The most important finding of this study was that the intervention was a significant and independent predictor of the decrease in PMSS over the observation period. When we tested the effects of each of the intervention groups, only the self-development group was a significant predictor of the reduction in PMSS. However, we found no effect of the intervention on general mental distress, as measured by the SCL-5 score. This suggests that the intervention affected the specific stress related to medical school, rather than general mental distress. The intervention, and in particular the self-development programme, reduced the specific factors related to attending medical school and negative attitudes towards medical training. Examples of such stressors that the PMSS seems to capture include: lack of thriving in the study situation, a sense of opposition towards teachers and the curriculum, a feeling of being controlled too much, of having too little space for personal interests, and not being seen as an individual.
Two recent papers have studied the effects of self-selected interventions among medical students. Both Finkelstein et al[12
] and Rosensweig et al[13
] report beneficial effects on mental health from a voluntary stress reduction class. The participating students had higher initial scores on mental health parameters than their peers who did not seek help and no gender differences were reported [12
]. We believe that our mandatory intervention design may be important. In planning the study, we assumed that some students would not participate voluntarily in a group intervention that had elements of psychotherapy, and that this would particularly apply to male students. This assumption was however not supported in our data. Nevertheless, the importance of a student's opportunity to choose between the two different types of group should not be underestimated.
In a qualitative evaluation carried out among the students at the last meeting of the group sessions, the discussion groups were generally evaluated as being more popular. From this, we may have expected this type of group to be more effective than the self-development groups were [29
]. However, in contrast, the self-development groups seem to be more effective. Why might this be?
The self-development groups may have given the students an experience of being seen as individuals, and that their personal recourses were acknowledged as valuable in becoming a good physician. Some of the students said that they experienced an openness about personal problems that was a new experience at medical school. They also mentioned that building a network among their peers was valuable, as the group members became closer to each other and could share problems. Thus, they had a feeling of a safety net that would help them solve new problems. They also thought it would be easier for them to talk to colleagues about personal or professional problems, and this lowered the threshold for them to seek professional help in the future. They simply learned that it was acceptable to have problems, since their peers had disclosed problems of their own. The participation in the groups may have helped the students to tolerate insecurity and ambiguity, a common aspect of all medical practice. This is consistent with reports from previous self-development groups of volunteer female medical students at the University of Bergen [30
Similar comments were also made by students of the discussion groups. The leaders of the discussion groups reported a high level of personal involvement from the students, and that the group discussion often dealt with private and personal issues [29
]. This in spite of the more rigid and preset structure of the meetings.
An important and specific part of the self-development groups was learning about relational patterns from their past, which hindered a more flexible attitude towards peers, teachers, and patients. This may contribute to a more robust and sustainable effect of the self-development groups than that of the more "external reality based" discussion groups. But this remains to be investigated by longer term follow- up of our cohort.
Since the students themselves chose which particular group intervention to join, even though participating in a group was mandatory, it seems that this self-selection was especially successful for those who chose the self-development groups. These students may have had high levels of insight into the type of help they needed. Another factor of great importance for the positive outcome is the specific qualifications of the group leaders of the self-development group. This factor may restrict the practical applicability of the programme in other medical schools, since such highly qualified psychiatrists with group-analytical training are not easy to recruit.
High levels of PMSS have been found to predict mental health problems that require treatment, and hence, the PMSS score may represent a vulnerability measure [5
]. Stress may affect academic performance negatively [8
], and increase the chances of developing depression [6
]. However, only long-term follow-ups will show whether these initial results are stable throughout and following graduate school, implying improved mental health, and improved management of the specific stressors involved in medical practice.
The evaluation after the groups had ended showed that most students appreciated the groups, even though they were mandatory [29
]. On the other hand, some students said that they lacked interest in the groups, and that they were not motivated to participate because of the mandatory requirement. The students showed ambivalent attitudes towards making the group programme a mandatory part of the curriculum on a permanent basis. Although neither of the two interventions was defined as treatment, students who participated in the groups said that one positive aspect of making them mandatory would be that teachers could pick out students who needed to seek professional help. The self-development and discussion groups have previously been voluntary for medical students in Bergen. At that time, however, only half of the students participated in the voluntary groups, and these were mostly female students [29
The intervention and design applied in this study has several strengths and limitations. The prospective design with pre-post intervention measures and a control group are major strengths. The mandatory intervention and that the group leaders kept track of any student absent ensured a good compliance, and that we reached all students in need of help. To our knowledge, few studies have evaluated this type of mandatory intervention programme using a control group. The instruments applied have also been validated for the Norwegian population. One important limitation of our study is the lack of a randomized, controlled trial design. The intervention groups and the control group were from two different student classes and were assessed during two different calendar years. It is possible that the pressures on the intervention and control groups have been different, so also the motivation to participate in the study. This design implies a risk of a confounding cohort effect. There were however no known changes in the curriculum from the one year to the other. Further, there were no significant differences in general mental distress and medical school stress at baseline between the two cohorts. Though, it is a weakness of our study that it was not conducted according to the design of a randomized controlled trial, and as a consequence we should be cautious to make too firm conclusions. The positive effects of such group interventions should be further explored with a randomized, controlled trial design. In our study a randomization would not have given the students the opportunity to choose between the two different types of groups. This would have forced unmotivated students to participate in self-development groups, and perhaps hindered the group process. On the other hand, even without randomization, any mandatory intervention runs the risk that unmotivated students may be included. Responses from both leaders and students confirmed that this was the case in some groups. This might have reduced the positive effects of the intervention of the present study. It may also be a limitation that the study was based on self-report measures. This may lead to less reliable reporting of mental distress, for example, an underreporting of such distress.