gms | German Medical Science

GMS Journal for Medical Education

Gesellschaft für Medizinische Ausbildung (GMA)

ISSN 2366-5017

Measurement of specific medical school stress: translation of the “Perceived Medical School Stress Instrument” to the German language

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  • corresponding author Thomas Kötter - University of Lübeck, Institute for Social Medicine and Epidemiology, Lübeck, Germany
  • author Edgar Voltmer - Friedensau Adventist University, Möckern, Germany

GMS Z Med Ausbild 2013;30(2):Doc22

doi: 10.3205/zma000865, urn:nbn:de:0183-zma0008659

This is the translated version of the article.
The original version can be found at:

Received: June 22, 2012
Revised: November 13, 2012
Accepted: February 7, 2013
Published: May 15, 2013

© 2013 Kötter et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Objective: Medical students encounter specific stressors during their studies. As a result, they develop anxiety, depression and burnout symptoms more frequently than their similarly aged, but employed counterparts. In 1984, Vitaliano et al. published a 13-item instrument for the measurement of stress specific to medical school: the “Perceived Medical School Stress Instrument“ (PMSS). Since then, it has been widely applied and validated in English-speaking countries. No German version of the PMSS exists to date. Thus, our aim was to translate the instrument into the German language in order to be able to measure medical school stress in German-speaking countries.

Method: The items of the PMSS were translated into German by three separate researchers. The resulting translations were compared and combined with each other to establish a first German version of each item in the PMSS. These items were then translated back into English by two native English speakers to validate the correct primary translation. Based on a revised German version, a cognitive debriefing with 19 German medical students and a theoretical testing on 169 German medical students, the final German translations for each of the 13 items were determined.

Results: The PMSS was easily translated into German and there was a high congruency between the primary translations into German and the secondary translations back into English. Incongruities between the translations were solved quickly. The assessment of the German equivalent of the PMSS showed good results regarding its reliability (Cronbach’s Alpha 0.81).

Conclusion: A German version of the PMSS is now available for measuring the medical school related stress in German-speaking countries.

Keywords: Questionnaire, Medical education, Stress, Translation


Stress related to medical education has been an important issue in English-speaking countries for the last several years [1], [2], [3]. However, it is now gaining awareness and importance in German-speaking countries as well [4], [5]. Medical students seem to be exposed to several, specific stressors during their studies in comparison to their similarly aged counterparts who study other subjects or are already employed, for example high expectations, high selection pressure, limited teamwork opportunities, high competition levels and very little training in practical skills during their studies [6]. There are also specific emotional stressors experienced, such as the dissection in anatomy courses [7], and the work with suffering and dying patients in clinical settings [1]. As a result, medical students show higher rates of anxiety, depression and burnout symptoms [3], [8], [9]. Not only has medical school-related stress a negative impact on the health of medical students, but also on their academic performance and empathy for patients [10], [11]. High stress levels were shown to increase suicidal thoughts and thoughts of giving up medical school [12]. At the same time medical students and doctors are hesitant to admit to psychosocial stress or accept professional help [13]. It is just as important to recognize stress in students early, as it is to develop stress-preventing resources through health-promoting interventions. Most instruments used to gather work-related stress information, e.g. the German questionnaire “work-related behavior and experience patterns” (AVEM - Arbeitsbezogene Verhaltens- und Erlebensmuster) [5], [14], [15], are based on the general risks and individual coping strategies. Only few instruments gather information about the specific stressors themselves. Dyrbye et al. [12] recently created the “Medical Student Well-Being Index” which consists of seven items gathering information on symptoms of burnout (including emotional exhaustion and cynicism), depression, stress and fatigue, as well as information on the mental and physical quality of life. However, this instrument has not been widely validated, nor is there much data to compare. Bachmann und Brunner [6] collected data from two Universities in Zurich using instruments, which were neither specific for medical education nor broadly implemented amongst students in other disciplines (e.g. [16]). In 1984, Vitaliano et al. presented the „Perceived Medical School Stress Instrument“ (PMSS), which was meant to acquire information on stress amongst medical students and which was subsequently widely implemented [9], [17], [18], [19], [20]. Bramness et al. [20] used a slightly modified version of the PMSS in studies with Norwegian students. In other Norwegian studies [9], [19], a three-factor-structure was determined describing firstly, that „medical school is cold and threatening“, secondly „worries about work and competencies“, and thirdly „worries about finance and accommodation“. The objective of this project was to develop of a German version of the PMSS (PMSS-D) and to assess its psychometric properties.


Applying recommendations made by the „Quality of Life Special Interest Group - Translation and Cultural Adaptation Group“ [21] we completed the following steps to create the PMSS-D:

Preparation: Electing the slightly modified Norwegian version of the PMSS [20], which is based on the English original [17], [18], as the basis for the translation.
German translation: The original questionnaire (modified by [20]) was translated by both authors and a native German-speaking translator, all with fluent English skills. One translator possessed a translation diploma and all were experts regarding the methods and contents of the questionnaire.
Comparison: These three translations were synoptically compared and a consensus between the translators eliminated any divergent translations. This resulted in a preliminary German version of the PMSS.
Translations back into English: Two separate native English speakers with fluent German skills were asked to translate the preliminary PMSS-D back into English.
Review of the secondary English translations: The authors compared the secondary English translations of the PMSS-D with the original questionnaire. Discrepancies were analyzed and considered while editing the preliminary PMSS-D.
Harmonization: All translations were compared and any incongruities were rationalized and cleared up.
The edited PMSS-D was presented to medical students in their fifth year for a theoretical test evaluation. This was done as part of a longitudinal study on the development of psychosocial health in medical students. The students were informed of the test and could choose whether or not to participate (informed consent). All data was analyzed anonymously and the entire study had previously been cleared by the ethics commitee at Freiburg University.
Cognitive Debriefing: A group of 19 medical students (native German speakers with fluent English skills; n=19) in their first year received an English and a German copy of the PMSS. They were asked for a free text commentary on both versions and the test-retest reliability was assessed.
Review of Cognitive Debriefing: On the basis of the results of the cognitive debriefing, the final version of the PMSS-D was formulated.
Editing: The final copy was edited for small mistakes such as grammatical errors.

Statistical analysis was completed using SPSS 15.0. Ordinal descriptive statistics are presented in the form of means and standard deviations (SD). Nominal statistics are presented using percentages. The reliability of the PMSS-D was measured by using the item-intercorrelations and Cronbach's alpha results to assess the scale’s internal consistency. Variations within the study group's ordinal variables were calculated using a two-tailed t-test or a simple variance-analysis (ANOVA).

The short version (SF-12) of a questionnaire on health-related quality of life (SF-36) [22] was used as an external validation method. In the SF-12, selected items from the longer version are combined to create a physical and mental summary scale. 87-94% of the variance in the SF-36 physical and mental summary scale scores can be explained through the SF-12 items. Reference scores can be found for number of different populations [23], [22].


The modified English version of the PMSS, as well as the PMSS-D based on this version, are depicted in Figure 1 [Fig. 1].

The translations into German and back into English, as well as the comparisons and the harmonization (steps 1-6 of the method) were completed easily and with few discrepancies. Small incongruities in the translations were quickly and effectively resolved by consensus between the translators.

The Norwegian PMSS authors used the same 5-point Likert scale as Vitaliano et al. used in the original PMSS [9], [19], [20] (ranging from „I strongly disagree“ to „I strongly agree“). However, in the original version the scale score encompassed 0-4 points, while Tyssen et al.[9] used a scale from 1-5. To ensure direct comparability to data from Tyssen et al., which represents the largest sample within the Norwegian studies, we also used a scale from 1-5 (1 = I strongly disagree; 5 = I strongly agree).

There were no changes necessary in the phrasing of the questions as a result of the cognitive debriefing. The correlation coefficient (Pearson’s r) between the English and the German versions was .943.

56.3% of the fifth year medical students participated in the test evaluation (n=169 of 300 fifth-year medical students). The mean age was 25.6 years (SD=3.1), and 71.3% of the participating students were female.

The results from our sample are shown in Table 1 [Tab. 1]:

The item inter-correlation was moderate with a maximum Pearson’s r of 0.45. Cronbach's alpha was 0.81. The mean sum score of perceived medical school stress was 30.7 (SD =7.6) and there didn't seem to be any differences between male and female students regarding the overall stress level. Female students did, however, have a significantly higher amount of anxiety regarding the inability to master the entire pool of medical knowledge, while male students more frequently described medical school as cold, impersonal and bureaucratic and considered it more of a threat than a challenge (medium effect size).

Students who scored above the 75th percentile in the sum of their perceived stress had significantly lower scores in the physical and mental well-being scales (see Table 2 [Tab. 2]) with an especially high effect size for mental well-being.


The objective of this study was to translate the PMSS into German. This was done in several steps using a systematic and recognized method and proved to be feasible. In the test evaluation the instrument proved itself to be valid and reliable.

As experience has shown, the translation process cannot be done word for word. It is important that the ideas behind the words are correctly interpreted and translated as well. Also, cultural differences and special features of the target population need to be kept in mind [24]. For example, the expression 'Medical School“ in the English original describes, when translated directly into German, the university or faculty where medicine is taught. In the German translation the term „das Medizinstudium“ needed to be used to describe the studying of medicine as a student.

The results of the test evaluation show the good reliability (Cronbach's alpha 0.81) of the PMSS-D, which correlates with the Norwegian results for the modified PMSS [9]. As expected, the first external validation test resulted in a stronger reduction of physical and mental well-being in students who experience high stress levels compared to those with low stress levels. There is a higher effect size for the difference in mental well-being.

The stress sums measured by the PMSS-D in our sample were higher than those acquired from Norwegian students in higher semesters [9], [19]. These differences between Norwegian and German students might be consistent with the higher satisfaction of Norwegian doctors with their working conditions (whether in a hospital [25] or a practice [26]) compared to their German colleagues. Our results did not show a significant difference between male and female students in their stress levels but male students more frequently experienced the university atmosphere as cold, impersonal, and bureaucratic. Males also experienced medical school as more of a threat than a challenge in comparison to their female counterparts. On the other hand, the female students had a higher fear of not being able to acquire the necessary specialized knowledge.

A strength of this study is the application of the internationally accepted „Principles of Good Practice for the translation of Assessment Instruments“ [21]. A review of translation methods for assessment instruments by Maneesriwongul and Dixon [27] showed that there is no gold standard. The “International Society for Quality of Life Assessment” created guidelines for a translation process that respects cultural specialties. These guidelines were used in the recommendations made by the “International Society for Pharmacoeconomics and Outcome Research” which were used as an orientation for the translation of the PMSS-D [21].

The population included in our study consisted of medical students in their fifth year at a German university. A generalized statement is difficult to make from this data. The implementation in normal populations requires further psychometric testing and external validation.

With the creation of the PMSS-D there is now an instrument for the measurement of stress amongst medical students available in German-speaking countries as well. The PMSS-D can be used on its own or combined with other tests reflecting health-promoting resources in medical students. The objective of future studies should be the (further) development of health-promoting and illness preventing interventions aiming at the setting and the individual student.

Competing interests

The authors declare that they have no competing interests.


Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: causes, consequences, and proposed solutions. Mayo Clin Proc. 2005;80(12):1613-1622. DOI: 10.4065/80.12.1613 External link
Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81(4):354-373. DOI: 10.1097/00001888-200604000-00009 External link
Hunt J, Eisenberg D. Mental health problems and help-seeking behavior among college students. J Adolesc Health. 2010;46(1):3-10. DOI: 10.1016/j.jadohealth.2009.08.008 External link
Buddeberg-Fischer B. Medizinstudierende und Medizinstudium. In: Buddeberg C (Hrsg). Psychosoziale Medizin. Berlin, Heidelberg, New York: Springer; 2004. S.13-19. DOI: 10.1007/978-3-642-18825-1_2 External link
Voltmer E, Kieschke U, Schwappach DL, Wirsching M, Spahn C. Psychosocial health risk factors and resources of medical students and physicians: a cross-sectional study. BMC Med Educ. 2008;8:46. DOI: 10.1186/1472-6920-8-46 External link
Bachmann N, Berta D, Eggli P. Macht Studieren krank? Bern: Huber; 1999.
Bernhardt V, Rothkötter HJ, Kasten E. Psychological stress in first year medical students in response to the dissection of a human corpse. GMS Z Med Ausbild. 2012;29(1):Doc12. DOI: 10.3205/zma000782 External link
Rosal MC, Ockene IS, Ockene JK, Barrett SV, Ma Y, Hebert JR. A longitudinal study of students' depression at one medical school. Acad Med. 1997;72(6):542-546. DOI: 10.1097/00001888-199706000-00022 External link
Tyssen R, Vaglum P, Gronvold NT, Ekeberg O. Factors in medical school that predict postgraduate mental health problems in need of treatment. A nationwide longitudinal study. Med Educ. 2001;35(2):110-120.
Stewart SM, Lam TH, Betson CL, Wong CM, Wong AM. A prospective analysis of stress and acedemic performance in the first two years of medical school. Med Educ. 1999;33(4):243-250. DOI: 10.1046/j.1365-2923.1999.00294.x External link
Thomas MR, Dyrbye LN, Huntington JL, Lawson KL, Novotny PJ, Sloan JA, Shanafelt TD. How do distress and well-being relate to medical student empathy? A multicenter study. J Gen Intern Med. 2007;22(2):177-183. DOI: 10.1007/s11606-006-0039-6 External link
Dyrbye LN, Harper W, Durning SJ, Moutier C, Thomas MR, Massis FS Jr, Eacker A, Power DV, Szydlo DW, Sloan JA, Shanafelt TD. Patterns of distress in US medical students. Med Teach. 2011;33(10):834-839. DOI: 10.3109/0142159X.2010.531158 External link
Tjia J, Givens JL, Shea JA. Factors associated with undertreatment of medical student depression. J Am Coll Health. 2005;53(5):219-224. DOI: 10.3200/JACH.53.5.219-224 External link
Schaarschmidt U, Fischer AW. Arbeitsbezogenes Verhaltens- und Erlebnismuster AVEM. 2. überarbeitete und erweiterte Auflage. Frankfurt/Main: Swets Test Services; 2003.
Aster-Schenck IU, Schuler M, Fischer MR, Neuderth S. Psychosocial resources and burnout risk factors in medical school: A cross-sectional study and analyses of need for preventive curricular interventions. GMS Z Med Ausbild. 2010;27(4):Doc61. DOI: 10.3205/zma000698 External link
Kiessling C, Schubert B, Scheffner D, Burger W. First year medical students' perceptions of stress and support: a comparison between reformed and traditional track curricula. Med Educ. 2004;38(5):504-509. DOI: 10.1046/j.1365-2929.2004.01816.x External link
Vitaliano PP, Maiuro RD, Mitchell E, Russo J. Perceived stress in medical school: resistors, persistors, adaptors and maladaptors. Soc Sci Med. 1989;28(12):1321-1329. DOI: 10.1016/0277-9536(89)90351-1 External link
Vitaliano PP, Russo J, Carr JE, Heerwagen JH. Medical school pressures and their relationship to anxiety. J Nerv Ment Dis. 1984;172(12):730-736. DOI: 10.1097/00005053-198412000-00006 External link
Holm M, Tyssen R, Stordal KI, Haver B. Self-development groups reduce medical school stress: a controlled intervention study. BMC Med Educ. 2010;10:23. DOI: 10.1186/1472-6920-10-23 External link
Bramness JG, Fixdal TC, Vaglum P. Effect of medical school stress on the mental health of medical students in early and late clinical curriculum. Acta Psychiat Scand. 1991;84(4):340-345. DOI: 10.1111/j.1600-0447.1991.tb03157.x External link
Wild D, Grove A, Martin M, Eremenco S, McElroy S, Verjee-Lorenz A, Erikson P; ISPOR Task Force for Translation and Cultural Adaption. Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes (PRO) Measures: report of the ISPOR Task Force for Translation and Cultural Adaptation. Value Health. 2005;8(2):94-104. DOI: 10.1111/j.1524-4733.2005.04054.x External link
Bullinger M, Kirchberger I. Der SF-36 Fragebogen zum Gesundheitszustand. Handbuch für die deutschsprachige Fragebogenversion. Göttingen: Hogrefe Verlag für Psychologie; 1998.
Bullinger, Kirchberger I, Ware JE. Der deutsche SF-36 Health Survey. Übersetzung und psychometrische Testung eines krankheitsübergreifenden Instruments zur Erfassung der gesundheitsbezogenen Lebensqualität. J Public Health. 1995;3:21-36. DOI: 10.1007/BF02959944 External link
McKenna SP, Doward LC. The Translation and Cultural Adaptation of Patient-Reported Outcome Measures. Value Health. 2005;8(2):89–91. DOI: 10.1111/j.1524-4733.2005.08203.x External link
Rosta J, Nylenna M, Aasland OG. Job satisfaction among hospital doctors in Norway and Germany. A comparative study on national samples. Scand J Public Health. 2009;37(5):503-508. DOI: 10.1177/1403494809106504 External link
Vollmer E, Rosta J, Siegrist J, Aasland OG. Job Stress and Job Satisfaction of Physicians in Private Practice: Comparison of German and Norwegian Physicians. Int Arch Occup Environ Health. 2012;85(7):819-828. DOI: 10.1007/s00420-011-0725-5 External link
Maneesriwongul W, Dixon JK. Instrument translation process: a method review. J Adv Nurs. 2004;48(2):175-186. DOI: 10.1111/j.1365-2648.2004.03185.x External link