Research article
Open Access

Students' self-perception about their Quality of Life is overestimated: is this the base of their mental troubles?

Mariana Neves Ceratti[1], Patricia da Silva Fucuta[1], Fernanda N.P. Quessada[1], Felipe Colombelli Pacca[1], Patricia Maluf Cury[1][a]

Institution: 1. FACERES Medical School
Corresponding Author: Prof Patricia Maluf Cury ([email protected])
Categories: Educational Strategies, Students/Trainees, Behavioural and Social Sciences
Published Date: 07/01/2020


Purpose: The aim of this study is to investigate the medical student perception about their QoL, in order to be aware of their own problems.


Methods: We applied three instruments: SF36 health questionnaire; a QoL self-perception questionnaire and a questionnaire regarding self-awareness and coping strategies to medical students from first to fourth year.


Results: 203 students answered the questionnaires (women 64.5% and median age 20 years). Students self-perception about QoL was overestimated in most of the domains except in physical role functioning (p <0.001). There was a significant difference between genders, and men showed a greater deviation from SF36 to QoL self-perception for mental health domain than women (p=0.04). Regarding questionnaire about self-awareness, most of them felt that the way they think is consistent with what they act frequently, know their own needs and evaluate their QoL as good or great. In relation to coping strategies, seek out other people was one of the most common functional strategies used. When analyzing such results between genders, women increased their food intake more than men (P = 0.002).


Conclusion: Student self-perception about QoL is mistaken and overestimated.


Keywords: medical student; quality of life; mental health


Quality of life (QoL) is a concept that encompasses physical health, psychological state, level of independence, social relationships, personal beliefs, and relationships with factors in the environment, aspects of which may change completely over time (The WHOQOL Group, 1995; Lins and Carvalho, 2016).


A good QoL is known to be fundamental for personal achievement and for an integrated and productive society; it is also crucial to overall health, which is why knowledge on the quality of life of certain populations is very important (Chigerwe, Boudreaux and Ilkiw, 2018). Many methods can be used to evaluate QoL, including a variety of questionnaires available in the literature (Jang et al., 2018). The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), for example, divides QoL into eight domains: physical functioning, general health, pain, social functioning, mental health, role functioning and role functioning. (Makiyama et al., 2004; Lins and Carvalho, 2016; Jang et al., 2018).


In Ireland, that more than one third (35%) of physicians experience psychological distress. Symptoms of severe depression, anxiety, and stress were found in 7,2%, 6,1%, and 9.5% of respondents, respectively (Hayes, 2017). QoL may be even harder for medical students to achieve. While medical school is often a significant achievement, it is also a place where students experience new difficulties and frustrations, as well as an adaptation period (Cvejic et al., 2017). A study of medical students in Germany found high rates of depression, as well as of cognitive and emotional burnout; these factors result in significantly lower mental QoL, particularly among women (Burger and Scholz, 2018).


Various studies have also reported differences in stress levels between genders with a greater prevalence of stress among women in a previous study by our team and in studies by other researchers (Botelho et al., 2017; Tempski et al., 2012).


This situation is concerning given the increased rate of mental disorders and suicide among medical students as observed in an extensive systematic Review and Meta-Analysis (Rotenstein and cols, 2016).


A rarely discussed but important factor in this situation is medical students’ perception of their own QoL. It is based on this perception that students make conclusions regarding their situation and what they need in it. A study in New Zealand found that, in their self-perception, medical students classified their QoL as better than or the same as that of students from other fields of study using the WHOQOL- BREF scores (Henning et al., 2012). However, their finding is inconsistent with those of other studies using other questionnaires, which have shown that medical students’ QoL is negatively affected by their environment (Tempski et al., 2012; Cvejic et al., 2017).


In a prior pilot study by our team, we found that students’ self-perception of QoL was overestimated in most of the domains using SF-36 questionnaire. At the emotional role functioning and mental health domain scores should be considered when evaluating the need for mental health or suicide prevention programs for medical students. We decided to increase sample and sought to understand the reasons for the discrepancy between medical students’ self-perceived QoL and the data from their QoL questionnaire.


This was a cross-sectional, quali-quantitative, descriptive study performed after receiving approval from the institution’s ethics committee. Statistical power estimates were performed after the results from the pilot study and the final sample size was 190 students. Those who were married or who had children were excluded, as were students who had transferred into the program less than six months prior to the study, students who were repeating a year after failing, or on academic probation.


Students from the first to 4th year of our medical school were invited to participate in our study and complete three questionnaires: the SF-36, a second in which students gave their subjective opinions on their QoL in the eight domains described in the SF-36 (Table 1), scoring these domains from 1 to 100, and a third questionnaire regarding self-awareness and coping strategies (created by the authors).


Table 1: Questionnaire 2: self-perceived quality of life:  for the evaluation of medical students' subjective opinions.



0-100 Grade

Physical functioning

The normality and difficulty in which daily activities are being done.

Students gave their opinions

Role functioning (physical)

Pain or other physical difficulty when performing daily activities.

Students gave their opinions


Amount of pain or discomfort anywhere in the body during the week.

Students gave their opinions

General health

Health as a whole, diseases or infections recently, chronic or relapsing disease.

Students gave their opinions


The willingness and animation to perform daily activities and leisure.

Students gave their opinions

Social functioning

Integration with the environment, family and society in which you live.

Students gave their opinions

Role functioning (emotional)

Limitation of daily activities for such reason, such as depression and anxiety.

Students gave their opinions

Mental health

Mood state, manifestations of anxiety, mental tiredness.

Students gave their opinions


The statistical analysis relied on non-parametric evaluation methods for the quantitative questions, with paired t-tests, Spearman's correlation test, the Mann-Whitney U test, and chi-square tests.


Two hundred and three first- to fourth-year medical students from FACERES medical School of Medicine (FACERES) in Brazil completed the questionnaires, 64.5% of whom were women. The mean age of the sample was 20 years (with a range of 17 to 41 years). Students’ self-perceived QoL was found to be overestimated in the general health, physical role functioning, pain, energy/fatigue, emotional role functioning, social functioning, and mental health domains (p<0.001) and underestimated in the physical functioning domain (p<0.001). Details are shown in Table 2.


Table 2: Comparison between SF-36* results and students’ self-perceived quality of life.


SF-36 Health Survey

Self-Perceived QoL


Physical functioning

87.3 ± 14.0

76.7 ± 18.6

< 0.001

Role functioning (physical)

50.6 ± 36.8

82.5 ± 24.3

< 0.001


68.0 ± 21.0

78.8 ± 24.8


General health

57.2 ± 17.3

81.9 ± 21.1

< 0.001


44.1 ± 20.2

69.4 ± 24.7

< 0.001

Social functioning

60.0 ± 25.0

76.2 ± 26.8


Role functioning (emotional)

32.8 ± 39.4

70.8 ± 27.5


Mental health

55.7 ± 19.8

65.7 ± 26.3



Subtitle: SF-36*: Medical Outcomes Study 36-Item Short-Form Health Survey. QoL: quality of life.


A significant difference was found between the genders only in the mental health domain, in which men exhibited a greater discrepancy between self-perceived QoL and SF-36 score (p=0.041) (Table 3).


Table 3: Comparison of men's and women's deviations between self-perceived quality of life and SF-36 scores.





Physical functioning

-11.1 ± 20.9

-9.5 ± 20.8


Role functioning (physical)

33.9 ± 40.9

28.1 ± 36.5



9.61 ± 24.3

13.0 ± 23.1


General health

25.1 ± 24.2

23.7 ± 22.0



23.9 ± 20.6

27.6 ± 22.8


Social functioning

17.0 ± 21.8

14.4 ± 21.3


Role functioning (emotional)

38.4 ± 39.7

37.4 ± 40.6


Mental health

7.67 ± 22.4

14.3 ± 21.8



There were no differences in terms of age or year in the program.


In their responses on the third questionnaire 67.5% of respondents reported that the way they think is frequently or always consistent with the way they act; 72.9% reported that they know all or most of what their own needs are, and 73.9% rated their QoL as good or great. When asked about their coping strategies, 38.9% of the medical students included herein reported a preference for spending time alone, 41.9% reported seeking out other people, 12.8% use drugs or alcohol, 33.5% increase their food intake, 10.8% play sports, 13.3% seek professional help, 11.3% seek religious guidance, and 11.3% reported other methods. When the results from each gender were compared, women increased their food intake more frequently than men (p=0.002). Details are shown in Figure 1. Students’ responses to the other coping strategy options did not differ by gender.


Figure 1: Coping methods-Comparison between gender and total. Chi-square tests(*p value = 0.002 between men and women).


This study demonstrated that medical students’ self-perceived QoL was overestimated in almost all domains:  physical, social and emotional functioning, general and mental health, Pain, energy/ fatigue. Regarding to role functional capacity, it was underestimated. As aforementioned in the New Zealand study, medical students’ self-perceived QoL scores to be high when the students classified their QoL as better than or the same as that of students from other fields of study (Henning et al., 2012). Though their results were focused in different domains and not very clear, it seems to be the only study in the literature to consider self-perception in a similar context. While an optimal level of stress may improve learning ability (Rafidah, 2009), elevated stress levels may cause physical and mental health problems (Niemi and Vainiomäki, 1999), thus affecting students’ academic performance.


In our study we observed a great difference between the SF-36 questionnaire and the student´s self-perception in role emotional domain, even when the majority of them  reported that the way they think is frequently or always consistent with the way they act, and that they know all or most of what their own needs are, rating their QoL as good or great. This is worrying, as if they don´t know their difficulties, they won´t be able to motivate themselves to change and look for help.


Another point is coping strategies, that are essential for students handling stress and experiencing better mental health. These strategies included a high value on interpersonal relationships, a good balance between leisure and studies, time set aside for physical activity, a healthy diet, and prioritizing sleep and physical health (Zonta, Robles and Grosseman, 2006). In our study, medical students used these strategies rarely: in their responses to questions on their coping strategies, few reported playing sports and seek religious guidance or professional help. Seek out other people was one of the most common functional strategies used, but some of the students use dysfunctional methods that are ineffective or which have been proven to have no effect, such as spending time alone using drugs or alcohol and increasing food intake. Erchens et al., found a similar findings when studying burnout and coping strategies in medical students (Erchens et al., 2018). However, our finding women increase food intake more than men was not described in their work or in other studies (Fares et al., 2016; Thompson et al., 2016)


With suitable concern over and knowledge about their QoL, students can engage in more productive coping methods.


When genders were compared, male students exhibited a significantly greater discrepancy between self-perceived QoL and their SF-36 results in the mental health domain. Previous studies have shown that women may exhibit greater anxiety and distress in stressful situations than men, and that female students have worse perceptions of their academic performance (Paro et al., 2019). With suitable concern over and knowledge about their QoL, students can engage in more productive coping methods.



In this study, a clear relationship was found between students’ overestimated self-perceived QoL and worse mental health. This was a novel study that found that additional efforts are necessary to make medical education environments more informative and encouraging in order to motivate students to examine their QoL and concern themselves more with their mental health, since QoL and mental health have a major influence on students’ academic performance, skills, and interactions with patients.



One limitation in our study was the inability to collect data from all medical students in the program at roughly the same time (for example, just before final exams). Future studies could investigate associations between QoL scores and factors outside of academic life, such as family relationships and living conditions (whether students live alone or with others) Studies like these could help to eliminate confounding factors like these that could be influencing the overestimated self-perceived QoL scores found in this study.


This study found that medical students’ self-perceived quality of life scores are overestimated, given the fact that most of them reported that the way they think is consistent with the way they act and that they know their own needs. These perspectives may prevent them from seeking help or making changes when necessary. Given these findings, more studies on this topic are necessary, as are institutional interventions such as talks, campaigns, and even changes to the medical school curriculum in attempts to motivate students to know themselves better and prioritize their mental health.

Take Home Messages

  • Medical students’ self-perceived quality of life is overestimated, and this is reflected in their worse mental health.
  • Coping methods, though essential for handling stress and improving mental health, were rarely used.
  • Students must understand their quality of live and concern themselves with their mental health because of the influence these two factors have on their academic careers.

Notes On Contributors

1. M. N. Ceratti: 5th year Medical student, Faceres Medical School. Bibliographic review, data collection, results analysis and drafted the manuscript.


2. F. N. P. Quessada: Psychologist, works at Faceres Medical School. Discussed and helped to elaborate the questionnaire and analysis of the results.


3. P. S. Fucuta: Physician, MD, PhD, and  Bioestaticician, is a medical teacher at Faceres Medical School. Statistical analysis and discussed results and final text.


4. F. C. Pacca: Pedagogue, Master, teaches research methodology at Faceres Medical School. Helped with data collection and results analysis.


5. P. M. Cury: Professor, MD, PhD, is the medical coordinator and teaches at Faceres Medical School. Advisor, literature review, data collection, results analysis and final correction. ORCID:


We thank Danielle Jacqueline Deremo Cosimo for english review.


This study was presented by the same authors in AMEE 2019 Conference with the number 5KK11 (1672) ( 


Figure 1 is made by the authors, and was not copied from another source.


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Burger, P.H.M. and Scholz, M. (2018) ‘Gender as an underestimated factor in mental health of medical students’, Ann Anat, 218, pp. 1-6.


Chigerwe, M., Boudreaux, K.A. and Ilkiw, J.E. (2018) ‘Assessment of Depression and Health-Related Quality of Life in Veterinary Medical Students: Use of the 2-Item Primary Care Evaluation of Mental Disorders Questionnaire (PRIME-MD PHQ) and the 8-Item Short Form-8 Survey (SF-8)’, J Vet Med Educ, 45, pp. 358-366.


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Erschens, R., Loda, T., Herrmann-Werner, A., Keifenheim, K.E., et al. (2018) ‘Behaviour-based functional and dysfunctional strategies of medical students to cope with burnout’, Med Educ Online, 23(1), pp. 1535738.


Fares, J., Tabosh, H., Saadeddin, Z., El Mouhayyar, C., et al. (2016) ‘Stress, Burnout and Coping Strategies in Preclinical Medical Students’, N Am J Med Sci, 8(2), pp. 75-81.


Hayes, B., Prihodova, L. , Walsh, G., Doyle, F., et al. (2017) ‘What's up doc? A national cross-sectional study of psychological wellbeing of hospital doctors in Ireland’, BMJ Open, 7, pp. e018023.


Henning, M.A., Krägeloh, C.U., Hawken, S.J., Zhao, Y., et al. (2012) ‘The Quality of Life of Medical Students Studyingin New Zealand: A Comparison With Nonmedical Students and a General Population Reference Group’, Teaching and Learning in Medicine, 24, pp. 334-40.


Jang, E.S., Kim, Y.S., Kim, K.A., Lee, Y.J., et al. (2018) ‘Factors Associated with Health-Related Quality of Life in Korean Patients with Chronic Hepatitis C Infection Using the SF-36 and EQ-5D’, Gut Liver, 12, pp. 440-448.


Lins, L. and Carvalho, F.M. (2016) ‘SF-36 total score as a single measure of health-related quality of life: Scoping review’, SAGE Open Med, 4. 


Makiyama, T.Y., Battisttella, L.R., Litvoc, J. and Martins, L.C. (2004) ‘Study on the quality of life of hemiplegic stroke patients and their caregivers’, Acta Fisiatrica, 11, pp. 106-109.


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There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (

Ethics Statement

This study was approved by Faceres Medical School Research Ethics Commitee, Ethics Approval number 89742218.5.0000.8083.

External Funding

Financial support: Research grant from Fundação de Amparo à Pesquisa - FAPESP (process 2018/16988-9).


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Ken Masters - (26/03/2020) Panel Member Icon
An interesting paper that examines medical students' self-perception about their Quality of Life, and then questions whether the over-estimation is a basis of their mental troubles.

Overall, this is a useful paper, the study has been performed well, the results clearly presented and the Discussion is clear. There are, however, niggling issues that need to be addressed. Most of them are minor, and relatively easily addressed, but they really should be addressed in a Version 2 of the paper so that the paper can reach “Recommended” status.

• The title of the paper ends with the provocative question: “is this the base of their mental troubles?” Unfortunately, this question is never really addressed (although it is hinted at in the Conclusion). The paper’s Discussion should either directly address this question, or it should be dropped from the title.

• “and a third questionnaire regarding self-awareness and coping strategies (created by the authors).” More details of this questionnaire are required.

• In the reporting of the Results, raw numbers followed by percentages in brackets should be given (not merely percentages).

• When statements like this are made: “When genders were compared, male students exhibited a significantly greater discrepancy between self-perceived QoL and their SF-36 results in the mental health domain.” In thee cases, it would be useful for the reader if the authors could give an indication of the direction of the discrepancy. (i.e. was the self-perceived QoL higher or lower than their SF-36).

• “In Ireland, that more than one third (35%) of physicians experience psychological distress” This sentence needs correcting.
• “systematic Review and Meta-Analysis” consistency of upper-casing is required.
• “Rotenstein and cols, 2016” This citing needs to be corrected.
• “conclusions regarding their situation and what they need in it” The expression here is a little sloppy and needs to be corrected.
• “the first to 4th year” consistency of writing is needed here.
• There are several other examples of minor errors in the language. The paper should have a careful proof-read.

So, a useful paper, but one that does have issues. I look forward to Version 2 that addresses these issues.

Possible Conflict of Interest:

For transparency, I am an Associate Editor of MedEdPublish.

Irine Sakhelashvili - (13/01/2020) Panel Member Icon
Thank the authors for interesting in the students’ health status and mental well-being. Indeed, the medical students expose a lot of stress and difficulties because of a heavy content curriculum and I agree with the authors, this might be considered as a very serious health concern. Also agree that most of them are not aware of a possible negative consequence, not only their academic performance but for their health too. In this term the presented study contributes to the investigations in this direction. However, I have a question relating the methods: 1. SF-36 questionnaire itself is self-reported instrument, the students answering on SF-36 questions already expressed their subjective perception of every domains. SF-36 also gives an opportunity to measure severity of “symptoms.” If we agree that both used questionnaires (SF-36 and Likert-style assessment of self-perception) are self-reported, so what’s the differences? Another question relates to the table 3: Comparison of men's and women's deviations between self-perceived quality of life and SF-36 scores. It is not clear, there is shown mean and SD after summing both scales scores or….?! I would be highly appreciated if the authors will clarify this table.
Most interesting part in this article for me was comparison of the students coping strategies. In this term the study gives us an additional evidence about the troubles of medical students. Particularly noteworthy it that students are using the unsocial behavior or unhealthy strategies for handling stress. Such studies are very important. Moreover, based of evidences high universities should think about the effective interventional programs for helping the students.
Possible Conflict of Interest:

Irine Sakhelashvili is a member of Panel of Reviewers