Research article
Open Access

Students' self-perception about their Quality of Life is overestimated: is this the base of their mental troubles? [Version 2]

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

Institution: 1. FACERES Medical School
Corresponding Author: Prof Patricia Maluf Cury ([email protected])
Categories: Educational Strategies, Students/Trainees, Behavioural and Social Sciences
Published Date: 28/07/2020


Purpose: The aim of this study is to investigate the medical student perception about their QoL,  in order to become ware of their own probems.


Methods: We applied three instruments: a SF36 health questionnaire, a QoL self-perception questionnaire and a questionnaire regarding self-awareness and coping strategies. The questionnaires were sent to all medical students from first to fourth year.


Results: 203 students answered the questionnaires (64.5% were women and average age was 20 years old). 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 the questionnaire about self-awareness, most of them felt that the way they think is consistent with how they act and they are aware of their own needs. They evaluated their QoL as good or great. In relation to coping strategies, “seeking out help of others” was one of the most common strategies used. When analyzing the 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 (physical) and role functioning (emotional) - (Makiyama et al., 2004; Lins and Carvalho, 2016; Jang et al., 2018).


In Ireland, more than one third (35%) of physicians experience psychological distress and 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 a transition 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 et al., 2016).


A rarely discussed but important factor in this situation is medical students’ perception of their own QoL. This is based on the perception that students make decisions based on the specific situation and its requirements. 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, this outcome 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. In 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 fourth 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 on self-awareness and coping strategies, with the first part evaluated on a Likert scale addressing self-awareness and the second part on coping methods, with 8 answer options: being alone; seeking  help from other people; using drinks or drugs; increased food intake; playing sports; seeking professional help; seeking religious and other help.


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, 131 (64.5%) of whom were women. The mean age of the sample was 20 years old (within a range of 17 to 41 years old). Students’ self-perceived QoL was found to be overestimated in the general health, physical role functioning, pain, anergy/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, with self-perceived QoL higher than their SF-36 (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 137 (67.5%) of respondents reported that the way they think is frequently or always consistent with the way they act; 148 (72.9%) reported that they know all or most of what their own needs are, and 150 (73.9%) rated their QoL as good or great. When asked about their coping strategies, 79 (38.9%) of the medical students included herein reported a preference for spending time alone, 85 (41.9%) reported seeking out other people, 26 (12.8%) using drugs or alcohol, 68 (33.5%) increasing their food intake, 22 (10.8%) playing sports, 27 (13.3%) seeking professional help, 23 (11.3%) seeking religious guidance, and 23 (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 strategies 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 are not aware of 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 seeking religious guidance or professional help. Seeking 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 that 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)


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). If students are more aware of their QoL, they 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 environment more informative and encouraging in order to motivate students to examine their QoL and focus on 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.


Cvejic, E., Parker, G., Harvey, S. B., Steel, Z., et al. (2017) ‘The health and well-being of Australia's future medical doctors: protocol for a 5-year observational cohort study of medical trainees’, BMJ Open, 7, pp. e016837.


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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Rafidah, K., Azizah, A., Norzaid, M. D., Chong, S. C., et al. (2009) ‘The Impact of Perceived Stress and Stress Factors on Academic Performance of Pre-Diploma Science Students: A Malaysian Study’, International Journal of Scientific Research in Education, 2(1), pp. 13-26. 


Rotenstein, L. S., Ramos, M. A., Torre, M., Segal, J. B., et al. (2016) ‘Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis’, JAMA, 316, pp. 2214-2236. 


Tempski, P., Bellodi, P. L., Paro, H .B. S., Enns, S. C., et al. (2012) ‘What do medical students think about their quality of life? A qualitative study’, BMC Medical Education, 5, pp. 12-106.


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Zonta, R., Robles, A. C. C. and Grosseman, S. (2006) ‘Stress Coping Strategies Developed by Medical Students at the Federal University of Santa Catarina’, Brazilian Medical Education Magazine, 30, pp. 147 – 153. 




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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Barbara Jennings - (16/12/2020) Panel Member Icon
Thank you to the authors for this interesting article which explores a discrepancy between QoL scores & students’ own self perceptions across some critical lifestyle domains. The authors propose that the inflated perceptions (that was more marked in male students) will result in problems linked to a lack of self-awareness.
The study size was based on power calculations – resulting from a pilot study. But the authors do not elaborate on this e.g. regarding the size of any differences noted etc.
Also, the timings of the questionnaire dissemination is mentioned in the limitations of the study but not explained fully in the methods. Neither is the rationale for exclusion criteria based on demographics and the number of excluded potential participants is not presented.
There are also some typos scattered throughout the article that should have been corrected in a revised version. Not all of the reviewer comments from version 1 of the article have been addressed and the title is not fully congruent with the actual study conducted.
However, the authors have identified an important issue which definitely merits further study. The tables are well presented and the introduction is well written and referenced throughout.
Possible Conflict of Interest:

I am an Associate Editor of MedEdPublish. However, I have posted this review as a member of the review panel and so this review represents a personal, not institutional, opinion.

Ken Masters - (07/09/2020) Panel Member Icon
I was pleased to see that the authors addressed most of the concerns I raised in Version 1. Unfortunately, the central question of the paper (“is this the base of their mental troubles?”) remains unanswered and unexplored. The paper does show that a “relationship was found between students’ overestimated self-perceived QoL and worse mental health”, but, whether or not this is the base of the students' mental troubles has not been answered in the paper. (There may be an implied causality, but it could go in either direction, or the results could be related to a third issue.)

Given that the paper does not answer that question, the easiest solution to the problem would simply have been to drop that tag question from the title, as was suggested in the review to Version 1.
Possible Conflict of Interest:

For transparency, I am an Associate Editor of MedEdPublish.

Shamaila ijaz - (02/08/2020)
The abstract has a clear aim with precise results. The title is according to the research. Information is relevant. Most recent references are not quoted. The keywords were appropriate.
In introduction a gap is filled by increasing the sample size. Research question is clearly outlined. They believe that students make decisions based on specific situations.
In methods and results the process of subject selection is clear with sample of 190. The variables are clearly defined and three testing measurement used are appropriate. The study is designed in a way that it can be replicated.
The tables are well defined. The results are significantly defined with p values. The demographics are defined in percentages.
Discussion in the study have been compared with different researches across the world. The author has compared and contrasted their study. The strength and weakness are written. Conclusion defines the study in one line and suggestions are highlighted.
Possible Conflict of Interest:

I recommend this article as a useful contribution to the field that should be read by those with an interest in the area. I have no conflict of interest .