as a particularly suitable starting point.
A clearer distinction between vital basic knowledge that must be mastered by all and additional, more facultative knowledge seemed desirable to the students. The question of clinical relevance was asked particularly with regard to the basic science subjects (‘Most of the content you have to learn for the first medical examination, you will never need again’). Another important criterion for the prioritization of learning content was the relevance for examinations (‘I wonder if it is really necessary for us to do a laboratory because the content is not relevant for the exam’).
Redistribution of workload
A schedule that does not contain learning-intensive subjects, e.g. Biochemistry and Anatomy, at the same time in the semester course is a further starting point for a health-promoting measure suggested by the students.
Grading system
The need and relevance for the grading of course performance was criticized: ‘That’s right, you could actually omit these grades in Biochemistry because it really only exerts pressure’.
More flexible absence rules
The change in policy regarding absence appeared to be very important for the students: ‘In the end, you should tell your patients: Stay home if you’re sick. And what kind of role model are you if you are not doing it yourself?’
Curricular offers for study organization and health promotion
Promoting exchanges with students from advanced semesters, for example as part of (peer) mentoring groups, was proposed by the students as a starting point at the individual level (‘In the first semester, my peer mentors told me which lectures were and were not worth attending. If I’d attended all the lectures, I wouldn’t have passed the exams’). The participants also identified as useful the facilitation of compensatory activities, such as sports and relaxation. Skills such as ‘learning to learn’ or time management were also considered starting points for health-promoting interventions.
The elective course ‘Health and Well-being of Medical Students and Physicians’ was rated positively: ‘The project of personal health promotion in the elective was very helpful. The permission given and the fostering of the ability to not constantly have to learn, but also to take care of your own health, were most useful’.
Further starting points
Approaches such as an improvement in the quality of cafeteria food and a low-threshold counselling service for students were suggested.
Final prioritization
The final prioritization of proposals for health-promoting interventions resulted in a similar picture from the two focus groups. In both cases, principal issues among the setting-based interventions were:
-
prioritization of learning material,
-
formulation of learning objectives,
-
availability of psychosocial counselling and
-
awareness of the issue of students’ health.
One of the two groups advocated:
and placed this first on the ranking of possible actions.
At the level of individual behaviour:
was considered an important measure. Students felt that this would allow them to learn from older medical students about the possibilities for prioritization of learning material in order to be able to issue oneself ‘permission for leisure’.