Research article
Open Access

Medical Students' Preferences Regarding Preclinical Exam Scheduling: Implications for Improving Student Well-being

Kishore Jayakumar, BS[1], Jennifer Lapin, PhD[1], Jennifer Kogan, MD[1]

Institution: 1. Perelman School of Medicine at the University of Pennsylvania
Corresponding Author: Dr Jennifer Kogan ([email protected])
Categories: Assessment, Educational Strategies, Students/Trainees
Published Date: 06/07/2016

Abstract

Background:

Medical student burnout is prevalent. Investigators have called for research evaluating whether institutional and curricular interventions can improve student wellness. The impact that exam scheduling has on medical student burnout has not been studied.

Aim:

To determine medical students’ perceptions of the impact of preclinical exam scheduling on well-being.

Methods:

In 2014, a 36-item web-based survey was sent to 339 preclinical students attending the Perelman School of Medicine. Questions elicited demographics, scheduling preferences, and attitudes about how exam scheduling influenced ten burnout-associated or educationally relevant factors.

Results:

The survey response rate was 56%. Respondents most preferred Friday (73%, n = 139) and least preferred Monday (58%, n = 112) exams. Students selected Friday as the exam day most likely to result in improved quality of life; improved work-life balance; increased ability to pursue leisure activities/outside interests; improved mental health; decreased stress level; increased ability to visit significant others, friends, and family; and increased ability to promptly engage with material in the subsequent course.

Conclusions:

Scheduling preclinical exams on Fridays may be a curricular intervention that improves medical student well-being. Research is needed to determine generalizability of findings and influence of exam scheduling on knowledge acquisition and exam performance.

Keywords: Medical student education; Assessment; Wellbeing

Introduction

Burnout among medical students is prevalent and can be severe (Dyrbye et al., 2011, 2014; Dyrbye, Thomas, & Shanafelt, 2006; Santen, Holt, Kemp, & Hemphill, 2010). A 2013 systematic review found nine studies on burnout in medical students, with the prevalence ranging between 45 and 71 percent (IsHak et al., 2013). Burnout has been associated with psychological symptoms including anxiety (Voltmer, Kötter, & Spahn, 2012), depression (Baldassin et al., 2013; Basnet, Jaiswal, Adhikari, & Shyangwa, 2012; Compton, Carrera, & Frank, 2008; Dahlin, Joneborg, & Runeson, 2005; Schwenk, Davis, & Wimsatt, 2010; Voltmer et al., 2012), suicidal ideation (Dyrbye et al., 2008, 2011; Fan et al., 2012), serious consideration of dropping out of medical school (Dyrbye, Thomas, et al., 2010; Dyrbye et al., 2011), sleep deprivation (Mazurkiewicz, Korenstein, Fallar, & Ripp, 2012), and a perceived lack of control over schedule (Mazurkiewicz et al., 2012). Burnout also has professional consequences including altered specialty choice (Enoch, Chibnall, Schindler, & Slavin, 2013) and impaired academic performance (Sohail, 2013), competency (Clark & Zeldow, 1988), and professionalism (Dyrbye, Massie, et al., 2010). Burnout can persist throughout the duration of medical school (Santen et al., 2010).

Medical schools have instituted burnout-reducing interventions, which have preferentially focused on reactive wellness (Drolet & Rodgers, 2010) and stress management (Shapiro, Shapiro, & Schwartz, 2000; Shiralkar, Harris, Eddins-Folensbee, & Coverdale, 2013) programs rather than changes in the learning environment and curriculum. However, satisfaction with the overall learning environment is associated with resiliency to burnout (Dyrbye, Power, et al., 2010). A recent study suggested that medical schools need to address the underlying causes of stress within the curriculum and concluded that modifying course content, contact hours, course scheduling, grading, electives, learning communities, and mindfulness experiences was associated with reduced stress, anxiety, and depression (Slavin, Schindler, & Chibnall, 2014). Investigators have called for research evaluating whether institutional and curricular interventions can improve student wellness (Benbassat, Baumal, Chan, & Nirel, 2011; Dyrbye & Shanafelt, 2011; IsHak et al., 2013; Slavin et al., 2014; Walter et al., 2013). The most common curricular intervention examined to date has been adopting a pass/fail grading scheme, which has been associated with improved well-being, satisfaction, and group cohesion (Bloodgood, Short, Jackson, & Martindale, 2009; Reed et al., 2011; Rohe et al., 2006; Spring, Robillard, Gehlbach, & Moore Simas, 2011) and reduced rates of burnout and serious consideration of dropping out of school (Reed et al., 2011).

Exam-related stress among medical students is prevalent (Afzal, Afzal, Siddique, & Naqvi, 2012; Encandela, Gibson, Angoff, Leydon, & Green, 2014; Hashmat, Hashmat, Amanullah, & Aziz, 2008; Khan, Rasool, Sultan, & Tahira, 2013; Singh et al., 2012). A study examining stress levels among medical students at one institution revealed that studying and exams were the most frequently reported sources of stress (Walter et al., 2013). Despite these findings, there is no standard exam schedule across medical schools, and, to our knowledge, no studies have examined the impact of exam scheduling on medical student burnout.

The purpose of this study was to determine first- and second- year medical students’ preferences about the timing of exams in the first and second year of medical school. Our second objective was to explore students’ perceptions of the relationship between exam timing and perceived well-being and learning. We hypothesized that Monday exams would result in diminished quality of life, work-life balance and mental health; decreased time for leisure activities and with significant others, family, and friends; and reduced ability to promptly engage with material in the subsequent course.

Methods

At the Perelman School of Medicine there is an 18-month, 3-semester preclinical curriculum. The first semester is a disciplinary-based curriculum with students taking two to four concurrent courses (e.g., anatomy and biochemistry); the second and third semesters are a systems-based curriculum with students taking a single course at a time (e.g., cardiology). Exams in all three semesters usually consist of both individual and team components. For the team component, students collaborate in groups of six to seven students to complete a single exam. At the time of this study, students in the first semester had taken exams on various weekdays, while students in the second and third trimesters had taken over half their exams on Mondays. The grading system in the first semester is pass/fail while the grading system in the second and third trimesters is honors/pass/fail.

In October 2014, we administered a 36-item web-based survey (Appendix 1) to all first-year (M1) and second-year (M2) medical students attending the Perelman School of Medicine at the University of Pennsylvania. Participants were invited via email, and 3 weekly follow-up emails were sent to non-responders. The survey was administered using REDCap (Research Electronic Data Capture) tools at the University of Pennsylvania, a secure, web-based application designed to support data capture for research studies (Harris et al., 2009).

We designed the survey instrument based on previous research on medical student burnout (Dyrbye et al., 2011, 2014; Slavin et al., 2014). We pilot-tested the survey with four medical students to determine readability and completion time. The survey asked about demographics (age, year in medical school, and gender) and exam scheduling preferences (most and least preferred days of the week to take exams in typical weeks). Typical weeks were defined as standard Monday through Friday school weeks. Students were asked the preferred number of days before an exam that the last new material in a course should be presented and preferred order of taking individual and team components of exams. Students were also asked exam scheduling preferences (most and least preferred days of the week to take exams) in Monday holiday weeks (Tuesday through Friday school weeks such as the week of Labor Day). For exam timing questions there was a “no preference” option. For their most and least preferred days, students were asked to rate the strength of these preferences on a 5-point Likert scale (1 = not at all strongly, 5 = extremely strongly). Students were then asked to select the day of the week that would be most likely to increase and decrease burnout-associated or educationally relevant factors (quality of life; mental health; work-life balance; ability to pursue leisure activities/outside interests; ability to visit significant others, friends, and family; stress level; ability to promptly engage with material in the subsequent course; amount of sleep; ability to exercise; and procrastination). A “no difference” option was available. Finally, there was an open-ended question about exam scheduling.

Survey results were imported into Microsoft Excel and SPSS, Version 22.0 (IBM Corp., Armonk, NY) for analysis. Descriptive statistics were generated. A one-way ANOVA and Tukey’s HSD test tested the difference between exam day preferences and strength of preferences. A Phi Coefficient explored the relationship between exam day preferences and year of medical school. Directed content analysis was used to code the open ended responses about exam scheduling. Two reviewers (KJ, JK) separately coded the comments and differences in coding were reconciled by discussion. This study was exempted from review by the University of Pennsylvania Institutional Review Board. Participants were guaranteed anonymity and were assured that participation in the study was voluntary. No incentives were provided to complete the survey.

Results

The overall response rate was 56% (190/339), with 60% (99/165) of M1s and 52% (90/174) of M2s responding. One respondent did not specify a class year. Respondent characteristics are shown in Table 1. The age and gender distributions of the respondents were similar to those of the overall medical school classes.

Respondents’ preferences regarding the timing of exams in typical weeks and Monday holiday weeks are shown in Figures 1 and 2, respectively. In typical weeks, respondents indicated that Friday was the most preferred day (73%, n = 139), whereas Monday was the least preferred day (59%, n = 112). Very few students preferred Tuesday (1%, n = 2), Wednesday (1%, n = 2) or Thursday (8%, n = 15).This disparity intensified in Monday holiday weeks: Friday before the holiday was the most preferred day (79%, n = 151), whereas Tuesday after the holiday was the least preferred day (80%, n = 152). Very few students preferred the Wednesday (1%, n = 2), Thursday (4%, n = 17), or Friday (10%, n = 18) after the holiday. There was a statistically significant association between class year and most and least preferred exam days, with M2s slightly more likely than M1s to prefer Monday (Phi = 0.404, P < 0.0005) and avoid Friday (Phi = 0.404, P < 0.0005) in typical weeks.

The strength of preference for most preferred day depended on the day of the week chosen in both typical (P = 0.001) and Monday holiday weeks (P = 0.001). For typical weeks, the mean strength of preferences for Friday exams (3.71) was greater than that for Monday exams (3.00) (P = 0.015). For Monday holiday weeks, the mean strength of preferences for Friday exams (3.97) was also greater than that for Tuesday exams (3.00) (P = 0.086). Similarly, the strength of preference for least preferred day also depended on the day of the week chosen in both typical (P = 0.003) and Monday holiday weeks (P < 0.0005).

For a Monday exam, students indicated that the last new material for a course should be presented on the previous Thursday (54%, n = 102), Wednesday (39%, n = 74), or Friday (6%, n = 12). For a Friday exam, the students indicated that the last new material for that course should be presented on Tuesday (64%, n = 121) or Wednesday (36%, n = 68), with no respondents selecting Thursday. When a course had an individual exam and team exam, students indicated that they would prefer to take both components on the same day (81%, n = 153), the individual component the day after the team component (16%, n = 31), or the team component the day after the individual component (3%, n = 5).

Respondents identified Friday as the day most likely to result in increased quality of life (74%); improved mental health (62%); improved work-life balance (79%); increased ability to pursue leisure activities/outside interests (79%); increased ability to visit significant others, friends, and family (81%); decreased stress level (47%); and increased ability to promptly engage with the material in the subsequent course (84%) (Figure 3). In contrast, respondents identified Monday as the day most likely to result in decreased quality of life (69%); diminished mental health (59%); diminished work-life balance (76%); decreased ability to pursue leisure activities/outside interests (71%); decreased ability to visit significant others, friends, and family (87%); increased stress level (45%); decreased ability to promptly engage with the material in the subsequent course (77%); and increased procrastination (42%) (Figure 4). In general, a plurality of respondents stated that there would be no difference among exam days in amount of sleep and ability to exercise.

Twenty-two percent (41/190) of students answered the open-ended question about exam scheduling. The mean number of ideas per open ended question was 1.9 (range 0-10). The most common themes identified in the comments were the importance of recharging over the weekend (7%, n = 14), promptly engaging with the material in the subsequent course (7%, n = 13), having a dedicated study period (6%, n = 11), and enjoying the weekend (4%, n = 7). The only new theme identified by respondents was the relationship between exam day and exam performance, but comments did not identify a preferred exam day. (1%, n = 2).

Discussion

Our findings indicate that most preclinical medical students at our institution strongly prefer to take exams on Friday and not to take exams on Monday. Students also reported that taking exams on Fridays is most likely to result in many outcomes associated with improved well-being such as increased quality of life, improved work-life balance, and increased ability to pursue leisure activities/outside interests, while taking exams on Mondays is most likely to result in many outcomes associated with diminished well-being such as decreased quality of life, diminished work-life balance, and decreased ability to pursue leisure activities/outside interests. The findings of this study are consistent with recent literature on medical student burnout, which found that modifying curricular factors, including contact hours and course scheduling, can be associated with stress reduction (Slavin et al., 2014).

The Monday-Friday disparity implies that students value the weekend as a time to recharge, pursue leisure activities, visit family and friends, and engage with the next course. The consistency of sleep and exercise throughout the week might explain why a plurality of students indicated that the exam day would not affect these factors.

Most students seemed to value being able to finish their exams well in advance of starting the next course, as 84 percent of students indicated that Friday exams would help them quickly adapt to the next course, and 32 percent of the comments addressed having time between an exam and the next course so as to engage promptly with the subsequent course. In addition, most students seemed to dislike splitting an exam into multiple days, as 81 percent of students stated they would rather finish individual and team components of an exam on the same day. Regardless of exam day, students indicated that a sufficient window of time between the presentation of the last new material in a course and the exam is important, as most students desired a window of at least 3 days, and 6 percent of respondents included a reference to it in open-ended comments. It is unclear from our data whether students envisioned this window as a period of dedicated studying time immediately prior to an exam or a period of time in which any new material presented would not be tested. A dedicated period for studying may be challenging to implement given increasingly compressed time for the preclinical curriculum. How student well-being is influenced by the duration of the window between presenting new material and exams requires additional investigation.

This study has several limitations. First, generalizability may be limited given that we only surveyed students at a single institution, and their preferences may not be representative of those of students at other institutions. However, the similarity in exam scheduling preferences between M1s and M2s may strengthen the generalizability, as M1s and M2s had different curricular focus, number of concurrent courses, exam schedules, and grading schemes. Response bias is possible, though the demographics of respondents were similar to that of the first and second year classes. However, it is possible that respondents had different preferences regarding exam scheduling compared to non-respondents. Finally, this study does not address whether exam timing affects actual burnout and well-being, and we did not explore how exam timing influences student performance.

Conclusion

To our knowledge, this is the first study to examine the potential impact of preclinical exam scheduling on medical student well-being. Scheduling preclinical exams on Fridays and avoiding Mondays may be a curricular intervention that improves medical student well-being. Additional research is warranted to determine if such strategic scheduling could improve medical students’ well-being. Further research is also needed to determine generalizability of findings and the influence of exam scheduling on knowledge acquisition and exam performance.

Table 1

Figure 1

Figure 2

Figure 3

Figure 4

Previous Presentations

An earlier version of this work was presented as an oral abstract at the 2015 Northeast Group on Educational Affairs (NEGEA) Annual Retreat, April 17-18, 2015, Worcester, Massachusetts.

Take Home Messages

  • Medical student respondents prefer to take preclinical exams on Fridays and least prefer to take them on Mondays.
  • The majority of respondents state that taking preclinical exams on Fridays would result in improvements in burnout-related factors, while taking exams on Mondays would result in worsening in burnout-related factors.
  • The vast majority of students prefer to have the last new material in a course presented at least three days before an exam.
  • The findings suggest that scheduling preclinical exams on Fridays and avoiding Mondays may be a curricular intervention that improves medical student well-being.

Notes On Contributors

Kishore L. Jayakumar, BS, is a fourth-year medical student, Perelman School of Medicine at the University of Pennsylvania.

Jennifer Lapin, PhD, is Director of GME Evaluation and Assessment, Perelman School of Medicine at the University of Pennsylvania.

Jennifer R. Kogan, MD, is Professor of Medicine, Assistant Dean of Faculty Development, and Director of Undergraduate Education in the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania.

Acknowledgements

We thank Jonathan Wood, BA, Perelman School of Medicine at the University of Pennsylvania, for his contributions to the survey. He did not receive any compensation for his contributions.

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Appendices

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Reviews

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Mohamed Al-Eraky - (13/07/2016) Panel Member Icon
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The best thing in this study that it empowers a fourth year medical students to be the leading author. I congratulate the co-authors for providing this opportunity for a student to present the problem of burn out from students' perspective.
P Ravi Shankar - (08/07/2016) Panel Member Icon
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This is an interesting study. Stress and burnouts are important issues among medical students and curricular interventions which can reduce the same need to be welcomed. As the Chair of the Curriculum Committee in a Caribbean medical school I am well aware of stress and burnout among medical students. Our students may face the added problem of being in a new country and away from their friends and family. While we have not yet formally studied examination scheduling preferences among our students, most students here favor having their examinations on Monday. On the few occasions when exams were scheduled on a Friday students had expressed their displeasure.
I was intrigued by the team component of the exam described by the authors. Further details on how these are conducted would be of personal interest to me but I do not recommend that they be added in the manuscript. The issue of when (the day) the last new material for an exam should be presented was also of interest. At present we usually schedule our exams either on Mondays or Tuesdays and include material covered till/on the Friday of the week before on the exams. One problem we have noted is that students often, do not turn up for sessions, if the material covered during that session will not be assessed during the forthcoming exam.
The paper is well written and the presentation of ideas is smooth. The authors could provide some more information regarding the organization of the preclinical curriculum at their institution. Also there is a debate about whether ‘preclinical’ or ‘basic sciences’ would be the better term as the medical curriculum increasingly emphasizes early clinical exposure. I appreciate the fact that a medical student is the first author of the paper. The methodological aspects of the paper seem to be sound and proper ethical procedures seem to have been followed. It will be interesting to research whether students at other medical schools will show similar examination scheduling preferences.
Trevor Gibbs - (07/07/2016) Panel Member Icon
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I enjoyed reading this interesting paper that took a slightly different view in looking at student stress and burnout. Although, as the authors state, this paper did not support or refute whether the timing of examinations caused stress or burnout, it does support what we already had a good idea about; - notably that students preferred an examination strategically placed at a time which gives a recovery period and a rest period to build up to be be ready for the next exam. The paper was clearly written, used an appropriate methodology and will be of use to those interested in the area / topic. The background to the paper and the reference list was very helpful to those researching the area.
I appreciated the authors' explanations of the limitations of their paper, although I feel that there was a missed opportunity to reflect on the structure of our assessment methods and structure. . With respect, I think that this paper reflects an assessment system that assesses a silo approach to teaching and learning- do a course, be assessed at the end of it and move onto the next course. I wonder if the same results would be obtained from a school that looks at assessment in a different way, in an integrated approach, in a system that places greater importance on formative assessment and feedback, or even in a school that uses the Progress Test.
Emma Jones - (07/07/2016) Panel Member Icon
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This article is a very interesting read for medical students and medical educators involved in examination timetables. It explores the idea of modifying curriculum and scheduling to meet the preferences of medical students in order to reduce burnout, rather than targeting mindfulness or stress relief methods. One such example mentioned is the shift away from grading and towards pass/fail assessment which has been shown to reduce medical student stress.

56% of students responded to the survey in this study which is a relatively high response rate and may indicate that this topic is important to students. The medical students demonstrated that they most preferred Fridays rather than Mondays as their exam date and would prefer to have at least 3 days between learning the last new material and sitting the exam. Further support for these findings would involve studying similar outcomes amongst medical students in their clinical years of study, or creating a randomised control trial based on examination dates and measuring outcomes such as student stress and exam performance.

Burnout amongst medical professionals is becoming increasingly recognised. Methods for dealing with stress, such as seeking counselling, are commonly offered to medical staff however treatment is never quite as effective as prevention and I feel there is great merit in reducing the stress of a work environment. Perhaps simple methods such as employees being able to preference their day off or which day they have on-call can help to reduce burnout in hospitals as well.