Relationship Between Perceived Stress and Academic Performance in Orthopaedic Residents: A Cross-Sectional Study

Introduction

Orthopaedic residency training is undertaken by board-certified physicians who aim to become orthopaedic surgeons in the future. In the Philippines, this is a 4- or 5-year program for public and private institutions, depending on the criteria from the Philippine Board of Orthopaedics (PBO). This includes a clinical and surgical rotation wherein the resident has to obtain knowledge to be able to diagnose and manage different orthopaedic ailments in multiple subspecialties. On top of that, they have to develop surgical skills and enhance their critical thinking. Residents are subject to an estimate 110-hour work weeks. This subjects the physician to an intense workload with high expectations which leads to a very stress-filled environment.

Stress refers to the mental, emotional or physical response elicited by various internal and external influences.[1] Studies have thoroughly investigated the impact of stress on overall health, job performance, ability to learn and even mortality rates.[1] Stress can lead to a range of personal effects such as physical, mental and emotional fatigue, diminished memory and focus, increased susceptibility to illness and substance use among others. For residents, studies have shown that those who suffer from stress are less likely to show empathy towards their patients and peers and are prone to make mistakes, especially in their surgeries.[2] A study showed that the prevalence of burnout was highest among physicians compared to other healthcare professions with residents exhibiting the most significant levels. A nationwide study on stress perception among surgical residents revealed that this subset of physicians showed high levels of negative stress and helplessness compared to the overall population.[3] Shanafelt, et al. was able to establish that orthopaedic surgeons have the highest rates of burnout as well.[4] Additionally, a survey done last 2020 showed that 40% of orthopaedic residents suffered from stress disorder.[4]

Perceived stress is the subjective assessment of an individual’s stressors in life and how they handle those challenges.[5] It includes feelings of being overwhelmed or unable to cope, regardless of the circumstance. Several factors such as personality traits, past experiences and coping strategies can impact perceived stress levels. This can be measured with validated tools such as the PSS. Elevated levels of perceived stress can adversely affect mental and physical health, leading to conditions such as anxiety and depression among others.[5]

There have been several studies that looked into stress or burnout and their association with patient care, however, the link between this and actual performance is still debatable.[6] As of this study, only a few authors investigated on the effect of stress or burnout with an objective measurement in the form of the ITE. Two studies concluded that burnout was associated with poor performance in the ITE for Orthopaedic Surgery and General Surgery.[6,7]

This primary goal of this study was to evaluate the relationship between perceived stress and academic performance among orthopaedic residents. Another goal was to identify contributing factors or be able to compare perceived stress and academic performance level among different demographic groups.

Mental health is increasingly recognized to be equally as important as physical health. Issues such as anxiety, depression and stress can affect one’s function and daily living. The conversation on mental health was once thought to be a social stigma but it is now being prominently discussed in different forums. In addition, stigma-related obstacles to seeking help would actually also lead to increased burnout and distress in physicians. This study aims to look for the association of perceived stress levels to academic performance, more specifically the ITE of orthopaedic residents in the Philippines. To the best of our knowledge, this will be the first study of its kind both at the local and global levels.

Methodology

Study Design

This is a cross – sectional study of orthopaedic surgery residents who have undertaken the 2024 PBO ITE.

Participants/Target Population

With a total of 309 orthopaedic residents who were eligible to take the 2024 ITE and assuming a 95% confidence level and a 5% margin of error, the target sample size was about 126 residents.

Inclusion Criteria

This would include orthopaedic residents from PBO Year Level 1 to 4 of any age and sex who have taken the 2024 ITE last October 2024 from PBO - accredited hospitals, both public and private.

Exclusion Criteria

Those who are considered PBO level 0 or the first-year residents of private institutions were not included as they are not required to take the ITE.

Data collection/Recruitment Process

1. The questionnaire was conducted through Google Form which included the consent form as the first page before proceeding to the questionnaire portion.

2. It will be distributed electronically via email or social media message to current orthopaedic surgery residents of different training institutions, through social media platforms and personal messages from the researcher, not including the research adviser.

3. Follow-up reminders will be given prior to the end of the data collection period to enhance response rates. The latest and more complete response will be the one recorded if there are any duplicated responses.

    

Data Collection Tool

Perceived Stress Scale (PSS) - 10

Originally constructed by Cohen and colleagues, this 14-item questionnaire is designed to measure the degree to which situations in an individual’s life are considered stressful, unpredictable and overloading. The PSS-10 has been translated and validated in several languages, including Spanish, Turkish, Portuguese, Chinese, Thai and Japanese. It has been applied to a wide range of populations, including patients, students, pregnant women and adults from the general population to measure perceived stress. A study by Lee in 2012 reviewed the psychometric evidence of the PSS. This included a review of 19 articles and concluded that the PSS is short and answerable in 2 minutes, as well as, an easy to use questionnaire with acceptable psychometric properties.

For PSS-10, each of the 10 items is scored on a 5-point scale (0 to 4), resulting in a total score ranging from 0 to 40. Higher scores would indicate higher perceived stress. Scores from 0-13 would be considered low stress. Scores ranging from 14-26 would be considered moderate stress. Lastly, scores from 27–40 would be considered high perceived stress.

In–Service Training Examination (ITE)

The orthopaedic ITE is a test that is taken by orthopaedic surgery residents. This is given by the PBO every year to evaluate and assess the knowledge of residents as well as to be able to gauge the training institution’s program. Starting from the PBO year level 1 residents, they would be answering a 120-point exam and this total would increase as the resident’s year level goes higher (ie, the total score for year level 1 is at 120, year level 2 at a total of 170 items, year level 3 at 240 items and year level 4 at 300 items.)

The results of the 2024 ITE were asked in the form of the raw score given to that resident. To allow for comparison between the residency year levels in spite of varying item totals per year level, the resident’s raw score was standardized by converting it into a percentage. This was done by dividing raw scores by the appropriate year level of the resident (eg, 120 for year level 1, 170 for year level 2, etc.), then multiplying it by 100. By doing this, it would allow for a more uniform scale (0%–100%) to be able to make comparisons of performance between residents regardless of the year level.

Demographics Information

This questionnaire also included individual variables such as age, gender, marital status, family status, level of training, the institution (if public or private), work hours, hours of sleep, alcohol/substance use, mental health awareness or support for the purpose of subgroup analysis.

Outcomes

The primary outcome will be the scores of the PSS–10 and the academic performance of the orthopaedic resident, more specifically, the ITE scores.

Data Analysis

Descriptive statistics will summarize the demographic data which will be displayed through graphs and figures. The statistical analysis included the use of logistic regression in order to analyze the relationship between variables. After the univariate analysis, a multivariate analysis was subsequently performed on the variables that were found to be significant. Variables with a P-value <0.05 were considered statistically significant.

Results

Table 1: Baseline demographics and characteristics of the study population

PBO: Philippine Board of Orthopaedics, HR: Human Resources Department of the institution

The study included 126 orthopaedic residents, with 73.8% being male. Most participants were aged 31-35 years (51.6%), followed by 26-30 years (41.3%). Regarding marital status, 81% were single, while others were married with children (14.3%), married without children (5.6%), living with a partner (2.4%), or single parents (1.6%). All four training years were represented: Year 1 (48 residents), Year 2 (30), Year 3 (21) and Year 4 (27).

Most residents (73.8%) trained in public institutions, while 26.2% were in private ones. Work hours were demanding, with 16.7% reporting more than a 120-hour work week while 55.6% were working 81-120 hours weekly and 27.8% working at 40-80 hours. Sleep patterns showed 48.4% getting 5-6 hours per night, while 38.1% reported only 0-4 hours.

Alcohol use was reported by 60.3% and substance use by 3.2%. Mental health awareness was high, with hospitals being the primary support system (41%), followed by family (29.5%) and friends (23%).

Table 2: Academic performance of the participants in the 2024 ITE last October

Table 2 shows the mean academic performance was 59.81% (SD=9.65), with 41.3% scoring 51%-60%, and 32.5% scoring 61%-70%. The highest score range was 81%-90% with the lowest at 21%–30%.

Table 3: Perceived stress scale–10 data gathered from the study participants

Table 3 reveals that the median perceived stress score is "sometimes," with most residents (64.3%) experiencing moderate stress and 30.2% experiencing high stress. They often feel nervous, stressed and unable to control important aspects of their life.

Table 4: Univariate analysis on factors affecting stress levels

PBO: Philippine Board of Orthopaedics

Table 4 indicates that academic performance is significantly linked to stress levels, with those with high stress having a mean of 55.2, compared to 61.8 for those with low to moderate stress. Sleep duration is also significant (p = 0.0289), with residents getting 0-4 hours of sleep being 5.83 times more likely to experience high stress compared to those with 7+ hours of sleep. Awareness of mental health issues was significant, with those unaware being 13.34 times more likely to have high stress.

Table 5: Multivariate analysis on factors affecting stress levels

Table 5 shows the multivariate analysis where academic performance (OR = 0.94, p = 0.0106) and non-awareness of mental health issues (OR = 11.32, p = 0.0059) remain significant factors associated with high stress.

Figure 1: Correlation between academic performance and perceived stress

Figure 1 shows that a significant inverse correlation between academic performance and perceived stress (r = -0.3138, p = 0.00010) was also found.

Discussion

Residency in Orthopaedic Surgery is well-known for its demanding workload. This comprises of extended hours in the operating room, in the wards or on-call and even includes academic settings such as lectures and exams. These are the basic expectations placed on an Orthopaedic Surgery resident in the medical field. These roles in the hospital, along with the lengthy work hours, often lead to significant perceived stress. This can negatively affect both mental health and academic performance of the resident. The findings of this study add to the growing body of evidence that perceived stress and inadequate sleep significantly impair academic performance among orthopaedic residents.

Perceived stress is an emerging issue for medical residents. This describes the belief that the academic, clinical and surgical demands exceed the resident’s ability to cope or manage effectively. This also pertains to how the individual interprets or reacts to a given situation. This study explored the relationship between perceived stress and academic performance among orthopaedic residents in the Philippines revealing several critical insights. The inverse relationship between perceived stress and academic performance (r = -0.3138, p = 0.00010) in this study aligns with previous research highlighting stress as a key factor impairing cognitive function. According to Afshar, stress is becoming a widespread concern among medical students and residents, especially in the surgical fields, where rigorous training can hinder academic performance.[8] Stress can impair concentration and cause cognitive overload making it tough to retain and apply medical information.

Residents experiencing high perceived stress scored markedly lower in the ITE with a mean score of 55.2% compared to 61.8% among those with low to moderate stress levels. This supports the hypothesis that elevated stress impairs cognitive and academic functioning, potentially through mechanisms such as reduced concentration, cognitive overload and emotional exhaustion. Research by Alvi highlights that surgical residents struggle to balance academic excellence with emotional resilience, with perceived stress contributing to burnout and decreased academic performance.[2] These effects are particularly detrimental in surgical fields where orthopaedic residents must find a balance between hands-on practice and theoretical study which is vital. Additionally, Aljuhani et al., pointed out the mental health challenges faced by orthopaedic surgeons, noting that high stress levels are linked to reduced professional satisfaction and potentially compromised decision-making.[4]

Another study further mirrors the findings of this study where they mention that orthopaedic residents experiencing burnout exhibited poor performance on the Orthopaedic ITE.[9] Furthermore, Maswadi emphasized that stress and burnout among Orthopaedic Surgery residents in Jordan directly correlate with lower academic achievement and diminished professional satisfaction.[3]

Sleep deprivation emerged as a significant factor in this study, with residents sleeping 0–4 hours per night being 5.83 times more likely to report high stress compared to those who slept seven or more hours. This finding echoes the work of Galanko and Smeds who highlighted cognitive impairments associated with insufficient sleep.[7,10] Sleep is crucial for cognitive performance, memory retention and learning. In the context of medical residency, especially in orthopaedic surgery, sleep deprivation is common due to challenging workload and work hours. In these studies, they revealed that residents who received less sleep performed poorly in both written and practical exams.[7,10]

The extreme work hours observed in this study exacerbate sleep deprivation, which, in turn, intensifies stress and undermines academic performance. Nearly 38.1% of residents reported sleeping only 0–4 hours nightly, while 48.4% slept 5–6 hours. Ebrahim also found that residents with inadequate sleep often have difficulty with concentration leading to poor test scores and weaker retention of medical knowledge.[11] Other than hindering learning and performance, articles by Kirwin and Lange highlighted that sleep loss also increases stress and burnout to the residents’ well-being.[1,12] These findings suggest the need for targeted interventions such as revised on-call schedules and educational initiatives promoting sleep hygiene.

The combination of stress and sleep deprivation creates a complex challenge for Orthopaedic Surgery residents. Stress triggers physiological responses, such as the release of cortisol, which can disrupt sleep and create a cycle where stress worsens sleep deprivation and vice versa. This cycle can hinder academic performance, as stressed residents struggle to focus during lectures or study sessions, while lack of sleep diminishes their ability to retain and apply information in clinical settings. The cumulative effect of these demands can also reflect in the current study which shows the resident population with substantial perceived stress levels—64.3% reported moderate stress and 30.2% reported high stress.

Mcluckie, et al. found that highly stressed residents were less likely to seek social support and more prone to unhealthy coping mechanisms, which further disrupted their sleep and academic functioning.[13] Stress-related insomnia and fragmented sleep can severely impair cognitive processing, as Lee pointed out, especially when residents need to absorb large amounts of information, perform complex tasks and make quick decisions.[5]

While demographic variables such as sex, age and marital status were not significantly associated with stress levels, the demanding nature of orthopaedic residency, as reflected by long working hours and insufficient sleep, emerged as a consistent stressor. The extensive working hours reported in this study (55.6% working 81–120 hours per week) reflect systemic challenges in orthopaedic training programs. Research by Kirwin suggests these regulations have mixed effects on orthopaedic surgery residents.[12] On one hand, reduced work hours may allow for more sleep, leading to improved cognitive function and academic performance. On the other hand, these restrictions could limit residents' exposure to critical clinical cases necessary for skill development in orthopaedic surgery.

Some studies, including Sargent, et al., argue that work-hour restrictions have improved residents' mental health and sleep, resulting in better academic performance and fewer clinical errors.[14] However, the trade-off between quality rest and clinical exposure remains a concern, especially in specialized fields like orthopaedics. One study emphasized the need for work-hour reforms that balance sufficient rest with enough clinical exposure for developing surgical skills.[6]

Those unaware of mental health issues in society were 13.34 times more likely to experience high stress (p = 0.0014). This emphasizes the importance of promoting mental health awareness and the development of support systems in the residency training programs. This is consistent with the findings of two studies wherein they accentuated that awareness and access to mental health support reduced stress and improved resilience among residents.[1,15] However, while awareness was high among participants (91.3%), the availability of structured support systems remains limited, with hospitals being the primary source of support. With this being said, one of the limitations of the study was that participants were not asked to be more specific with regard to the specific type of help the hospital provides.

To address this gap, programs can draw on strategies discussed by McTaggart & Walker and Kirwin, et al. such as integrating mental health education into residency curricula and creating confidential support networks.[12,16] These efforts could mitigate the stigma around seeking help, which remains a barrier in many places. This study’s findings align with much of the existing literature; however, one can point out discrepancies due to cultural and systemic differences in countries like the Philippines. Global efforts such as the 80-hour workweek limit introduced by the Accreditation Council for Graduate Medical Education (ACGME) have aimed to reduce resident fatigue. This cannot be implemented the same way in the Philippines. This can be seen in the current study wherein more than half the residents report working 80 to 120 hours per week with 16.7% reporting more than 120 hours at work. It is these situations that likely intensify stress and contribute to the inverse relationship between perceived stress and academic performance.

Another important note to point out is the comparison of public and private hospitals. Public hospitals are known to have more patient load leading to more work for the residents of that institution. However, in this study, there was noted to be no significance (p = 0.9832) when comparing public and private hospitals on being a factor contributing to perceived stress.

In the Philippine context, where residents often juggle both clinical responsibilities and additional academic requirements, the lack of sufficient sleep creates a vicious cycle. Sleep deprivation reduces the capacity for effective stress management, while high stress levels further impair sleep quality. This cycle not only affects academic performance but also raises concerns about patient safety and long-term mental health risks for residents.

Limitations

One limitation of the study is the cross-sectional design. This only captures the data at one point in time thus, limiting the ability to fully conclude causation between stress and academic performance. The second is that the data is self–reported. The participants may underreport certain negative behavior such as substance use. The differences in training institutions can also be a factor that can further be analyzed in future studies as well.

Conclusion

The study displays the inverse relationship between perceived stress and academic performance among Orthopaedic Surgery residents in the Philippines with higher levels of perceived stress demonstrating poorer performance in the ITE. Variables such as lack of sleep and limited mental awareness appeared as significant contributors to elevated stress which further affects academic performance.

This underlines the need for targeted interventions to lessen stress and improve overall wellbeing of residents. Strategies such as promotion of mental health, employing programs for stress management and addressing sleep deficiency can be looked into so as to enhance academic performance and quality of life of residents.

With this study being the first of its kind in the country, this can serve as a jumping point for further research and practical initiatives aimed at supporting orthopaedic residents and hopefully in the future, to other residency training programs.