A Comprehensive Study of Depression, Anxiety, and Stress Among USMLE Aspirants: A Cross-Sectional Survey

doi:10.21203/rs.3.rs-4314117/v1

Background

The United States Medical Licensure Examination (USMLE) represents a critical step for medical licensure in the United States, requiring extensive preparation that can lead to significant mental health challenges among aspirants. This study aims to explore the prevalence and contributing factors of depression, anxiety, and stress among USMLE aspirants.

Methods

This cross-sectional survey investigates the prevalence and contributing factors of depression, anxiety, and stress among USMLE aspirants. We deployed a detailed online and paper-based questionnaire targeting a diverse pool of 321 medical students and graduates globally. The survey incorporated validated scales such as the Perceived Stress Scale, Generalized Anxiety Disorder 7-item scale, and Patient Health Questionnaire-9 to evaluate mental health statuses. Data analysis was conducted using SPSS, focusing on demographic correlations and mental health outcomes.

Results

A total of 321 participant’s data were collected, out of whom 51.1% (n = 164) were male and 48.9% (n = 157) were female. 91.3% (n = 293) were International Medical Graduates (IMG), while 8.7% (n = 28) were American Medical Graduates (AMG), educational status results show undergraduates 38.6% (n = 124) and graduates 61.4% (n = 197). Participants were interviewed through a validated questionnaire, and 75.1% (n = 241) had depression, 71.96 (n = 231) had anxiety, (n = 16) had low stress, (n = 231) had moderate, and (n = 66) had severe perceived stress.

Conclusion

Our study reveals a high prevalence of depression, anxiety, and stress among USMLE aspirants, with significant variations across demographic subgroups and chosen medical specialties.

USMLE

mental health

depression

anxiety

stress management

The United States Medical Licensing Examination (USMLE) is a licensing assessment mandatory for all allopathic medical students transitioning from student to intern to resident physician. Graduates of accredited osteopathic medical schools may also use the USMLE to meet licensure requirements in most jurisdictions. This three-step examination certifies that successful candidates have the minimum basic and clinical knowledge and clinical skills necessary for the unsupervised practice of medicine in the United States (US).[1, 2] The USMLE program is governed by the Federation of State Medical Boards (FSMB), the National Board of Medical Examiners (NBME), the Educational Commission for Foreign Medical Graduates (ECFMG), and the public. The FSMB represents the state medical and osteopathic boards in the US. In most jurisdictions, FSMB supports all the boards in protecting public health and patient safety through proper licensing, physician regulation and discipline, and other health care professionals.[3] NBME provides a variety of quality assessments and educational services for students, professionals, and medical institutions. These assessment tools are used in medical education, licensure, and certification.[4] The ECFMG is a private, nonprofit, nongovernmental organization that is authorized by federal regulations to serve as the certifying agency for international medical graduates (IMGs) entering the U.S. physician workforce as trainees in graduate medical education (GME).[5] ECFMG Certification is the standard for evaluating the qualifications of IMGs entering the U.S. healthcare system. The Accreditation Council for Graduate Medical Education (ACGME) requires IMGs who enter ACGME-accredited residency or fellowship programs to be certified by ECFMG.[6]

For Step 1, Step 2, CK, and Step 3, which are the computer-based testing (CBT) components of the USMLE program, test scheduling and delivery are provided by Prometric.[7] These CBT examinations are currently administered at more than 345 US/Canadian Prometric test centers and approximately 100 international Prometric test centers. The Step 1 and Step 2 CK examinations are administered worldwide; the Step 3 examination is administered only in the United States.[3] In 2022, 91% of US and Canadian medical students and graduates, as well as 71% of foreign medical graduates (IMGs), passed Step 1; for USMLE Step 2CK, 98% of US and Canadian medical students and grads passed, while 86% of IMGs did.[8, 9] Similarly, 97% of US and Canadian medical students and graduates passed the USMLE Step 3, whereas 89% of IMGs did.[9] In addition, the NRMP will offer 36,277 first-year residency jobs in 2023.[9]

Throughout the journey of USMLE aspirants, stress, anxiety, and depression pose prevalent challenges. The demanding nature of the USMLE exams, which serve as a pivotal milestone in the pursuit of a medical career, often leads to heightened levels of stress and anxiety among students. The immense pressure to excel, combined with the vast amount of knowledge to be mastered, creates an environment conducive to mental health issues. Aspirants may be overwhelmed by the fear of failure, the competitive nature of the exams, and the required extensive study hours. This chronic stress can manifest as anxiety, characterized by persistent worry, restlessness, and difficulties in concentration. In some cases, prolonged stress and anxiety can contribute to the development of depression. Recognizing the impact of these mental health challenges on USMLE aspirants is crucial, as it underscores the importance of providing adequate support, resources, and interventions to promote their well-being and ensure a healthy path toward achieving their professional goals. This study highlights the prevalence of stress, anxiety, and depression experienced by USMLE aspirants, as well as the factors that contribute to these challenges.

Study design and sample size

This is a cross-sectional online survey to assess the prevalence of stress, anxiety, depression, and their contributing factors. A total of 321 participants participated in the study. The sample size was calculated using the World Health Organization’s (WHO) calculator. The minimum recommended sample size was 270.

Data Collection and Methodology

The convenience sampling method was applied through online platforms relevant to USMLE aspirants. Following the Helsinki Declaration, records of all participants were checked and eligible participants were included in the study based on the inclusion criteria. A structured questionnaire was developed consisting of demographic questions (e.g., gender, ethnicity, educational background, etc.), standardized scales for assessing stress (e.g., Perceived Stress Scale), anxiety (e.g., Generalized Anxiety Disorder 7-item scale), and depression (e.g., Patient Health Questionnaire-9), and questions related to the problems they are facing during their USMLE journey and the chosen specialty. The survey was hosted on Google Forms and distributed internationally through social media platforms (X, Instagram, Facebook, and WhatsApp) frequented by USMLE aspirants and medical school mailing lists. The survey was accessible to collect the responses from January 20th,2023, to December 1st, 2023. Participants were encouraged to complete the survey in one setting to preserve the data integrity. Individuals currently preparing for or have recently completed the USMLE were included in the study, and participants who were not actively engaged in USMLE preparation were excluded from the study. Informed consent was obtained before the participants commenced the survey.

Statistical analysis

All the Data is transferred from Google Forms to Excel Sheets. Quantitative analysis was performed using SPSS version 20 for Windows. Descriptive analysis was employed to characterize the participant's demographic information, such as age, gender, marital status, graduation status, educational background, working status, preparation stage, and specialty choice. Cross tabulations chi-square test was applied to explore the association between all the demographic variables vs. depression, anxiety, and stress levels.

Among all participants interviewed in this survey, a majority were male, accounting for 51.1% (n = 164), with females representing 48.9% (n = 157). The respondents predominantly fell into two age groups, with the larger number, 88.8% (n = 285), in the 20–30 age group, and the remainder, 11.2% (n = 36), in the 30–40 age group. A significant portion of the respondents, 83.8% (n = 269), were single, 13.7% (n = 44) were married, 1.2% (n = 4) were in a relationship, and 1.2% (n = 4) were in a common-law partnership. In terms of medical education background, 91.3% (n = 293) were International Medical Graduates (IMGs), while 8.7% (n = 28) were American Medical Graduates (AMGs). Regarding educational status, 38.6% (n = 124) were undergraduates, and 61.4% (n = 197) were graduates. Detailed demographic information of the participants is provided in Table 1.

Table 1

Participants' demographic characteristics
Variables	Number (n)	Percentage
Gender
Male	164	51.1%
Female	157	48.9%
Age
20–30 years	285	88.8%
30–40 years	36	11.2%
Marital status
Single	269	83.8%
Married	44	13.7%
In a relationship	4	1.2%
Common law	4	1.2%
Graduation status
AMG’s	28	8.7%
IMG’s	293	91.3%
Educational Status
Undergraduate	124	38.6%
Graduated	197	61.4%
Study year (For undergraduates)
First year	24	7.5%
Second year	4	1.2%
Third year	32	10.0%
Fourth year	44	13.7%
Final year	20	6.2%
Years of graduation (For postgraduates)
Less than 5 years	169	52.6%
More than 5 years	28	8.7%
Working status (For postgraduates)
Yes	117	36.4%
No	204	63.6%
Stage of preparation
Not taken any USMLE Steps exam	116	36.1%
Taken one USMLE Steps exam	108	33.6%
Taken two of USMLE Steps exam	32	10.0%
ECFMG certified	65	20.2%

Interviews about their challenges during exam preparation or the residency match process revealed that 23.7% (n = 76) experienced a lack of background knowledge, 19.9% (n = 64) faced a lack of connections for the match process in the US, 18.7% (n = 60) encountered financial issues, 10% (n = 32) had low scores, 9% (n = 29) reported difficulty in time management with a job, followed by fear of rejection during the match process 5% (n = 16), visa problems 2.5% (n = 8), and time management with kids 1.2% (n = 4), as depicted in Fig. 1. Further inquiries about their preferred specialty applications are shown in Fig. 2. Participants were also interviewed using the PHQ-9 Questionnaire for depression, the Generalized Anxiety Disorder 7-item (GAD-7) scale for anxiety, and the Perceived Stress Scale for stress assessment.

A significant proportion, 75.1% (n = 241), were found to have depression, classified into mild, moderate, moderately severe, and severe categories. The prevalence of depression showed a significant difference between males and females (p = 0.001), with the majority of males falling into the mild category (17.4%, n = 56), and a more evenly distributed severity pattern among females. Similar distribution trends across depression severity levels were observed in both age groups (p = 0.381). A detailed subgroup analysis of depression in terms of marital status, graduation year, year of study, participants' medical school country, and working status is provided in Table 2. The analysis indicated a higher prevalence of depression among those who lacked background knowledge for preparation (n = 52), followed by those who lacked connections in the US for the match process (n = 48) and had financial issues (n = 40).

Table 2

Prevalence of depression based on the PHQ-9 Questionnaire and the subgroup analysis
Variable	None-minimal	Having depression	Mild	Moderate	Moderately severe	Severe	P value
Gender
Male	60	104	56	44	04	0	0.001
Female	20	137	69	24	24	20	0.001
Age
20–30 years	72	213	109	64	24	16	0.381
30–40 years	8	28	16	4	4	4	0.381
Marital Status
Single	68	201	97	56	28	20	0.001
Married	12	32	28	4	0	0
In relationship	0	4	0	4	0	0
Common law	0	4	0	4	0	0
AMGs Vs IMGs
AMGs	12	16	8	4	0	4	0.023
IMGs	68	225	117	64	28	16	0.023
Graduation status
Undergraduate	40	84	40	36	0	8	0.001
Graduated	40	147	85	32	28	12	0.001
Year of Study
First year	0	24	8	16	0	0	0.001
Second year	4	0	0	0	0	0
Third year	12	20	16	4	0	0
Fourth year	24	20	12	8	0	0
Final year	0	20	4	8	0	8
Year of Graduation
Less than 5 years	32	137	69	28	28	12	0.001
More than 5 years	8	20	16	4	0	0	0.001
Working status
Yes	28	89	49	16	20	4	0.001
No	52	152	76	52	8	16	0.001
Stage of preparation
Not taken any steps exam	36	80	28	40	4	8	0.001
Taken only one Steps exam	20	88	48	24	12	4
Taken two Steps exams	8	24	8	4	8	4
ECFMG certified	16	49	41	0	4	4

For anxiety, assessed using the GAD-7 scale, 71.96% (n = 231) of participants had anxiety, further categorized into mild, moderate, and severe. There was a statistically significant difference in the prevalence of anxiety between males and females. Detailed prevalence and subgroup analysis based on age, marital status, graduation year, year of studying, participants' medical school country, and working status are presented in Table 3. The prevalence of anxiety was notably higher among those lacking background knowledge for preparation (n = 54), followed by those lacking US connections for the match process (n = 46), and those facing financial issues (n = 42).

Table 3

Prevalence of anxiety based on the Generalized Anxiety Disorder 7-item scale and the subgroup analysis.
Variable	None-minimal	Having anxiety	Mild	Moderate	Severe	P value
Gender
Male	66	98	66	20	12	0.001
Female	24	133	51	40	42	0.001
Age
20–30 years	84	201	97	54	50	0.078
30–40 years	6	30	20	6	4	0.078
Marital Status
Single	82	187	79	54	54	0.001
Married	6	38	36	2	0
In relationship	0	4	0	4	0
Common law	2	2	2	0	0
AMGs Vs IMGs
AMGs	12	16	8	8	0	0.021
IMGs	78	215	109	52	54	0.021
Graduation status
Undergraduate	52	72	22	26	24	0.001
Graduated	38	159	95	34	30	0.001
Year of Study
First year	2	22	6	12	4	0.001
Second year	4	0	0	0	0
Third year	12	20	6	2	12
Fourth year	34	10	6	4	0
Final year	0	20	4	8	8
Year of Graduation
Less than 5 years	36	133	73	30	30	0.001
More than 5 years	2	26	22	4	0	0.001
Working status
Yes	16	101	59	28	14	0.001
No	74	130	58	32	40	0.001
Stage of preparation
Not taken any steps exam	44	72	26	30	16	0.001
Taken only one Steps exam	20	88	48	14	26
Taken two Steps exams	6	26	12	6	8
ECFMG certified	20	45	31	10	4

Regarding stress levels, assessed using the Perceived Stress Scale, a small fraction, 16 participants, reported low stress, whereas a substantial number, 239 participants, experienced moderate stress, and 66 reported high perceived stress. A statistically significant gender difference in stress levels was observed (p = 0.001), with a larger proportion of male respondents reporting moderate stress. The subgroup analysis of stress, presented in Table 4, showed a higher prevalence among individuals lacking background knowledge for preparation (n = 56), followed by those with financial issues (n = 52) and those lacking US connections for the match process (n = 42).

Table 4

Prevalence of stress based on the Perceived Stress Scale and the subgroup analysis
Variable	Low	Moderate	High	P value
Gender
Male	12	140	12	0.001
Female	4	99	54	0.001
Age
20–30 years	16	213	56	0.215
30–40 years	0	26	10	0.215
Marital Status
Single	16	197	56	0.002
Married	0	38	6
In relationship	0	0	4
Common law	0	4	0
AMGs Vs IMGs
AMGs	10	14	4	0.001
IMGs	6	225	62	0.001
Graduation status
Undergraduate	6	94	24	0.904
Graduated	10	145	42	0.904
Year of Study
First year	0	16	8	0.001
Second year	0	4	0
Third year	6	22	4
Fourth year	0	40	4
Final year	0	12	8
Year of Graduation
Less than 5 years	10	123	36	0.736
More than 5 years	0	22	6	0.736
Working status
Yes	6	89	22	0.840
No	10	150	44	0.840
Stage of preparation
Not taken any steps exam	0	90	26	0.001
Taken only one Steps exam	10	72	26
Taken two Steps exams	4	18	10
ECFMG certified	2	59	4

Table 5 illustrates the statistically significant differences in depression, anxiety, and stress levels based on the specialty chosen, emphasizing the nuanced impacts these factors have on USMLE aspirants' mental health.

Table 5

Difference between depression, anxiety and stress based on specialty
Depression	None-minimal	Having depression	Mild	Moderate	Moderately severe	Severe	P value
Anesthesiology	4	4	4	0	0	0	0.001
Dermatology	8	8	4	4	0	0
Emergency medicine	0	8	4	4	0	0
Family medicine	4	4	4	0	0	0
General surgery	0	16	0	12	0	4
Internal medicine	40	124	72	16	24	12
Neurological surgery	4	12	4	8	0	0
Neurology	4	12	8	4	0	0
Obstetrics and gynecology	4	9	5	4	0	0
Orthopedic surgery	0	4	4	0	0	0
Pathology - anatomic and clinical	0	4	0	4	0	0
Pediatrics	8	12	12	0	0	0
Physical medicine and rehabilitation	0	4	0	0	0	4
Plastic surgery	0	4	0	4	0	0
Psychiatry	0	12	0	8	4	0
Thoracic surgery	4	4	4	0	0	0
Total	80	241	125	68	28	20
Anxiety	None-minimal	Having anxiety	Mild	Moderate	Severe		P value
Anesthesiology	4	4	0	0	4		0.001
Dermatology	4	12	4	8	0
Emergency medicine	4	4	2	2	0
Family medicine	4	4	4	0	0
General surgery	0	16	0	16	0
Internal medicine	44	120	62	28	30
Neurological surgery	4	12	12	0	0
Neurology	4	12	8	0	4
Obstetrics and gynecology	6	7	3	0	4
Orthopedic surgery	0	4	4	0	0
Pathology - anatomic and clinical	0	4	4	0	0
Pediatrics	8	12	12	0	0
Physical medicine and rehabilitation	0	4	0	0	4
Plastic surgery	0	4	0	0	4
Psychiatry	4	8	0	4	4
Thoracic surgery	4	4	2	2	0
Total	90	231	117	60	54
Stress	Low	Moderate	High				P value
Anesthesiology	4	4	0				0.001
Dermatology	4	4	8
Emergency medicine	2	6	0
Family medicine	0	8	0
General surgery	0	14	2
Internal medicine	6	128	30
Neurological surgery	0	16	0
Neurology	0	12	4
Obstetrics and gynecology	0	7	6
Orthopedic surgery	0	4	0
Pathology - anatomic and clinical	0	4	0
Pediatrics	0	16	4
Physical medicine and rehabilitation	0	0	4
Plastic surgery	0	4	0
Psychiatry	0	4	8
Thoracic surgery	0	8	0
Total	16	239	66

This study examines variations in the prevalence and intensities of depression, anxiety, and stress across different demographic categories of USMLE candidates, taking into account differences in gender, age, marital status, and educational background. The main obstacles highlighted for USMLE candidates are a lack of fundamental knowledge, inadequate social assistance, and financial burden. Various potential factors that contribute to mental health concerns among USMLE hopefuls have been identified, such as academic pressures, financial stress, and the high stakes involved with the USMLE tests. The study's results indicate a high occurrence of depression (75.1%), anxiety (71.96%), and different levels of stress among the participants, highlighting the substantial mental health burden experienced by this population. The prevalence of depression was further analyzed and categorized into mild, moderate, moderately severe, and severe levels using the PHQ-9 Questionnaire. Subsequent analyses were performed to examine the relationship between depression and various demographic variables, including gender, age, marital status, AMGs versus IMGs, graduation status, year of study, year of graduation, working status, and stage of preparation. Significantly, there was a notable difference (p < 0.05) in the occurrence of depression across these factors, except for age.

Similarly, anxiety and stress levels were classified as mild, moderate, or severe for anxiety, and low, moderate, or high for perceived stress. Further analysis showed statistically significant differences (p < 0.05) in the occurrence of anxiety among most demographic subgroups, except for age. Stress levels varied significantly among all demographic groups, except for age, graduation status, year of graduation, and job status.

The prevalence rates outlined in our findings highlight the urgent requirement for care, since 241 (75.1%) participants encountered depression and 231 (71.96%) disclosed anxiety. This analysis offers a clear and striking depiction of the severe mental health emergency experienced by individuals aspiring to take the USMLE. The distribution of stress levels is particularly concerning. Only 16 individuals (5%) reported minimal stress, while a combined total of 305 participants (95%) had moderate to high levels of perceived stress. This highlights a predominant trend of heightened stress in this community.

The analysis also revealed that the selection of a medical specialty had an impact on mental health outcomes. The study found that individuals who chose internal medicine had the highest occurrence of depression (n = 241), followed by those in general surgery (n = 16), and neurosurgery, neurology, and pediatrics (n = 12). The same pattern was observed in the frequency of anxiety and the high levels of perceived stress, especially among applicants in the field of internal medicine. A considerable number of participants reported facing challenges during the USMLE preparation and match process, including a lack of foundational knowledge, inadequate connections for the match procedure in the US, and financial difficulties. These challenges significantly contributed to their mental health issues.

The USMLE plays a crucial role in the medical sector by serving as a standardized evaluation to evaluate the knowledge, abilities, and competency of medical practitioners. Nevertheless, despite the abundance of literature regarding the USMLE tests, there has been a scarcity of studies investigating their precise influence on student well-being. This discrepancy indicates that the stress endured by persons who are getting ready for these examinations is a prevalent matter that warrants additional examination. An unreported survey conducted by a medical school found that 70% of students experienced anxiety because they believed that the substance of their curriculum did not fit well with the requirements of the United States Medical Licensing Examination (USMLE). This emphasizes the considerable psychological effect of feeling unprepared.

The stress associated with USMLE tests is not exclusive to this particular situation, but rather corresponds with broader discoveries in medical education research, as indicated by comparative literature. An investigation conducted by Dyrbye et al. (2014) regarding the mental health of medical students in the United States revealed that the occurrence of burnout and depressive symptoms among medical students was notably greater compared to the general population.[10] The study identified academic pressure as a prominent factor contributing to this disparity. The anxiety associated with USMLE preparation is similar to the stress experienced due to the great importance of passing the exam, as it not only determines licensing but also affects the chances of securing a residency placement.[11] The anxiety associated with high-stakes exams such as the USMLE is intensified by the extensive amount of material that needs to be mastered, the competitive environment of medical training, and the potential impact on future career prospects.[11] These factors closely align with the conclusions drawn from the wider body of research on stress and mental health among medical students.

The literature on various high-stakes testing situations provides additional insights into the effects of standardized exams on student well-being. For example, a study conducted by Tyssen et al. (2007) examined stress levels among medical students in Norway, who undergo a distinct set of tests.[12] The study found comparable results, indicating that students had elevated levels of stress and anxiety. These studies emphasize the widespread difficulty of finding a balance between the necessity for thorough evaluation of medical knowledge and abilities and the psychological welfare of students. The USMLE exams exemplify a crucial issue: the congruence between the content of the curriculum and the demands of the exams. The disparity between the content taught to students and the content assessed in tests can intensify feelings of inadequacy and lack of readiness, resulting in increased levels of worry and stress. This misalignment necessitates the implementation of a comprehensive approach in medical education, wherein the development of the curriculum is tightly synchronized with the needs of licensure examinations. The objective is to alleviate the psychological strain on students while simultaneously guaranteeing the excellence of medical education and patient care.[12]

Studies conducted by Tackett et al.[13] have provided evidence of the detrimental impact of USMLE preparation on the well-being of students. This includes a deterioration in quality of life, increasing levels of burnout, heightened anxiety and depression, and a notable number of students seeking mental health support. The "Step-Siblings" initiative, an innovative technique, demonstrates the potential advantages of near-peer mentorship in mitigating stress and improving the overall well-being of medical students.[14] A meta-analysis on the global prevalence of anxiety among medical students conducted by Tian-Ci Quek et al.[15] revealed a higher prevalence of anxiety among medical students compared to the general population. Similarly, a study conducted by Marie Dhalin et al.[16] showed a higher prevalence of depression in medical students.

The increased incidence of anxiety and depression among medical students, in comparison to the general population, highlights the necessity for comprehensive mental health assistance within medical education. The distress is caused by various factors such as academic strain, financial worries, and exposure to demanding clinical environments. These factors can have a negative impact on students' academic performance and may result in substance usage. Studies have shown psychological distress among prospective medical students was related to academic, non-academic, parental education, and cultural backgrounds.[17] Several factors—including academic pressure, workload, financial concerns, sleep deprivation, exposure to patients' suffering and deaths, student abuse, and a “hidden curriculum” of cynicism, have been hypothesized to contribute to this decline in students' mental health.[18–20] Some have suggested that psychological distress among students may adversely influence their academic performance, contribute to academic dishonesty, and play a role in alcohol and substance abuse.[21, 22]

The relationship between personal resilience, coping techniques, and external support systems should be further investigated to uncover factors that can reduce the psychological effects of USMLE preparation. This comprehension could guide the creation of comprehensive support systems that cater to the educational and psychological requirements of those striving for success.[23] The impact of digital platforms and social media on the levels of stress experienced by USMLE aspirants is a topic that warrants further examination.[24] This is particularly important given the extensive use of these platforms for study assistance and social engagement among medical students. Furthermore, the notable disparities in the occurrence of depression and anxiety based on gender, as emphasized in this study, need the implementation of mental health support and interventions that are sensitive to gender. Customizing support services to specifically target the distinct obstacles encountered by male and female candidates could improve the effectiveness of these interventions.[25]

The creation of a cohesive community among those preparing for the USMLE, facilitated by activities such as peer mentorship, study groups, and wellness seminars, could significantly diminish feelings of loneliness and competition that contribute to mental health problems.[26] Promoting a culture of transparency and emotional openness in medical school helps cultivate a more nurturing atmosphere where students feel empowered to request assistance without apprehension of social disapproval or criticism. Develop educational interventions to prepare students for the USMLE, focusing on effective study strategies; where one such course designed by Carle Illinois College of Medicine sought to improve their students’ experience during the dedicated preparation period via a unique course designed to provide support for academics and mental wellness which had a significant impact and improvement in aspirants.[27]

The limitations of this study, such as its use of convenience sampling and reliance on self-reported data, emphasize the necessity for more research to investigate the enduring effects of these stressors on the mental well-being of medical professionals. Future research should prioritize the development and assessment of specific support techniques and educational interventions aimed at alleviating the mental health difficulties experienced by USMLE candidates.

This study highlights a high prevalence of depression, anxiety, and stress among USMLE aspirants, as demonstrated by the systematic use of validated instruments such as the Patient Health Questionnaire-9, Generalized Anxiety Disorder 7-item scale, and Perceived Stress Scale. The data demonstrate significant psychological costs across demographic subgroups and medical specialties, emphasizing the varied problems that individuals encounter when negotiating the demanding USMLE program. These mental health difficulties, exacerbated by the intense preparation required for the USMLE, necessitate a strategic emphasis on comprehensive support networks. Addressing these difficulties is critical not just for aspirants' well-being, but also for the larger medical community, as it ensures a resilient future workforce capable of providing high-quality treatment. The study's findings on the mental health landscape among USMLE aspirants open the way for targeted treatments and legislation aimed at mitigating the impact of these stressors, establishing a more supportive atmosphere for medical students and graduates as they begin their professional careers.

USMLE

United States Medical Licensing Examination

IMGs

International medical graduates

AMGs

American medical graduates

FSMB

Federation of State Medical Boards

NBME

National Board of Medical Examiners

ACGME

Accreditation Council for Graduate Medical Education

ECFMG

Educational Commission for Foreign Medical Graduates

GME

graduate medical education

CK

clinical knowledge

CS

Clinical Skills

CBT

Computer-based testing

GAD

Generalized anxiety disorder.

Ethics approval and consent to participate:

Ethical approval was granted by the Institutional Research and Ethical Review Board at Khyber Medical College, Peshawar with reference number 247/DME/KMC. Written informed consent was taken from participants before recruitment in the study.

Consent for publication:

Not applicable

Competing interests:

The authors declare that they have no competing interests

Funding:

No funding was received for conducting this study.

Author Contribution

QAK, NFB, and BS conceptualized the idea. QAK, NFB, BS, AMF, MA, and FZK collected the data. QAK, AMF, MA, FZ, HAK, and RV contributed to the manuscript writing. EW critically revised the manuscript and did the final editing. All the co-authors reviewed and approved the manuscript before submission.

Acknowledgments:

Not applicable

Availability of data and materials:

All data generated or analyzed during this study are included in this published article [and its supplementary information files.

Alvin MD. The USMLE Step 2 CS: Time for a change. Med Teach. 2016;38(8):854–6.
Scoles PV. Comprehensive review of the USMLE. Adv Physiol Educ. 2008;32(2):109–10.
Landess J. State Medical Boards, Licensure, and Discipline in the United States. Focus (Am Psychiatr Publ). 2019;17(4):337–42.
Wright WS, Baston K. A national survey: use of the National Board of Medical Examiners® basic science subject exams and Customized Assessment Services exams in US medical schools. Adv Med Educ Pract. 2018;9:599–604.
Hallock JA, Kostis JB. Celebrating 50 years of experience: an ECFMG perspective. Acad Med. 2006;81(12 Suppl):S7–16.
Ramesh T, Horvitz-Lennon M, Yu H. Opening the Door Wider to International Medical Graduates - The Significance of a New Tennessee Law. N Engl J Med. 2023;389(21):1925–8.
Borsheim B, Ledford C, Zitelny E, Zhao C, Blizzard J, Hu Y. Preparation for the United States Medical Licensing Examinations in the Face of COVID-19. Med Sci Educ. 2020;30(3):1267–72.
Ozair A, Bhat V, Detchou DKE. The US Residency Selection Process After the United States Medical Licensing Examination Step 1 Pass/Fail Change: Overview for Applicants and Educators. JMIR Med Educ. 2023;9:e37069.
USMLE, Performance, Data. https://www.usmle.org/performance-data.
Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89(3):443–51.
Moir F, Yielder J, Sanson J, Chen Y. Depression in medical students: current insights. Adv Med Educ Pract. 2018;9:323–33.
Tyssen R, Dolatowski FC, Røvik JO, Thorkildsen RF, Ekeberg Ø, Hem E, et al. Personality traits and types predict medical school stress: a six-year longitudinal and nationwide study. Med Educ. 2007;41(8):781–7.
Tackett S, Jeyaraju M, Moore J, Hudder A, Yingling S, Park YS, et al. Student well-being during dedicated preparation for USMLE Step 1 and COMLEX Level 1 exams. BMC Med Educ. 2022;22(1):16.
Lynch TV, Beach IR, Kajtezovic S, Larkin OG, Rosen L. Step Siblings: a Novel Peer-Mentorship Program for Medical Student Wellness During USMLE Step 1 Preparation. Med Sci Educ. 2022;32(4):803–10.
Quek TT, Tam WW, Tran BX, Zhang M, Zhang Z, Ho CS et al. The Global Prevalence of Anxiety Among Medical Students: A Meta-Analysis. Int J Environ Res Public Health. 2019;16(15).
Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: a cross-sectional study. Med Educ. 2005;39(6):594–604.
Yusoff MS, Abdul Rahim AF, Baba AA, Ismail SB, Mat Pa MN, Esa AR. Prevalence and associated factors of stress, anxiety and depression among prospective medical students. Asian J Psychiatr. 2013;6(2):128–33.
Guthrie EA, Black D, Shaw CM, Hamilton J, Creed FH, Tomenson B. Embarking upon a medical career: psychological morbidity in first year medical students. Med Educ. 1995;29(5):337–41.
Stewart SM, Lam TH, Betson CL, Wong CM, Wong AM. A prospective analysis of stress and academic performance in the first two years of medical school. Med Educ. 1999;33(4):243–50.
Silver HK, Glicken AD. Medical student abuse. Incidence, severity, and significance. JAMA. 1990;263(4):527–32.
Richman JA, Flaherty JA, Rospenda KM, Christensen ML. Mental health consequences and correlates of reported medical student abuse. JAMA. 1992;267(5):692–4.
Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81(4):354–73.
Wiedermann CJ, Barbieri V, Plagg B, Marino P, Piccoliori G, Engl A. Fortifying the Foundations: A Comprehensive Approach to Enhancing Mental Health Support in Educational Policies Amidst Crises. Healthc (Basel). 2023;11(10).
Wrede SJS, Claassen K, Rodil Dos Anjos D, Kettschau JP, Broding HC. Impact of digital stress on negative emotions and physical complaints in the home office: a follow up study. Health Psychol Behav Med. 2023;11(1):2263068.
25, Gorth DJ, Magee RG, Rosenberg SE, Mingioni N. Gender Disparity in Evaluation of Internal Medicine Clerkship Performance. JAMA Netw Open. 2021;4(7):e2115661–e.
Patel D, Andersen S, Leon G, Lee C, Simanton E. Exploration of the Role of Relationships and Virtual Learning on Academic Performance and Mental Health. Cureus. 2022;14(8):e28338.
Yodh JG, Jaleel A, Wallon RC. Improving Student Experiences During USMLE Step 1 Dedicated Preparation Period via a Course Designed to Holistically Support Academic and Wellness Needs. Medical science educator [Internet]. 2023 2023/06//; 33(3):[653-8 pp.].

No competing interests reported.

A Comprehensive Study of Depression, Anxiety, and Stress Among USMLE Aspirants: A Cross-Sectional Survey

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Methods

Study design and sample size

Data Collection and Methodology

Statistical analysis

Results

Discussion

Conclusion

Abbreviations

Declarations

Competing interests:

Funding:

Author Contribution

Acknowledgments:

Availability of data and materials:

References

Additional Declarations

Status:

Version 1