The effects of examination stress on the performance of emergency medicine residents

CONTEXT: Despite the finding that residents are exposed to significant stressors during their training, little is known about the impact of these stressors on performance. The objectives of this project were to measure the subjective anxiety felt by emergency medicine (EM) residents during in-training examinations, and to determine the effect of this anxiety on their ability to diagnose visual stimuli such as X-rays, photographs and electrocardiographs. METHODS: Two examinations, matched for difficulty and length, were constructed based on the performance of 23 residents in 2 Royal College of Physicians and Surgeons of Canada (RCPSC) EM residency programmes. These examinations were then administered at 2-week intervals to another 24 residents in 2 additional RCPSC EM programmes. One examination was administered under high-stress conditions (in-training examination) and the other under low-stress (control) conditions. Perceived anxiety was measured using the state scale of the State-Trait Anxiety Inventory before and after each iteration of the examination. RESULTS: Residents reported higher levels of anxiety in the high-stress condition (41.5 versus 35.9, P < 0.05). Examination scores were higher in the high-stress condition (70.4 versus 64.4, P < 0.01). The scores of junior residents improved in the high-stress condition, whereas those of intermediate and senior residents did not change. CONCLUSIONS: Emergency medicine residents report higher anxiety during in-training examinations compared with control conditions. Residents at all levels exhibited similar perceptions of anxiety. Junior residents performed better under stress, achieving higher scores during the in-training examination than during the control condition. The performance of more experienced residents was not affected by the stress condition.