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Keywords: Emotional intelligence, medical school, personality, previous academic performance, psychological health
Yusoff MS, Esa AR, Mat Pa MN, Mey SC, Aziz RA, Abdul Rahim AF. A longitudinal study of relationships between previous academic achievement, emotional intelligence and personality traits with psychological health of medical students during stressful periods. Educ Health 2013;26:39-47
Yusoff MS, Esa AR, Mat Pa MN, Mey SC, Aziz RA, Abdul Rahim AF. A longitudinal study of relationships between previous academic achievement, emotional intelligence and personality traits with psychological health of medical students during stressful periods. Educ Health [serial online] 2013 [cited 2022 Jan 18];26:39-47. Available from: https://www.educationforhealth.net/text.asp?2013/26/1/39/112800
Means of selecting applicants for medical school generally can be grouped as cognitive and non-cognitive. Cognitive methods look at applicants' previous academic performance, whereas non-cognitive methods look at intangible skills using measurement methods such as psychometric assessments and interviews. The selection process based on previous academic merit, the cumulative grade point average (GPA), seems to be a simple one where applicants with the highest marks or merit are selected to enter medical training. In reality, it is rather more complicated due to high marks or merits do not necessarily make a good doctor in the future. [1],[2] Most medical schools prefer to select their medical students based on the previous academic merit because it has been found to be a better predictor of medical student success in medical schools. [1],[3],[4]
Even so, one must remember that, the predictive values of previous academic achievement fades with progression through the course. [1] However, to our knowledge, no prior studies have reported the relationships of medical students' previous academic achievement on their psychological health during medical training. Thus, this study attempted to investigate possible relationships that might exist between medical students' previous academic achievement and their psychological health during stressful periods.
Emotional Intelligence is defined as the ability to perceive, express, understand, motivate, control and regulate emotion. [5],[6],[7],[8]
There is considerable evidence showing that emotional intelligence influences success in a variety of occupational settings. [9],[10] Although evidence varies widely in their quality, there are a number of well-done and convincing reports that demonstrate the favourable relationships between emotional intelligence and several important areas, which include social relationships, workplace performance, psychological wellbeing and physical health. [7] A recent systematic review revealed that high emotional intelligence was reported to positively contribute to doctor-patient relationships and interpersonal skills, empathy, teamwork and communication skills, stress management and organisational commitment abilities, and clinical and examination performance on specific areas such as clinical diagnostic and prognostic ability. [11] These facts suggest that, emotional intelligence plays significant roles in several areas related to the competencies of future medical doctors. Despite the encouraging outcomes, to the authors' knowledge, none of the articles reported on the relationships between pre-admission emotional intelligence and psychological health of medical students during medical training specifically during stressful periods. Therefore, this study attempted to investigate possible relationships that might exist between pre-admission emotional intelligence and psychological health of medical students during stressful periods of medical training.
Personality researchers have proposed five dimensions of personality, which are extroversion, conscientiousness, agreeableness, neuroticism and openness [12],[13],[14] The Big-Five factor structure has become a scientifically useful structure in personality traits research. [15] Extroversion refers to characteristics such as energetic, excitability, enjoying being with people, talkativeness, enthusiasm, assertiveness and high amount of emotional expressiveness. [16],[17],[18] Conscientiousness refers to features such as high levels of thoughtfulness, with good impulse control and goal-directed behaviour, being organised and mindful of details. [16],[17],[18] Agreeableness is commonly characterised by trustworthiness, helpfulness, kindness, sympathy, generosity and cooperativeness. [16],[17],[18]
Neuroticism is commonly linked with features such as emotional instability, distress, depression, anxiety, moodiness, irritability, poor coping ability and sadness. [16],[17],[18] Openness is reflected in individuals with qualities such as creativity, artistic, broad range of interest, imaginative, insightful and down-to-earth. [16],[17],[18] Many studies have shown that the personality traits predict individuals' performance in various non-medical occupation settings with regard to cognitive ability, mental health, job performance, wellbeing, career success and personal qualities. [19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30] Likewise, in the medical context, the personality traits associate with several important areas, which include approach to work, mental health, career success, learning approach and academic performance of medical students and professionals. [21],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40] Likewise, there is some initial evidence to support association of the personality traits with career choices in medicine, [41] particularly conscientiousness trait, which is found to be the strongest predictor of job performance and trainability. [42],[43]
In summary, a range of evidence has consistently supported the favourable relationships between previous academic performance, emotional intelligence and personality with various areas of individual performance, which include job performance, mental health, academic success, career success, positive personal qualities and wellbeing either in the medical context or outside the medical context. Nevertheless, very limited data are reported on Asian context particularly in Malaysian medical schools. Therefore, this study might enrich the body of literatures in this area.
This study was designed to answer four research questions: (1) what kind of relationship exists between medical students' previous academic achievement and their psychological health during stressful periods of medical training? (2) What kind of relationship exists between medical students' pre-admission emotional intelligence and their psychological health during stressful periods of medical training? (3) What kind of relationship exists between medical students' pre-admission personality traits and their psychological health during stressful periods of medical training? (4) What factors are associated with medical students' psychological health during stressful periods of medical training? Based on the literature, the author's hypothesised that pre-admission emotional intelligence and personality traits would demonstrate significant relationships with psychological health of medical students during stressful periods, whereas, previous academic achievement would not demonstrate any significant relationships.
Study setting and sample
In 2009, the School of Medical Sciences Universiti Sains Malaysia was granted permission from the Malaysia Ministry of Higher Education (MOHE) to select medical students semi-independently. The selection process involved three stages, which were the primary pool (i.e. all interest applicants were filtered based on their GPA), the secondary pool (i.e. qualified applicants of the primary were called to attend a psychometric test, which is known as the Malaysian University Selection Yearly Inventory (MUnSYI) and the tertiary pool (i.e. about 600 suitable applicants were invited for interviews). [44] The primary and secondary pools were conducted by MOHE, and the tertiary pool was conducted by the medical school. All applicants who were called for interviews were invited to participate in this study. These applicants were principally from the Science Foundation Course of Malaysian Ministry of Education (which is known as the Matriculation stream), the High School Certificate of Malaysia (which is known the HSC stream) and the Advanced Level General Certificate of Education (which is known as the A-Level stream). Their ages ranged from 18 to 21 years.
The medical school provides an integrated, problem-based and community-oriented medical curriculum. This 5-year programme is divided into three phases. Phase I (year 1) is the fundamental year focusing on organ-based systems. Phase II (years 2 and 3) is a transitional phase to clinical years that continues the system-based approach and introduces the basics of clinical clerkship. Phase III (years 4 and 5) is the clinical phase whereby the students are rotated through all the clinical disciplines. The first year medical students take three end-of-course examinations and one final examination before they can progress to the second year of study. The final examination contributes 70% to students' total mark and the three end-of-course examinations each contribute 10%. Students must earn a total examination score of at least 50% to be allowed to progress to the second year. Otherwise, they must repeat phase I. The final examination is more stressful period (time 2) compared with the end-of-course examinations (time 1) as perceived by medical students. [45],[46]
One year prospective study was conducted on the successful applicants to the medical school. Data collection was completed within one year from May 2009 until May 2010. Ethical approval was obtained from the Human Ethical Committee of Universiti Sains Malaysia prior to commencement of research.
Data collection was done through guided self-administered questionnaire. Verbal and signed consents were obtained from the study subjects. Each participant was given an ID for tracing and profiling purposes. Instructions and information about the study were given to them. They were clearly informed that the results of this study will not have any influence on their interview scores or selection decision to enter medical course.
The Universiti Sains Malaysia Emotional Quotient Inventory (USMEQ-i) and Universiti Sains Malaysia Personality Inventory (USMaP-i) were distributed to all applicants of the medical course during a face to face session after they completed their interview sessions. The students were told to follow the instructions given in the inventories. Questionnaires required about 20 minutes for completion and were returned immediately. Students' GPAs for work prior to matriculation were obtained from the academic office of their school and used as parameter of their previous academic performance prior to admission.
Successful applicants were followed and their stress, anxiety and depression levels were measured using the Depression Anxiety Stress Scale 21-item (DASS-21) during one of the end-of-course examinations (i.e. the third end-of-course examination) (time 1) and the final examination (time 2) of the first year medical training, which are perceived as the stressful periods by the medical students. [45],[46]
Demographic profile pertaining to sex, race, entry qualification (i.e. the Matriculation, HSC or A-Level stream), parents' income and status of residence (rural or urban) were obtained from the study subjects via a form while GPA was obtained from the academic office.
The USMEQ-i measures emotional intelligence of the subjects. There are seven domains of emotional intelligence being assessed, which are emotional control (Cronbach's alpha = 0.89), emotional maturity (alpha = 0.82), emotional conscientiousness (alpha = 0.83), emotional awareness (alpha = 0.79), emotional commitment (alpha = 0.77), emotional fortitude (alpha = 0.66) and emotional expression (alpha = 0.60). [44],[47],[48] The USMEQ-i was found to be valid and reliable among students. [44],[47],[48] The Cronbach's alpha value for each domain ranged from 0.60 to 0.89. [44],[47],[48] These parameter estimates were obtained from a prior study conducted with 469 medical school applicants. [48]
The USMaP-i measures personality traits of the study subjects. It has five dimensions based on the Big-Five personality model, which were extroversion (alpha = 0.80), conscientiousness (alpha = 0.83), agreeableness (alpha = 0.63), neuroticism (alpha = 0.81) and openness (alpha = 0.70) (17). Its validity and reliability among students was established. [18],[46],[49] The alpha value for each dimension ranged from 0.63 to 0.83. [18],[46],[49] These parameter estimates were obtained from a study conducted with 462 medical school applicants. [49]
The DASS-21 measures depression, anxiety and stress levels of the study subjects. [50],[51],[52],[53] Its validity and reliability among student samples are well established. [53] The reliability coefficient of depression, anxiety and stress scales range from 0.81 to 0.97, and the three subscales showed discriminative ability to differentiate between psychiatric patient and non-psychiatric patients. [53] A high score indicates a high level of stress, anxiety and depression. [53] The DASS-21 was used in this study because it requires little time to administer, a well validated and reliable instrument. Furthermore, studies showed it is superior and more consistent compared with the full-scale version. [53]
Data were analysed by the Predictive Analytical Software (PASW) version 18. The Pearson correlation test was applied to measure correlation between GPA, personality and emotional intelligence with stress, anxiety and depression levels. In general, a correlation coefficient lesser than or equal to 0.20 was considered as weak correlation, more than 0.2 but less than 0.8 was considered a moderate correlation and 0.8 or more was considered as strong correlation. [54] Multiple linear regression test (stepwise method) was applied to determine the predictive values of GPA, emotional intelligence and personality traits on the psychological parameters during the stressful periods. The un-standardised Beta coefficient (B) was used to measure increment of the psychological health parameters as a result of one unit increase in the score of GPA, emotional intelligence and personality. [54],[55] The standardised Beta coefficient (β) was used to compare dominant roles of the factor variables that associate with the psychological health parameters. [55]
A total of 196 applicants successfully gained admission into the medical school. [Table 1] shows characteristics of the successful applicants in gender, entry qualification, ethnicity, residence, parent income and previous academic achievement (i.e. GPA).
Table 1: Profile of the successful applicants
The descriptive analysis of the key study's indicator and outcome variables are summarised in [Table 2].
Table 2: Descriptive analysis on the study's key indicators and outcomes by related groups
The most dominant personality trait was conscientiousness and the least dominant was neuroticism [Table 2]. Likewise, emotional expression was the most dominant emotional intelligence and the least was emotional control. The analysis showed that the participants were relatively more stressed, anxious and depressed during the final examination than during the third end-of-course examination.
The Pearson correlation analysis [Table 3] showed that extraversion and agreeableness negatively correlated with stress levels during the third continuous examination (Time 1) while neuroticism positively correlated; however, the correlations were weak. Extraversion had a weak negative correlation with depression score while neuroticism had a moderate positive correlation with depression score. The personality traits had no significant correlations with anxiety level during the Time 1.
Table 3: Correlations of personality traits with stress, anxiety and depression levels
At the Time 2, extraversion, conscientiousness and agreeableness had weak negative correlations with stress score while neuroticism had a moderate positive correlation [Table 3]. Extraversion had weak negative correlation with anxiety score while neuroticism had moderate positive correlation with the anxiety score. Extraversion had moderate correlation with depression score while agreeableness had weak negative correlation with the depression score. Neuroticism had moderate positive correlation with the depression score. Overall, neuroticism had the strongest correlation compared with the rest of the personality traits.
Emotional fortitude had weak negative correlation with the stress score at Time 1 while the other components of emotional quotient failed to reach significant correlation [Table 4]. Emotional control correlated weakly and negatively with the depression score at Time 1 while other components failed to reach significant correlation.
Table 4: Correlations of emotional quotient with stress, anxiety and depression levels
At the most stressful period (Time 2), emotional control and emotional fortitude had moderate and weak negative correlation with stress score, respectively [Table 4]. Emotional control had moderate negative correlations with anxiety and depression scores. Emotional maturity negatively and weakly correlated with depression score. Overall, emotional control had the strongest correlation compared with the rest components of emotional intelligence.
The final semester GPA weakly and negatively correlated with depression score at Time 1 [Table 5]. Similarly, it also weakly correlated with stress and depression scores at Time 2. The first semester GPA failed to reach any significant correlation with the psychological health parameters.
Table 5: Correlations of GPAs with stress, anxiety and depression levels
At Time 1, the analysis [Table 6] showed that stress scores were negatively associated with agreeableness and the final semester GPA. The anxiety scores were negatively associated with emotional control and positively associated with emotional conscientiousness. The depression scores were negatively associated with the GPA (final semester) and extraversion.
Table 6: Multiple Linear regression of emotional quotient, personality and GPA with stress, anxiety and depression levels
At Time 2, the analysis [Table 6] showed that stress scores were positively associated with neuroticism. Anxiety scores were positively associated with neuroticism and emotional expression. Depression scores were positively associated with neuroticism.
The analysis demonstrated that during less stressful period, GPA, emotional intelligence and personality traits were associated factors of the psychological health [Table 6]. However, during the most stressful period, neuroticism was the strongest associated factor of the psychological health parameters followed by emotional expression. Apart from that, during the most stressful period, GPA failed to demonstrate any relationships with the psychological health parameters.
In general we found that the five measured personality traits had significant correlations with the stress, anxiety and depression symptoms during stressful periods. Neuroticism demonstrated the strongest positive correlation with all the psychological health parameters indicating that those students who possess high neuroticism traits are more likely to develop psychological distress than those who pose low neuroticism traits. On further analysis, neuroticism was the strongest predictor for stress, anxiety and depression symptoms during the most stressful periods, which was the final examination. These findings correspond with findings of previous studies that reported the personality traits positively associated with psychological distress, especially neuroticism trait that showed the strongest positive relationship with various psychological disorder. [19],[23],[26],[31],[56],[57] One possible reason for this is that the general tendency of neurotic individuals to experience negative feelings and their generally poor stress-coping ability that made them more vulnerable to psychological problems. [20],[31],[42]
There were several lessons learned from these findings. First, medical schools should give extra attention to medical students who possess high level of neuroticism because they might need psychological support to adjust with the demanding environment of medical training. Second, introducing a stress management intervention early in medical training might help students who are susceptible to negative emotion to adjust and cope effectively with the stressful environment. Last, providing continuous support through mentoring to medical students' who possess high level of neurotic traits might help prevent psychological distress. Perhaps individuals with high levels of neuroticism are less suitable for jobs that require high psychological endurance, which are stress-inducing. [26],[57] Arguably, this particular trait should therefore be considered as a criterion to be screened for during the student admission process.
Our data found that specific aspects of emotional intelligence, which include emotional control, emotional maturity and emotional fortitude, positively correlated with psychological health. Although the result showed weak to moderate correlations, it could be said that a substantial association might exist between emotional intelligence and psychological health of medical students during stressful periods of medical training. This postulation is in line with the literature-reported individuals with high level of emotional intelligence associated with better psychological wellbeing. [7],[11],[31] One logical explanation is that if an individual is able to control their emotion, to avoid excessive reaction towards negative emotion and to endure the demanding environment, they would be less likely to develop psychological distress. One lesson learned is that medical schools should be aware of medical students who have low level of emotional intelligence because they might face problems to deal with the challenging medical training environment. Thus, they might require emotional support from the medical schools as early as possible. Nevertheless, it is interesting to follow up this cohort of students to explore on possible relationships that might exist between pre-admission emotional intelligence score and their psychological health during the clinical years of medical training.
Another interesting and unexpected finding is that the final semester GPA demonstrated a significant negative relationship with stress and depression scores during stressful period (i.e. Time 1). Although the results showed weak relationship between GPA and psychological health, it suggested that a substantial association might exist between previous academic performance and psychological health of medical students during stressful period. This is in line with a recent finding reported that previous academic performance prior to medical school admission associated with anxiety and depression symptoms of prospective medical students. [58] One important lesson is that, medical schools should provide more attention to medical students who had poor previous academic achievement might have problems to cope with the stressful environment of medical training. Therefore, these students might need psychological support from the medical school from the beginning of medical training. Nevertheless, follow up research should be conducted on this student cohort to look at the possible relationships that might exist between previous academic performance and their psychological health during the clinical years.
Despite these encouraging findings, this study has several limitations. First, this study involved a relatively small number of study subjects that might compromise the accuracy of the results obtained from the analysis. Second, this study was confined to a cohort of medical students of one medical school and in one country, limiting the generalisability of its results. Third, the sampling method was non-probability, which might lead to sampling bias that may compromise the results obtained. Fourth, several measurement constructs had Cronbach's alpha less than 0.7 that indicate a relatively low level of reliability. Last, psychological health measurement was collected through the face-to-face method, which was not fully anonymous and may lead to response bias. Despite these limitations, this study has several strengths. First, a prospective study design was used, which was able to explore the relationship between pre-admission measurement and future psychological health of medical students. Second, the DASS-21 is a valid, reliable and well established psychological health measurement tool to measure stress, anxiety and depression. Thus, comparison can be made with previous studies. Last, the tools used to measure emotional intelligence and personality was validated among medical school applicants. [48],[49] Considering the limitations and strengths, this study should be interpreted with caution and within its context.
This study found that neuroticism was the strongest associated factor of psychological health of medical students during the most stressful period. The personality traits, emotional intelligence and previous academic performance were associated factors of psychological health during a less stressful period. Early identification of medical students who are vulnerable to stressful environment by medical schools might help them to improve their psychological wellbeing during medical training. Nevertheless the results should be interpreted cautiously within its limitations.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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Anne-Sophie Baudry,Delphine Grynberg,Charlotte Dassonneville,Sophie Lelorain,Véronique Christophe
Scandinavian Journal of Psychology. 2018;
11 The influence of emotional intelligence, cognitive test anxiety, and coping strategies on undergraduate academic performance
Christopher L. Thomas,Jerrell C. Cassady,Monica L. Heller
Learning and Individual Differences. 2017; 55: 40
12 Prevalence of psychological stress, depression and anxiety among medical students in Egypt
Mohamed Fawzy,Sherifa A. Hamed
Psychiatry Research. 2017; 255: 186
13 Personality and achievement along medical training: Evidence from a cross-lagged analysis
Isabel Lourinho,Maria Amélia Ferreira,Milton Severo,Cesario Bianchi
PLOS ONE. 2017; 12(10): e0185860
14 Study of the Stress Level and Coping-Strategies in Normative Age Crisis
N.A. Chipeeva
Bulletin of the South Ural State University series "Psychology". 2017; 10(2): 70
15 Do medical students have a positive outlook on the world?
Patrycja Chylinska-Wrzos,Marta Lis-Sochocka,Ewelina Wawryk-Gawda,Kamila Bulak,Barbara Jodlowska-Jedrych
Polish Journal of Public Health. 2016; 126(3)
16 The Relationship between Positive Well-Being and Academic Assessment: Results from a Prospective Study on Dental Students
Cristina Teodora Preoteasa,Anca Axante,Anca Diana Cristea,Elena Preoteasa
Education Research International. 2016; 2016: 1
17 The interplay between academic performance and quality of life among preclinical students
Mohammad Abrar Shareef,Abdulhadi A. AlAmodi,Abdulrahman A. Al-Khateeb,Zainab Abudan,Mohammed A. Alkhani,Sanderlla I. Zebian,Ahmed S. Qannita,Mariam J. Tabrizi
18 Association of academic performance of premedical students to satisfaction and engagement in a short training program: a cross sectional study presenting gender differences
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20 Nature of Stress among Health Science Students in a Malaysian University
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text:
// Copyright (c) Multi-Emu.
// Licensed under the MIT license. See LICENSE file in the project root for full license information.

using System;
using System.Collections.Concurrent;
using System.Reflection;
using StsServer.Attributes;
using StsServer.Constants.Net;
using StsServer.Network.Packets.Headers;

namespace StsServer.Network.Packets
{
    class StsPacketManager
    {
        static readonly ConcurrentDictionary<StsMessage, HandleAuthPacket> AuthMessageHandlers = new ConcurrentDictionary<StsMessage, HandleAuthPacket>();
        delegate void HandleAuthPacket(StsPacket packet, StsSession client);

        public static void DefineMessageHandler()
        {
            var currentAsm = Assembly.GetExecutingAssembly();

            foreach (var type in currentAsm.GetTypes())
                foreach (var methodInfo in type.GetMethods())
                    foreach (var msgAttr in methodInfo.GetCustomAttributes<StsMessageAttribute>())
                        AuthMessageHandlers.TryAdd(msgAttr.Message, Delegate.CreateDelegate(typeof(HandleAuthPacket), methodInfo) as HandleAuthPacket);
        }

        public static bool Invoke(StsPacket reader, StsSession session)
        {
            var message = ((StsHeader)reader.Header).Message;

            Console.WriteLine($"Received Auth packet: {message} (0x{message:X}), Length: {reader.Data.Length}");

            HandleAuthPacket packet;

            if (AuthMessageHandlers.TryGetValue(message, out packet))
            {
                packet.Invoke(reader, session);

                return true;
            }

            return false;
        }
    }
}

redpajama_set_name: RedPajamaGithub


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