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OJHAS Vol. 10, Issue 1:
(Jan-Mar 2011) |
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| Depression, Anxiety and Stress Reduction
in Medical Education: Humor as an Intervention. |
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Ramesh Narula, Assistant
Professor, Department of Orthopedics,
Varsha Chaudhary, Assistant
Professor, Department of Community Medicine,
Kusum Narula, Demonstrator
,Department of Community Medicine,
Ram Narayan, Clinical Psychologist,
Rohilkhand Medical
College, Bareilly, Uttar Pradesh, India. |
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Address For Correspondence |
Assistant Professor,
Department of Orthopedics,
Rohilkhand Medical College,
Bareilly, UP, India
E-mail:
rameshnarula55@gmail.com |
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Narula R, Chaudhary V, Narula K, Narayan R. Depression, Anxiety and Stress Reduction
in Medical Education: Humor as an Intervention. Online J Health Allied Scs.
2011;10(1):7 |
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Submitted: Feb 25,
2011 Accepted: Mar 31, 2011; Published: April 15, 2011 |
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| Abstract: |
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Background: In recent years there has been a growing appreciation
of the issues of quality of life and stresses involved in medical training
as this may affect their learning and academic performance. Objective
of the study was to explore the effectiveness of humor when used
as intervention in large group teaching over negative emotions amongst
students. Method: The present Interventional, Randomized control
trial study was carried out on medical students of 4th Semester
of RMCH, Bareilly, which has total 90 students. Using simple random
sampling lottery method the whole class was divided in two groups-A
and B consisting of 45 students each. Group A as control group and Group
B experimental group. In first and last lecture of both groups Dass-21
was used as measuring scale, for depression, anxiety and stress and
results were compared to see the effect of humor on these three negative
emotions. Result: Comparison of Severe and Extremely severe
Stress: In Group A 40.54% in class -1 increased to
47.54% in class- 4, while in group B initial 13.15 % was reduced to
0 % (highly significant). Anxiety: In group A, after Class 1
-57.45% increased to 61.11% after class 4, while in group B, after class
1- 23.68% reduced to 2.27% only (highly significant). Depression: In group A, after Class 1 - 40.53% & 41.66 % after class 4 (not
significant), while in group B, after class 1- 18.41% reduced to 0%
(highly significant). Conclusion: In present study humor was
found to be very effective intervention in relieving students on their
negative emotions of depression, anxiety and stress to a larger extent.
Further research would justify the use of humor as an effective teaching
aid in medical education.
Key Words:
Humor; Stress; Dass-21
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Stress and burnout are prevalent throughout
medicine for practicing doctors, residents and students. Perceived stress
is associated with increased levels of depression, alcohol and drug
abuse, relationship difficulties, anxiety and suicide. Stress is receiving
increased attention because of the realization that tired, tense, anxious
doctors may not provide as high quality care as do those who do not
suffer from these debilitating conditions. Burnout is common among residents
and leads to decreased job satisfaction, as well as self-reported suboptimal
patient care. Pre-clinical medical students have higher levels of stress
than the general population due to such factors as academic pressures,
financial problems and excessive working hours, all of which can result
in personal and interpersonal relationship problems.(1)
Studies from United Kingdom, that have
examined coping strategies of medical students with the stresses of
undergraduate education have generally identified use of alcohol as
a coping strategy but some studies have reported the use of other substances
such as tobacco and drugs . But a study from Pakistan reported that
sports, music and hanging out with friends were common coping strategies.
Studies from developing countries like Pakistan, India, Thailand and
Malaysia have reported stress among medical students and have underscored
the role of academics as a source of stress . But these studies have
either not assessed the coping strategies or did not use COPE inventory.(2)
Although humor is used regularly by
medical and other teachers, there is almost no literature on the use
of humor in medical education; indeed, there is a paucity of research
on its use in education generally. There have been few published controlled
studies of the use of humor in learning, and only about half of these
have demonstrated improved learning outcomes. There is almost no literature
on the use of humor in medical teaching.(3)
Study design: The present
interventional, randomized control trial study(4) was carried out
with the objective to determine if humor is used as a teaching aid then
how does it make a difference to the students on their negative emotions
of depression, anxiety and stress. Total 90 students of the fourth semester were chosen
for the study. By simple random sampling
(lottery system) the whole class was divided in two groups - A and B - consisting
of 45 students each. Group A was taken as control group and Group B as experimental
group. For both groups four lectures each were delivered on same topic,
with a difference that in group A classes, no intervention was used while
in group B humor was used as an intervention.
Setting and participants: Study was undertaken after approval from institutional ethics committee
and written consent of participating students, by Department of Orthopedics
at Rohilkhand Medical College, Bareilly, which is a private institution.
Here students come from diverse cultural, socioeconomic and educational
backgrounds and majority of students belong to affluent families. They
are exposed to a new learning environment, making new friends, and generally
adapting to a new and somewhat uncertain world during their training
at the medical school.
Dass-21: During first and last lecture of
both groups, Dass-21 questionnaire was used as measuring scale(5) for
depression, anxiety and stress and results were compared to see the
effect of humor on these three negative emotions. Results were simplified
by using scoring template & Dass profile sheet for severity ratings.
Data analysis: Data was analyzed using SPSS for Windows (Version
10.0) and Chi-Square test was applied for statistical analysis. A p
value of 0.05 and less was considered significant.
Table 1
shows the effect of intervention on stress. In Group A,
level of stress increased from 40.54% in Class 1 to
47.54% in Class- 4, while in group B, the initially stressed 13.15 % was reduced to
0 % (highly significant). On the other, the number of normal students reduced to
41.7% from initial 43.24% in group A (not significant), whereas group
B, it increased from 55.26% to 86.36%(highly significant).
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Table 1:
Effect of intervention on stress |
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Group
A |
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No. |
Grading |
Class 1 (n= 37) |
Class 4 (n= 36 ) |
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No. |
% |
No. |
% |
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1 |
Normal |
16 |
43.24 |
15 |
41.7 |
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2 |
Mild |
3 |
8.11 |
1 |
2.78 |
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3 |
Moderate |
3 |
8.11 |
3 |
8.33 |
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4 |
Severe |
7 |
18.92 |
8 |
22.22 |
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5 |
Extremely Severe |
8 |
21.62 |
9 |
25.00 |
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X2 = 1.1358, df= 4, P > .05, Not Significant.
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Group
B |
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No. |
Grading |
Class 1- (n= 38) |
Class
4 (n= 44 ) |
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No. |
% |
No. |
% |
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1 |
Normal |
21 |
55.26 |
38 |
86.36 |
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2 |
Mild |
10 |
26.31 |
5 |
11.36 |
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3 |
Moderate |
2 |
5.26 |
1 |
2.27 |
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4 |
Severe |
2 |
5.26 |
0 |
0 |
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5 |
Extremely Severe |
3 |
7.89 |
0 |
0 |
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X2
= 10.17, df= 4, P < .05, Significant |
Table 2 shows the effect of intervention on
anxiety. In group A, severe and extremely
severe anxiety increased to 61.11% after class 4 compared to 57.45% after Class
1, while in group B, reduced to 2.27% only after Class 4, compared to 23.68%
after Class 1 (highly significant). On the other, the normal students in
Group A were 13.51% after Class 1 and 11.11% after Class 4.(not significant),
whereas in
Group B, initially 34.21 % were normal and after Class 4, 84.09% were normal.(highly
significant).
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Table 2:
Effect of intervention on
anxiety |
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Group A |
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No. |
Grading |
Class 1 (n= 37) |
Class 4 (n=36) |
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No. |
% |
No. |
% |
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1 |
Normal |
5 |
13.51 |
4 |
11.11 |
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2 |
Mild |
2 |
5.40 |
1 |
2.78 |
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3 |
Moderate |
8 |
21.62 |
9 |
25.00 |
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4 |
Severe |
9 |
24.32 |
10 |
27.78 |
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5 |
Extremely Severe |
13 |
35.13 |
12 |
33.33 |
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X2 = .617, df = 4, P >
.05 Not Significant |
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Group B |
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No |
Grading |
Class 1 (n= 38) |
Class 4 (n= 44) |
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No. |
% |
No. |
% |
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1 |
Normal |
13 |
34.21 |
37 |
84.09 |
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2 |
Mild |
7 |
18.42 |
2 |
4.54 |
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3 |
Moderate |
9 |
23.68 |
4 |
9.09 |
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4 |
Severe |
3 |
7.89 |
1 |
2.27 |
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5 |
Extremely Severe |
6 |
15.79 |
0 |
0 |
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X2 =
22.89 , df = 4, P < .001 (highly significant) |
Table 3 shows the effect of
intervention on depression. In group A, severe & extremely severe depression was
found in 40.53% students after Class 1 and in 41.66 % students after Class 4
(not significant), while in group B, it was found in 18.41% students after Class
1, but reduced to 0% after Class 4 (highly significant). On the other, in Group
A, the normal students were21.62 % after Class 1 and 16.66% after Class 4, (not significant),
whereas in
Group B, the corresponding figures were 47.36% & 81.81% respectively (highly significant).
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Table 3:
Effect of intervention on depression |
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Group A |
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No. |
Grading |
Class 1 (n= 37) |
Class 4 (n= 36) |
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No. |
% |
No. |
% |
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1 |
Normal |
8 |
21.62 |
6 |
16.66 |
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2 |
Mild |
7 |
18.91 |
8 |
22.22 |
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3 |
Moderate |
7 |
18.91 |
7 |
19.44 |
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4 |
Severe |
8 |
21.62 |
7 |
19.44 |
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5 |
Extremely Severe |
7 |
18.91 |
8 |
22.22 |
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X2 = .471 , df = 4, P
> .05, Not Significant. |
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Group B |
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No. |
Grading |
Class 1 (n= 38) |
Class 4 (n= 44 ) |
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No. |
% |
No. |
% |
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1 |
Normal |
18 |
47.36 |
36 |
81.81 |
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2 |
Mild |
12 |
31.57 |
5 |
11.36 |
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3 |
Moderate |
1 |
2.63 |
3 |
6.81 |
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4 |
Severe |
3 |
7.89 |
0 |
0 |
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5 |
Extremely Severe |
4 |
10.52 |
0 |
0 |
| X2= 16.54, df
= 4, P < .005, Significant |
Humor appears
to be widely used in medical teaching. At the Sydney Children's Hospital, a
recent survey of senior staff showed that almost all used humor in their
teaching (personal unpublished data). Almost 80% included humor in their
teaching sessions, and regularly elicited laughter from their students. Most
found it difficult to use humor and would like to use it more. Although they do
not see humor as essential to good teaching, they believe that too little use of
humor is made in teaching and that humor in teaching reduces stress; increases
motivation; improves morale, enjoyment, comprehension, interest and rapport; and
facilitates socialization into the profession. They did not think humor
trivialized, distracted, encouraged dogmatism, or demeaned patients (if used in
bedside teaching) or that its use was unprofessional. They thus attributed to
the use of humor in education those qualities which are claimed for it in the
educational literature.(6)
They stressed that humor should be appropriate to the topic and should
be in context. The importance of using humor that is relevant to the
subject is stressed by Ziv.(7)
It is also possible that the use of
humor in teaching could "seduce" students into believing the
teaching to be of high quality, a concept studied in the "Dr Fox"
experiment.(8,9) This research showed that a charismatic and impressive teacher
could be rated highly by students, despite the absence of content in the
material presented. Surprisingly, student performance may be enhanced by a
"seductive" lecture, even though they may have learned nothing. Content, on the
other hand, affects student learning, but does not affect student rating of the
teacher.(10,11)
The place of humor in medicine thus
appears to be paradoxical. Humor is widely used in medical teaching,
although rarely mentioned in medical educational writings and apparently
virtually never researched in this context. There is significantly more
literature on the therapeutic value of humor, yet its clinical use is
so rare that it attracts media attention. While better evidence of its
educational value is awaited, humor will, no doubt, continue to be used
in medical teaching, at least by those who accept that supporting evidence
is not always available in the form of randomized controlled studies.
In the present study, humor was found to
be very effective intervention in relieving students on their negative
emotions of depression, anxiety and stress to a larger extent. We therefore
conclude that humor is effective as an intervention.
Virtually all studies of laughter
and health indicate positive results. A wide range of low-risk humor
techniques can be very effective. Strategies for using humor must be
planned well and executed systematically to achieve specific outcomes.
Both content-specific and generic humorous material tailored to the
characteristics of each class can be effective in appropriate applications.
Humor tends to be more effective when two or more of the senses, especially
visual and aural , are involved rather than just one sense. Offensive
humor should never be used in the classroom .
So an ardent desire of every student
is to have a resourceful, motivated, interactive, inspiring teacher.
Students adore such teachers.
- Claudia Finkelstein, Alice Brownstein,
Craig Scott et al. Anxiety and stress reduction in medical education:
an Intervention. Medical Education 2007;41:258-264
Chandrashekhar T Sreeramareddy ,
Pathiyil R Shankar, VS Binu, et al.
Psychological morbidity, sources of stress and coping strategies among
undergraduate medical students of Nepal. BMC Medical Education 2007;7:26
John B Ziegler. Humour in medical
teaching. MJA
1999;171:579-580. Available at:
http://www.mja.com.au/public/issues/171_11_061299/ziegler/ziegler.html.
Accessed October 18th,
2010.
Park K. Principles of Epidemiology
and Epidemiologic Methods. Park’s Textbook of Preventive and Social
Medicine, 20th Edition. Jabalpur, M/S Banarsidas Bhanot Publishers.
February 2009. pp 77-79.
Depression Anxiety Stress Scale-21 (DASS-21).
Available at
http://www.scireproject.com/outcome-measures/depression-anxiety-stress-scale-21-dass-21.
Accessed July 17 t h
, 2010
Ziegler JB. Use of humour in medical
teaching. Med Teacher 1998;20:341-348.
Ziv A. Teaching and learning with
humor: Experiment and replication. J Exp Educ 1988;57:5-15.
Naftulin DH, Ware JE Jr., Donnelly
FA. The Doctor Fox lecture: a paradigm of educational seduction. J Med Educ 1973;48:630-635.
Ware JE Jr., Williams RG. The Dr.
Fox effect: a study of lecturer effectiveness and ratings of instruction.
J Med Educ 1975;50:149-156.
Abrami PC, Leventhal L, Donnelly
FA. Educational seduction. Rev Educ Res 1999;52:446-464.
Whitman N, Burgess PR. Teaching
basic science: Dr Fox in the physiology chicken coop.
Med Educ
1988;22:393-397.
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