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The Association Between Doctor-Patient Conflict and Uncertainty Stress During Clinical Internship Among Medical Students: A Panel Study

A peer-reviewed version of this preprint was published in:
Healthcare 2025, 13(9), 1080. https://doi.org/10.3390/healthcare13091080

Submitted:

27 March 2025

Posted:

01 April 2025

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Abstract
Background/Objectives: Medical students experience significant mental stress during clinical internships. This study aimed to assess the levels of uncertainty stress among medical interns, evaluate its temporal changes and associations with doctor - patient conflict and views of relevant reference populations, and provide insights for stress - alleviating policies and educational initiatives. Methods: A prospective longitudinal panel study was conducted. 131 medical students preparing for clinical internships were recruited via WeChat social media groups from June 2023 to June 2024. Data were collected at three time points: before internship, three months into the internship, and after the internship using an online survey on Wenjuanxing. Variables such as uncertainty stress, doctor - patient conflict, and reference population opinions were measured, and data were analyzed using repeated measures ANOVA and the GIM program. Results: A total of 122 students completed all three waves of the study. Uncertainty stress decreased over the internship period (β = 4.14, p < 0.05), while doctor - patient conflict increased (β = 76.26, p < 0.05). Uncertainty stress was positively associated with doctor - patient conflict from teachers and the reference population from teachers, and negatively associated with doctor - patient conflict. Conclusions: Although uncertainty stress reduces as internships progress, doctor - patient conflict rises. A supportive learning environment, especially from teachers, is crucial for mitigating stress. Medical schools and hospitals should implement comprehensive strategies to address individual stressors and institutional factors, considering the associations between uncertainty stress, doctor - patient conflict, and reference populations. However, the study has limitations such as a small sample size and reliance on self - reported measures, indicating a need for further research.
Keywords: 
medical students
;  
clinical internship
;  
uncertainty stress
;  
doctor - patient conflict
;  
reference population
;  
longitudinal study
Subject: 
Social Sciences  -   Psychiatry and Mental Health

1. Introduction

Mental stress refers to the strain or threat posed by various adverse events or circumstances from daily life and workplace, which manifest as both physical and mental tension and discomfort [1,2].Research indicates that severe mental stress can lead to a wide range of social and health problems, particularly psychological disorders and behavioral issues [3,4]. In China, the medical education system typically consists of a five-year undergraduate program, followed by potential postgraduate training. During the undergraduate program, students spend the initial years (generally the first three) focusing on theoretical knowledge, basic medical sciences, and preclinical courses. The clinical internship, a critical phase of practical training, generally begins in the fourth or fifth year of the program, depending on the institution [3]. Clinical internship, an essential component of medical education, plays a vital role in cultivating students' clinical capabilities and professional ethics [5]. This is of great significance for training qualified doctors. Typically, clinical internship is arranged in the final year or two of undergraduate education.
Medical students represent a particularly high-pressure group, facing demanding coursework, heavy academic burdens, and concerns about an uncertain future job opportunity [6]. A number of studies have highlighted that medical students experience significant mental stress, which necessitates further attention and intervention [6].
The stress is particularly prevalent during the clinical internship period for medical students [7]. After completing four-year theoretical study, medical student face a one-year internship, transitioning from a familiar campus environment to the complex, high-pressure atmosphere of a hospital [8]. This shift involves involves significant personal and professional changes , including navigating the intricate dynamics of the doctor-patient relationship, preparing for postgraduate exams, and addressing concerns of career decision and employment competition [9].
The clinical internship is a pivotal period for medical students, during which they frequently encounter substantial mental stress [6]. This stress can evoke intense emotional responses. Based on Festinger's cognitive dissonance theory, uncertainty has the potential to induce cognitive chaos [10]. When individuals are confronted with uncertainty, they may experience confusion in their cognitive processes, which often prompts them to adopt avoidance behaviors [11,12]. These avoidance behaviors, in turn, exacerbate the stress levels. Uncertainty - related stress is notoriously challenging to manage and can have significant negative implications [13].
During their internships, medical students are faced with a multitude of challenges [14]. They are thrust into an unfamiliar hospital environment, tasked with new job responsibilities, and burdened by concerns about their future employment [15]. Among these challenges, navigating the intricate doctor - patient relationships is particularly daunting as they have little to no prior experience in such situations [16,17]. All these factors contribute to the development of high levels of uncertainty stress.
This research is centered around the problem of uncertainty stress among clinical interns. Its objectives are three - fold: to measure the degree of uncertainty stress that medical students experience during their clinical internships; to monitor the temporal variations in uncertainty stress, doctor - patient conflicts, and the opinions of relevant reference groups throughout the internship; and to explore the correlations between uncertainty stress, doctor - patient conflicts, and the views of relevant reference groups. The findings of this study are expected to offer valuable insights for the formulation of policies and educational initiatives aimed at alleviating the mental stress of medical students, thereby facilitating their well - being and professional development.

2. Materials and Methods

Study Design

A prospective longitudinal panel study was designed to explore the temporal trends of uncertainty stress, doctor - patient conflict, and the views of relevant reference populations during clinical internships.
Participants were sourced through advertisements disseminated in social media groups on WeChat, a prevalent platform in China. The inclusion criteria were as follows: being medical students about to commence their clinical internships, having access to a smartphone, being proficient in Chinese, and demonstrating a willingness to engage in the study and provide follow - up information. The exclusion criteria encompassed refusal to provide essential data or having any medical conditions that might restrict participation. After providing consent, participants would receive an online questionnaire with instructions, participants shouldconfirm the “Confirmation and Authorization” before proceeding to the survey. A dedicated WeChat group was created to manage the follow-up data collection, with each participant receiving a unique QR code to prevent unauthorized responses and ensure traceability.
Data were collected over three phases: Phase 1 (before the clinical internship), Phase 2 (after three months into the clinical internship), and Phase 3 (after the internship). The data collection period spanned from June 2023 to June 2024.

Data Collection

The survey was conducted with online tool called Wenjuanxing (www.wjx.cn), a popular Chinese survey platform similar to Qualtrics or SurveyMonkey. A unique link was provided for each phase of the study, and participants accessed the survey through the WeChat group. All responses were anonymous, and the survey took approximately 10 minutes to complete. The same protocol was followed across all phases to ensure consistency in data collection.

Measurement

Demographic variables such as age, year, gender, ethnicity, residence, and parental education levels were recorded. Doctor-patient conflict was assessed as the primary explanatory variable, using questions”Have you experienced any unpleasant incidents between doctors and patients in the department during your study/internship?”.The key variable of this study composition is based on the Risk Belief and Subjective Norm Theory. The reference norm reflects students' perceptions of the opinions held by individuals with whom they share close relationships, including family members, relatives, friends, classmates, and teachers, specifically regarding doctors. Responses were measured using a 5-point Likert scale ranging from 'very good' to 'very poor.'
Uncertainty stress was measured using a modified version of a scale developed by Yang et al [18]. This scale has shown good validity and reliability, with a Cronbach’s alpha of 0.89 [19]. It consisted of four items:
  • Life Uncertainty: "Life is unstable and beyond control."
  • Social Change Uncertainty: "Uncertain about what will happen in the future."
  • Goal Uncertainty: "Uncertain about how to achieve my goals."
  • Social Values Uncertainty: "Unable to follow social values."
Respondents rated each item on a 5-point scale, ranging from "no stress" (0) to "very strong stress" (4). The total score was calculated by summing individual responses, with higher scores indicating higher perceived stress [10].

Data Analysis

Data were recorded into Microsoft Excel and imported into SPSS (version 25.0) for statistical analysis. Re-peated measures ANOVA was used to evaluate the temporal trends in uncertainty stress and related vari-ables,Post-hoc tests were conducted to examine differences between time points, utilizing Tukey-corrected pairwise tests. The Generalized Linear Mixed Model (GLMM) was used to examine associations between uncertainty stress and related variables.

3. Results

A total of 131 participants were recruited at baseline, with 122 (93%) completing all three waves of the study. Among all participants, 52.5% of them were females. Besides, mostof participants were Han Chinese,at 99.2%. In terms of residence, 37.7% of participants come from rural areas, the percentage ofparticipants come from urban areas, counties and townshipwere lower, at 27.9%, 19.7% and 14.8%. Regarding parental education, there were 14.8% of participants' fathers and 9.8%participants' mothers had a bachelor degree or higher education (Table 1).
The results indicate significant changes in uncertainty stress over the course of the study (β = 4.14, p < 0.05). Doctor-patient conflict increased over time, with higher exposure leading to more frequent confrontations (β = 76.26, p < 0.05). Similarly, there was an increase in the Reference population from teacher (Table 2).
Table 3 shows that uncertainty stress was positively associated with doctor-patient conflict (β =1.068, SE = 0.525, p < 0.05) and the Reference population from teachers(β =0.856, SE = 0.373, p < 0.05).

4. Discussion

This study fills a gap in the existing literature by examining how uncertainty stress evolves over time among clinical interns. Previous research has not fully explored the temporal changes in this specific stressor. The findings highlight a significant reduction in uncertainty stress as the internship progresses. The average stress score decreased from 9.91 at the start of the internship to 8.97 at the final observation point with the highest recorded score at baseline.
Medical students typically undergo a one-year clinical internship after completing four years of theoretical coursework. This transition marks a significant shift from the familiar and controlled campus environment to the unpredictable and complex hospital setting. Along with adjusting to new clinical duties, students also face various external pressures, such as navigating complex doctor-patient relationships, preparing for postgraduate entrance exams, making career decisions, and dealing with employment concerns [20]. As a result, the internship period is often marked by high levels of psychological stress and intense emotional experiences [21]. Over the course of the internship, as medical students gradually become more acquainted with the clinical environment, the stress associated with uncertainty shows a tendency to decline. This decrease in stress indicates that interns develop greater adaptability and resilience as they accumulate more experience. At the beginning, the stress brought about by an unfamiliar environment and complex responsibilities can be extremely burdensome [22]. However, as students become more self - assured in their abilities and devise effective coping mechanisms, they are better equipped to handle uncertain situations [23]. Their growing familiarity with the hospital environment, job duties, and the nuances of doctor - patient interactions enables them to build up resilience, which eventually results in a reduction of uncertainty - related stress during the entire internship [24].
Previous research has emphasized a significant link between doctor - patient conflict and uncertainty stress [25]. The Stimulus, Cognition, and Response (SCR) theory posits that environmental stimuli, regardless of whether an individual experiences them directly or not, can trigger both physiological and psychological reactions by affecting their cognitive system [26]. As interns progress in their clinical work, they become more acutely aware of the pressure related to uncertainty, and this leads to a better understanding of its complex nature [27]. The findings of this study emphasize the importance of behavioral interventions grounded in perceived beliefs. These interventions are designed to offer individuals opportunities to recognize and confront the challenges they encounter. By addressing the underlying cognitive structures, these interventions can promote behavioral change [28].
Moreover, research has shown that experiences of doctor-patient conflict and the attitudes of supervising physicians are strongly associated with mental stress. From a normative perspective, individuals who have significant relationships with medical students, such as mentors and senior physicians, play a critical role in shaping their stress levels [29]. This dynamic is reflected in the concept of the "neighborhood effect" in behavioral studies, where social interactions and environmental factors influence individual behavior. Consequently, when it comes to stress - reduction interventions, it is essential to not merely concentrate on individual interns. Instead, strategies at the group level should be integrated [30]. This might involve fostering positive peer influence and leveraging “opinion leaders” to advocate for positive behavioral shifts [31].
The outcomes of this research offer valuable perspectives on the trends of uncertainty stress and its relationship with risk beliefs and subjective norms among clinical interns. These insights present educational and administrative departments with a novel vantage point, enabling them to gain a better understanding of the uncertainty stress that medical students undergo and manage it more effectively. The study results indicated a decline in uncertainty stress during the observation period. However, it is noteworthy that negative perceptions from the teachers increased during the study period, suggesting an escalation in industry-related stressors during the clinical internship. Previous research has shown that excessive uncertainty stress can negatively impact work efficiency, increase the possibilityof errors, accidents, as well asadverse health outcomes [32]. This underscores the importance for educational management departments to monitor uncertainty stress and tailored eucational interventions timelyto help medical students manage excessive pressure.
Furthermore, our study found that perceived beliefs and social norms are closely linked to the uncertainty stress of medical students. Stress is an inevitable aspect of modern life, but minimizing its harmful effects is crucial. One effective strategy is to control the sources of stress. Medical students are inherently part of a high-stress cohort, and it is essential for management departments to regulate assessment criteria and stress levels within manageable bounds. Additionally, the study revealed that the influence of reference norms contributes to uncertainty stress among medical interns. This social issue, characterized by negative perceptions of doctors within the medical community, further exacerbates stress. Medical schools and hospitals must place a strong emphasize on medical ethics and professional conduct. Simultaneously, efforts should be made to combat societal misconceptions about the medical profession by promoting a positive public image of doctors.

Limitations and Future Directions

While this study provides valuable insights into the relationship between uncertainty stress and doctor-patient conflict, there are several limitations. Firstly, the sample size is relatively small, therefore the results may not be fully generalizable. Future studies should include larger, more diverse samples to enhance the robustness of the findings. Secondly, the study only used self-reported measures of uncertainty stress, doctor-patient conflict, and Reference population which may be subject to response biases. Future research should consider including objective measures of stress and conflict, such as physiological indicators or observational data. Thirdly, the study relied on single-item scales to measure some variables, which may not fully capture the complexity of the constructs. Future studies should usemulti-item scales to assess these variables more comprehensively. Finally, the study’s longitudinal design allows for the examination of temporal trends, further research might benefit from incorporating more frequent data collection points to capture more nuanced changes over time. Additionally, investigating the long-term effects of uncertainty stress beyond the internship period would provide a more comprehensive understanding of how these experiences influence medical students' mental health and professional development.

5. Conclusions

This study contributes to the growing body of research on uncertainty stress and its effects on medical students during clinical internships. The findings suggest that while uncertainty stress decreases over time, doctor-patient conflict increase as students progress through their internships. The associations between uncertainty stress and reference population from teachers underscore the importance of a supportive learning environment in mitigating stress. To address address both individual stressors and institutional factors, and to improve medical students' well-being and professional development during the intershipos, medical schools and hospitals must implement comprehensive strategies to support them.The results of this study have significant implications for medical education, offering insights into the psychological pressures faced by medical students and providing a basis for interventions aimed at reducing uncertainty stress and fostering better clinical training environments

Author Contributions

Conceptualization, H.W. and T.Y.; methodology, H.W.; software, H.W.; validation, H.W., X.Y. and L.Z.; formal analysis, H.W.; investigation, H.W.; resources, W.Z.; data curation, H.W.; writing—original draft preparation, H.W.; writing—review and editing, X.Y., L.Z., T.Y. and W.Z.; visualization, H.W.; supervision, W.Z.; project administration, H.W.; funding acquisition, W.Z. All authors have read and agreed to the published version of the manuscript.

Funding

This work was supported by the Key R&D Program of Zhejiang (grant no. 2023C03072) and Research and Development Program of the Stomatology, Hospital of Zhejiang University School of Medicine (RD2022RKZD01).

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of Zhejiang University School of Medicine (approval Code No. 056, Research Ethics Review of Zhejiang University School of Stomatology in 2022, approval date: April 17th, 2022).

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request. Due to privacy concerns regarding the medical students' personal information and responses, the data are not publicly available. However, researchers interested in further analyzing the data can contact the corresponding author to discuss access and data - sharing arrangements in line with ethical and privacy considerations.

Conflicts of Interest

The authors declare no conflicts of interest.

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Table 1. Demographic Characteristics of Participants.
Table 1. Demographic Characteristics of Participants.
Group N percentage
Gender
Male 58 47.5
Female 64 52.5
Ethnicity
Han 121 99.2
Minority 1 0.8
Residence
Rural 46 37.7
Township 18 14.8
County 24 19.7
Urban 34 27.9
Year
Grade Four 63 51.6
Grade Five 59 48.4
Grades
Upper third 36 29.5
Middle third 51 41.8
Lower third 35 28.7
Father'seducational level
Elementary school and below 11 9.0
Junior high school 41 33.6
High school 29 23.8
College diploma 23 18.9
Bachelor's degree or above 18 14.8
Mother's educational level
Elementary school and below 15 12.3
Junior high school 46 37.7
High school 28 23.0
College diploma 21 17.2
Bachelor's degree or above 12 9.8
Table 2. Time Change Trend in Uncertainty Stress, doctor-patient conflict, and Reference norm (Mean, SD).
Table 2. Time Change Trend in Uncertainty Stress, doctor-patient conflict, and Reference norm (Mean, SD).
Group N Uncertainty stress doctor-patient conflict Reference population from family or relatives Reference population from friends Reference population from classmate Reference population from teacher
Time1 122 9.91 (3.54) a 65 (53.3%) 57 (46.7%) 1.78 (0.74) 1.80 (0.70) 1.89 (0.74) 1.81 (0.72) a
Time2 122 9.80 (3.80) 68 (55.7%) 53 (43.3%) 1.88 (0.66) 1.90 (0.67) 2.02 (0.74) 1.99 (0.72) a
Time3 122 8.97 (3.30) b 120 (98.4%) 2 (1.6%) 1.73 (0.68) 1.80 (0.70) 1.93 (0.79) 2.01 (0.77) b
Mean(SD) 9.56 (3.56) 254 (69.6) 111 (30.4) 1.80 (0.70) 1.83 (0.69) 1.95 (0.76) 1.94 (0.74)
β( p) 4.14 (0.017) 76.26 (0.00) 2.25 (0.10) 1.45 (0.24) 1.53 (0.22) 3.70 (0.02)
Note: Data in the same column with the same superscript letter indicate that there is no significant difference (P > 0.05), while data with different superscript letters indicate a significant difference (P < 0.05)).
Table 3. Association Between Doctor-Patient Conflict and Uncertainty Stress.
Table 3. Association Between Doctor-Patient Conflict and Uncertainty Stress.
β SE t p
uncertainty Stress->doctor-patient conflict 1.068 0.525 2.036 0.042*
uncertainty Stress->Reference population from family or relative 0.503 0.463 1.086 0.278
uncertainty Stress->Reference population from friends -0.888 0.520 -1.078 0.088
uncertainty Stress->Reference population from classmates 0.229 0.408 0.561 0.575
uncertainty Stress->Reference population from teachers 0.856 0.373 2.295 0.022*
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Copyright: This open access article is published under a Creative Commons CC BY 4.0 license, which permit the free download, distribution, and reuse, provided that the author and preprint are cited in any reuse.
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