Abstract Title
Communication-related anxiety in UK undergraduate medical students


A Laidlaw
J Hunter
G Ozakinci


2JJ Communication


University of St Andrews - Medical School


Communication training and assessments can provoke anxiety in medical undergraduates, including when working with simulated patients, or with video feedback[1-3]. A quarter of students experiencing academic difficulties express problems approaching patients[4]. Our recent work showed that medical students were reticent to take part in workshops focussed on providing coping skills for communication-related anxiety due to stigma associated with admitting to experiencing anxiety[5].
There is evidence that medical students often replace positive coping strategies, like seeking professional help, with less useful long-term strategies like increased alcohol consumption[6]. Despite experiencing high levels of mental wellbeing issues, doctors are also less likely to seek help in comparison to other working populations[7].  Reducing the stigma associated with mental well-being issues, including communication-related anxiety, in the early stages of a student’s training may have important long-term effects for help-seeking after qualification. However, if we are to do this we need a greater understanding of the current experiences and views of students towards communication-related anxiety and admitting to mental wellbeing issues to others, such as peers and staff. The aim of this study was to identify factors influencing medical undergraduate experiences of communication-related anxiety and their support seeking behaviour for such difficulties.

Summary of Work

An online questionnaire was circulated to medical students across participating UK Medical Schools (n = 15) which included scales measuring social interaction anxiety[8], perceived stress [9],  attitudes towards communication training[10], support seeking behaviour and alcohol use [11]. Participants were recruited by e-mail or VLE announcements and used the link provided within the advert to access the information and consent form. Once the consent form was completed, participants could access the survey. This study was approved by the University of St Andrews Teaching and Research Ethics Committee and ratified by individual Medical School ethics boards where appropriate. 

Summary of Results


Table 1: Demographic characteristics of consenting participants

A total of 486 participants completed the questionnaire, from 15 UK Medical Schools, demographic information of this sample is shown in table 1.















Impact of gender on experience of anxiety


Figure 1: Gender differences in how participants score on each scale. SIAS = Social Interaction Anxiety Scale, PSS = Perceived Stress Scale, CSAS = Communication-Skills Attitudes Scale, AUDIT-C = drinking practices.


Gender played a key role in the experience of social interaction anxiety (SIAS: Female mean = 25.3, Male = 22.2, t = 2.2, df = 281.4, P = 0.035), perceived stress (PSS: F = 6.89, M = 5.39, t = 3.93, df = 416, P = 0.0001), attitudes towards communication training (CSAS: F = 102.4, M = 96.87, t = 3.86, df = 430, P = 0.0001) and alcohol consumption (AUDIT-C: F = 3.71, M = 4.79, t = -3.92, df = 384, P = 0.0001).











Figure 2: Gender differences in the nervousness experienced with interactions that are common-place during communication-skills training. Scale based on likert where 0 = “not at all” and 4 = “extremely”.


Female participants reported being significantly more nervous when speaking with real patients (X2= 12.669, df = 4, P = .013). Although there was a trend for female participants to report being more nervous when speaking with fellow students (X2 = 5.488, df = 4, P = .241) and simulated patients (X2 = 4.197, df = 4, P = .380), these differences did not reach statistical significance.











Impact of gender on help seeking attitudes and behaviour

Figure 3: Histograms generated from individual scale items. The pattern of scoring shows two peaks at “disagree” and “agree”.

Participants give dichotomous responses regarding whether they agreed or disagreed that peers and medicine in general would view them negatively if they admitted anxiety – Figure 3, possibly reflecting two different views held by medical students. There were no gender differences in the responses to these questions.








Figure 4: Histograms showing distribution of scoring on items relating to where students seek support.

When examined by gender, females are less likely agree that it was easy to talk with Student Support Services about personal difficulties – see Figure 4; however, this difference does not quite achieve significance (X2 = 8.291, df = 4, P = .081).











Figure 5: Histograms showing distribution of scoring on items relating to where students seek support.

There are no gender differences regarding whether participants would seek help from peers or medical school staff regarding difficulties with coursework.




Gender and other factors influenced participant experiences of communication-related anxiety and support seeking. This greater understanding of student experiences of and their attitudes towards communication-related anxiety and stress will assist in developing acceptable support.

Take-home Messages

Medical Schools should aim to create an environment whereby all students are confident in seeking support for communication-related anxiety.  


Thanks to the Medical School, University of St Andrews for supporting this study.


1. van Dulmen S, Tromp F, Grosfeld F, ten Cate O, Bensing J: The impact of assessing simulated bad news consultations on medical students' stress response and communication performance. Psychoneuroendocrinology 2007, 32:943 - 950.
2. Humphris G, Laidlaw A: The use of Reflection-on-Action in medical undergraduate communication skills teaching with naïve and experienced students. EACH 2006.
3. Lindon-Morris E, Laidlaw A: Anxiety and selfawareness in video feedback. The Clinical Teacher 2014, 11:174 - 178.
4. Sayer M, Saintonge MCD, Evans D, Wood D: Support for students with academic difficulties. Medical Education 2002, 36:643 - 650.
5. Dennis A, Warren R, Neville F, Laidlaw A, Ozakinci G: Anxiety about anxiety in medical undergraduates. The Clinical Teacher 2012, 9:330 -333.
6. Ball S, Bax A: Self-care in medical education: Effectiveness of health-habits intervention for first-year medical students. Academic Medicine 2002, 77(9):911 - 917.
7. Holmes J: Mental Health of Doctors. Advances in Psychiatric Treatment 1997, 3:251 - 253.
8. Mattick R, Clarke J: Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behavior Research and Therapy 1998, 36:455 - 470.
9. Cohen S, Kamarck T, Mermelstein R: A global measure of perceived stress. Journal of Health and Social Behaviour 1983, 24:385 - 396.
10. Rees C, Sheard C, McPherson A: Communication skills assessment: the perceptions of medical students at the University of Nottingham. Medical Education 2002, 36:868 - 878.
11. Bush K, Kivlahan D, McDonell M, Fihn S, Bradley K: The AUDIT Alcohol Consumption Questions (AUDIT-C): An Effective Brief Screening Test for Problem Drinking. Archives of Internal Medicine 1998, 158:1789 - 1795.


Summary of Work

Demographic Information:

Please state -

  1.  Your age:     please state here    . 
  2.  Your gender:  please tick - [M]      [F]
  3. The medical school you attend:  [drop-down menu]
  4. Your current academic year:  please tick - [1]   [2]   [3]   [4]   [5]   [6]
  5. Which activities have you taken part in during the communication-skills training course:

Please tick all that apply – [role playing]   [simulated patient scenarios]   [real patient interactions]   [group discussions]   [presenting cases to colleagues]   [other:   please state here  ]

Communication Skills Attitude Scale CSAS (Rees et al., 2002):

How accurately does each of the following statements describe you? Please answer on scale of 1 to 5 where 1 is least accurate and 5 is most accurate. - Please tick one box for each question: [1] [2] [3] [4] [5]

1. In order to be a good doctor I must have good communication skills

2. I can't see the point in learning communication skills

3. Nobody is going to fail their medical degree for having poor communication skills

4. Developing my communication skills is just as important as developing my knowledge of medicine

5. Learning communication skills has helped or will help me respect patients

6. I haven't got time to learn communication skills

7. Learning communication skills is interesting

8. I can't be bothered to turn up to sessions on communication skills

9. Learning communication skills has helped or will help facilitate my team-working skills

10. Learning communication skills has improved my ability to communicate with patients

11. Communication skills teaching states the obvious and then complicates it

12. Learning communication skills is fun

13. Learning communication skills is too easy

14. Learning communication skills has helped or will help me respect my colleagues

15. I find it difficult to trust information about communication skills given to me by non-clinical lecturers

16. Learning communication skills has helped or will help me recognise patients' rights regarding confidentiality and informed consent

17. Communication skills teaching would have a better image if it sounded more like a science subject

18. When applying for medicine, I thought it was a really good idea to learn communication skills

19. I don't need good communication skills to be a doctor

20. I find it hard to admit to having some problems with my communication skills

21. I think it's really useful learning communication skills on the medical degree

22. My ability to pass exams will get me through medical school rather than my ability to communicate

23. Learning communication skills is applicable to learning medicine

24. I find it difficult to take communication skills learning seriously

25. Learning communication skills is important because my ability to communicate is a lifelong skill

26. Communication skills learning should be left to psychology students, not medical students


Social Interaction Anxiety Scale SIAS (Mattick & Clarke, 1997)

How accurately does each of the following statements describe you? Please answer on scale of 1 to 5 where 1 is least accurate and 5 is most accurate. Please tick one box for each question: [1] [2] [3] [4] [5]

1. I get nervous if I have to speak with someone in authority (teacher, boss, etc.)

2. I have difficulty making eye-contact with others

3. I become tense if I have to talk about myself or my feelings

4. I find difficulty mixing comfortably with the people I work with

5. I tense-up if I meet an acquaintance in the street

6. When mixing socially I am uncomfortable

7. I feel tense if I am alone with just one other person

8. I am at ease meeting people at parties, etc

9. I have difficulty talking with other people

10. I find it easy to think of things to talk about

11. I worry about expressing myself in case I appear awkward

12. I find it difficult to disagree with another's point of view

13. I have difficulty talking to attractive persons

14. I find myself worrying that I won't know what to say in social situations

15. I am nervous mixing with people I don't know well

16. I feel I'll say something embarrassing when talking

17. When mixing in a group I find myself worrying I will be ignored

18. I am tense mixing in a group

19. I am unsure whether to greet someone I know only slightly

20. I get nervous if I have to speak with a fellow student

21. I get nervous if I have to speak with a simulated patient

22. I get nervous if I have to speak with a real patient 



Perceived stress Scale (Cohen et al 1983):


The questions in this scale ask you about your feelings and thoughts during the last month. In each case, please indicate your response by placing an “X” over the circle representing HOW OFTEN you felt or thought a certain way.


1. In the last month, how often have you felt that you were unable to control the important things in your life?

2. In the last month, how often have you felt confident about your ability to handle your personal problems?

3. In the last month, how often have you felt that things were going your way?

4. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?



Stress & Anxiety Support Seeking behaviour:

How accurately does each of the following statements describe you? Please answer on scale of 1 to 5 where 1 is least accurate and 5 is most accurate. Please tick one box for each question: [1] [2] [3] [4] [5]

  1. I immediately seek advice from school staff if experiencing any difficulties with coursework
  2. I usually feel in control of difficulties as they arise
  3. I quickly seek advice from peers if I have difficulties with my coursework
  4. I always try to solve difficulties myself
  5. I would worry that classmates were judging me negatively if I showed anxiety
  6. I only seek advice or support  with stress as a last resort
  7. I tend to ask for help with any difficulty that arises
  8. I never seek advice from school staff when I have difficulties with my course
  9. I find it difficult to talk to course advisors when I have an issue with coursework
  10. I feel ashamed if someone knows I am experiencing anxiety with my course
  11. I almost always seek advice when experiencing stress
  12. I often find that difficulties overwhelm me
  13. I know when to seek advice before a situation becomes too difficult to deal with
  14. I do not believe I have to hold back emotions to do well in medicine
  15. I often let a difficult situation escalate before seeking advice
  16. I find it hard to talk with student support when I have difficulties with my course
  17. I feel it is easy to talk with course advisors when experiencing difficulties with my course
  18. I feel lecturers or advisors would never judge me negatively about my anxiety
  19. I never worry what classmates think of me if I am visibly anxious
  20. I tend to judge others negatively if they experience anxiety over coursework
  21. I find it easy to talk to student support when I have difficulties with work
  22. I do not always know what I can or cannot deal with personally in terms of workload
  23. I know my personal limits when it comes to dealing with workload
  24. I never seek advice from peers if experiencing difficulties with coursework
  25. I do not feel that I would be held back in medicine if I show stress or anxiety
  26. I find it easy to talk with peers if I have difficulties with coursework
  27. I believe that medical students should keep their stress and anxiety to themselves
  28. I feel it is hard to talk to peers if I experience difficulties with coursework
  29. I worry that advisors or lecturers will judge me negatively  if I say I am anxious
  30. I believe I would be held back in medicine if I were to show anxiety or stress
  31. I do not feel ashamed if someone knows I am anxious about my course
  32. I never judge others negatively if they are anxious about coursework
  33. I feel that medical students should be able to talk about their anxiety and stress
  34. I feel I have to appear emotionally strong to excel in medicine


Drinking Practices Questionnaire AUDIT-C (Bush, Kivlahan, McDonell, Fihn & Bradley, 1998): Consider a "drink" to be a can or bottle of beer, a glass of wine, a wine cooler, or one cocktail or a shot of hard liquor (like scotch, gin, or vodka). Please tick one box for each question:

1.       How often did you have a drink containing alcohol in the past year?

[Never]   [Monthly or less]   [2 to 4 times a month]   [2 to 3 times a week]   [4 to 5 times a week] [6 or more times a week]

2.       How many drinks did you have on a typical day when you were drinking in the past year?

[0 drinks]   [1 to 2 drinks]   [3 to 4 drinks]   [5 to 6 drinks]   [7 to 9 drinks]   [10 or more drinks]

3.       How often did you have 6 or more drinks on one occasion in the past year?

[Never]   [Less than monthly]   [Monthly]   [Weekly]    [Daily or almost daily]


Please describe a situation where you felt anxiety in interacting with a patient (simulated or real) and how you coped with it.



Thank you for taking part in this survey.

Summary of Results
Take-home Messages
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