Tool for Predicting Medical Student Burnout From Sustained Stress Levels: Factor Analysis of the Medical Education Hassles Scale-R

Jane C. Johnson; Brian F. Degenhardt; Carol K. Smith; Thomas M. Wolf; D. Fred Peterson

doi:10.7556/jaoa.2018.036

Abstract

Context: Acute stress during medical school affects the health of students and is associated with burnout. The Medical Education Hassles Scale-R (MEHS-R) is designed to measure acute stress among medical students. Researchers using the MEHS-R primarily report overall hassles scores, which are unable to discriminate between different categories of hassles encountered.

Objective: The present study examined the factor structure of the MEHS-R to identify subscales that would be useful to categorize hassles for research and assessment purposes.

Design: Longitudinal, observational study.

Setting: Two osteopathic medical schools.

Participants: Five hundred six first-year medical students.

Main Outcome Measure: The MEHS-R was administered at orientation and 9 to 10 times throughout the first year, classified into examination, vacation, and routine medical school activity periods. Students rated the 101 items on a 4-point scale (0=none to 3=a great deal) to indicate how much of a hassle each item had been during the previous week. Demographic subgroups were males, females, married students, single students, whites, and ethnic minorities.

Results: Exploratory factor analysis was conducted on data collected at the first school during orientation. Seven subscales were identified: Academic and Time Pressures, Financial, Social, External Influences, Day-to-Day Functioning, Relationships With Immediate Family, and Health. Cronbach α were ≥0.75. Stability of these subscales was examined using confirmatory factor analysis. Both of the fit indices used indicated the 7-subscale model for the MEHS-R adequately fit the data obtained during examination and routine medical school activity periods, one fit index indicated adequate fit for the vacation period, and neither indicated adequate fit for the data from the second school. Of the 7 subscales, 5 had a strong correspondence with categories identified by the scale developers. Fit indices also indicated the 7-subscale model was adequately generalizable to the demographic subgroups with the exception of the ethnic minorities subgroup.

Conclusions: Exploratory factor analysis performed on the MEHS-R supported formation of subscales similar to categories identified during MEHS-R development. Results of the current study supported the use of the MEHS-R for the investigation of acute stress in medical students. In future research, targeted wellness interventions for medical students may be developed based on student responses to this instrument.

The acute stress associated with the pressures and demands of medical school has been well documented and shown to affect physical and psychological health.^1-6 Despite decades of recommendations for change in medical school education, managing stress in medical school continues to be a significant challenge for many students.^1,2,6-9 Greater stress experienced during medical school is associated with increased burnout, suicidal ideation, and serious thoughts of dropping out of school, whereas lower stress is associated with increased likelihood of resilience to and recovery from burnout.^10-13 Development of interventions targeted at medical students’ stress, which could potentially reduce burnout, could be accelerated by assessment tools that identify not only the overall stress level but also the types of stress experienced.

Assessing hassles as indicators of acute stress was first proposed by Kanner et al.¹⁴ Their scale comprised 113 items, or hassles, which were defined as “irritants that can range from minor annoyances to fairly major pressures, problems, or difficulties,” and it was directed primarily at adults in the general population aged 45 years or older.^14,15 The conceptual framework and method of Lazarus and Folkman¹⁵ described stress as a multidimensional construct. To measure the frequency and intensity of acute stress among medical students, Wolf et al¹⁶ developed the Medical Education Hassles Scale (MEHS), which was derived from this conceptualization.¹⁵ The MEHS originally consisted of 106 items pertaining to personal habits, interpersonal relationships, health habits, financial status, chores, and viewpoints on the outside world. The MEHS was shown to have adequate test-retest reliability over a 1-week period.⁵ Through extensive pilot testing, the MEHS was refined into the 101-item Medical Education Hassles Scale-R (MEHS-R).¹⁷ Although categories were listed by Wolf et al,¹⁷ neither the items included in these categories nor the relative impact of the categories was reported. Generally, 3 summary measures of the 101 items have been calculated and reported within the literature: the number of items endorsed, the mean frequency score, and the mean intensity score. However, these summary measures are not consistent with the multidimensionality of stress and do not distinguish between individual or different types of hassles, some of which may be affected by changes in the educational system. To examine the variations of separate areas of hassles throughout medical school, it is necessary to distinguish the frequency and intensity of categories of hassles. This understanding would allow researchers and medical school administrators to more easily identify the individual issues stressing students.

The present study was designed to increase the utility of the MEHS-R as a research tool. Our goal was to identify which of the 101 hassles listed in the MEHS-R were related to each other, both statistically and conceptually, and to use this information to form and validate subscales for the MEHS-R. If valid subscales were identified, they would facilitate more focused evaluation of differences in acute stress between groups of medical students and changes in acute stress over time. Additionally, by distinguishing between separate dimensions of acute stress, interventions that are consistent with the osteopathic philosophy of viewing individuals within their entire environment—mind, body, and spirit—could be developed and evaluated for their efficacy in reducing acute stress during medical school. We hypothesized that exploratory factor analysis performed on the data from the MEHS-R would support formation of subscales that were similar to the categories identified by Wolf et al¹⁶ in development of the MEHS.

Methods

Participants

First-year medical student volunteers were recruited during orientation at 2 rural osteopathic medical schools—over a 3-year period at the first school and during 1 year at the second. The institutional review board of each school approved the protocol for the present study. Informed consent was obtained from all volunteers prior to participation.

Instruments

A demographic questionnaire was administered to participants requesting information on gender, age, marital status, and ethnic background. Marital status was categorized as either married or single. Ethnic background was categorized as white or ethnic minority, which included persons who designated themselves as African American, Asian, Hispanic, Native American/American Indian, Pacific Islander, Pakistani, or other.

Data regarding hassles were obtained through the use of the 101-item MEHS-R.¹⁷ The items of the MEHS-R are listed in Table 1. Participants rated each item on a 4-point scale indicating how much of a hassle that item had been within the past week (0=none or not applicable, 1=somewhat, 2=quite a bit, and 3=a great deal).

Table 1.

Factor Scores Produced by Promax Rotation of the First 8 Principal Components From the Medical Education Hassles Scale-R, 7 Subscales Derived From Exploratory Factor Analysis, Percent of Variance Explained by Each Factor, and Cronbach α for the Subscales

Item		Factor^a
Item		1	2	3	4	5	6	7	8
1	Finding a place to study	0.30	−0.16	0.19	−0.05	0.15	0.02	0.04	0.05
2	Condition of the streets	−0.13	0.01	0.12	0.16	0.16	0.15	0.15	−0.09
3	Relating to professors	0.21	0.02	0.27	-0.11	0.01	0.03	0.10	0.07
4	Concern about accidents	−0.05	0.07	0.14	0.31	0.06	−0.09	0.14	0.29
5	Not enough money for entertainment and recreation	−0.04	0.70	−0.11	−0.01	−0.01	0.07	0.15	−0.01
6	Concerns about money for emergencies	−0.02	0.70	-0.14	0.02	−0.08	0.07	0.15	0.08
7	Filling out forms	0.15	0.02	−0.07	0.02	0.32	−0.07	−0.06	0.08
8	Physical illness	0.26	−0.08	0.14	0.10	0.14	−0.07	0.14	0.10
9	Prejudice and discrimination from others	0.17	−0.01	0.43	0.17	−0.09	−0.11	0.09	0.06
10	Use of drugs	0.03	0.01	0.25	0.11	−0.12	0.01	0.10	−0.08
11	Concern with contraception	−0.04	0.05	−0.01	0.11	−0.05	0.28	0.28	0.17
12	Heavy work load	0.71	0.02	0.03	−0.18	0.11	−0.06	0.01	0.08
13	Shopping for groceries	0.00	0.05	0.04	−0.04	0.59	−0.05	0.06	−0.06
14	Instructor giving poor lecture	0.53	−0.08	0.07	0.13	-0.07	−0.01	0.05	−0.09
15	Being lonely	0.09	−0.07	0.46	−0.07	0.21	−0.15	0.12	−0.19
16	Cutting down on electricity, water, etc	−0.14	0.41	0.13	−0.06	0.09	0.13	0.11	−0.05
17	Too many responsibilities	0.32	0.18	0.07	−0.07	0.37	−0.11	0.05	0.09
18	Not enough time to develop sexual relationships	0.05	−0.07	0.46	−0.04	0.19	−0.06	0.08	−0.01
19	Physical appearance	0.04	0.04	0.24	−0.04	0.30	0.06	0.29	−0.06
20	Troublesome neighbors	−0.10	−0.01	0.13	0.26	0.20	0.11	-0.01	−0.06
21	Concerns about weight	0.04	0.04	−0.04	−0.01	0.12	−0.04	0.79	−0.03
22	Not enough money for tuition and books for medical school	−0.06	0.82	−0.07	0.00	−0.02	0.02	−0.04	−0.05
23	Change in the weather	−0.12	0.20	-0.03	0.24	0.37	−0.14	0.01	0.01
24	Having to wait	0.02	0.03	0.14	0.45	0.21	0.01	−0.12	0.00
25	Friends or relatives too far away	0.16	0.12	0.26	−0.12	0.22	−0.16	0.13	−0.05
26	Worry if made right decision in coming to medical school	0.08	0.22	0.45	−0.08	0.12	−0.18	−0.16	−0.11
27	Feeling exploited by medical school system	0.23	0.34	0.28	−0.09	−0.19	−0.04	−0.03	−0.03
28	Lack of understanding about school commitments from spouse or lover	−0.06	0.16	0.08	−0.08	0.05	0.74	−0.10	−0.13
29	Lack of understanding about school commitments from children	−0.01	0.03	−0.03	−0.06	0.08	−0.11	−0.04	0.72
30	Lack of understanding about school commitments from other family member(s)	−0.11	0.04	0.60	0.02	−0.06	0.05	−0.03	0.05
31	Lack of understanding about school commitments from friend	−0.02	0.03	0.50	0.07	0.05	0.10	−0.21	−0.11
32	Not enough time for entertainment and recreation	0.36	0.27	0.09	−0.11	0.25	0.07	−0.11	0.00
33	Buying clothes	−0.09	0.41	0.09	0.07	0.29	−0.17	0.08	0.00
34	Difficulty finding parking	0.06	0.01	−0.12	0.58	0.00	0.02	−0.06	0.02
35	Traffic	0.02	0.03	−0.08	0.66	0.18	−0.08	−0.07	−0.10
36	Sexual problems	−0.01	−0.12	0.53	−0.02	0.02	0.18	−0.06	−0.04
37	Not enough money for clothing	−0.15	0.69	0.12	0.09	−0.02	−0.06	0.08	−0.04
38	Not enough time to do the things you need to do	0.39	0.25	0.05	−0.11	0.33	−0.02	−0.05	−0.01
39	Not enough money for food	−0.02	0.63	0.06	0.08	−0.18	0.09	0.05	−0.02
40	Cramming	0.79	−0.08	−0.03	0.03	−0.02	0.03	−0.02	−0.01
41	No sleep	0.60	−0.07	0.01	0.04	0.13	0.09	−0.05	0.07
42	Inconsiderate smoker(s)	0.17	0.13	−0.03	0.54	−0.10	−0.13	0.07	0.02
43	Making mistakes	0.64	−0.01	0.03	0.03	0.09	0.05	0.00	−0.11
44	Doing laundry	0.08	−0.07	−0.18	0.10	0.66	−0.02	0.05	−0.11
45	Crime	−0.02	0.07	0.05	0.72	0.01	−0.06	0.01	−0.01
46	Not enough money for housing	0.02	0.71	−0.09	0.01	−0.06	0.07	0.02	0.11
47	Weight loss	0.11	0.07	−0.11	-0.12	0.06	0.04	0.70	0.03
48	Flirting	−0.01	−0.11	0.36	-0.12	0.22	0.10	0.16	−0.18
49	Problems interacting with spouse or lover	−0.05	0.05	0.14	-0.09	0.09	0.77	0.01	−0.14
50	Problems interacting with children	−0.08	−0.13	0.05	-0.07	0.02	0.03	0.09	0.75
51	Problems interacting with other family member(s)	−0.09	−0.03	0.58	0.17	−0.13	0.10	0.06	0.08
52	Problems interacting with friends	0.03	−0.02	0.71	−0.04	−0.06	0.00	−0.04	0.06
53	Doing poorly on exams	0.88	−0.03	−0.01	0.12	−0.24	0.03	0.03	−0.09
54	Noise	0.28	−0.01	0.06	0.40	0.10	−0.02	0.01	−0.11
55	Personal problems interfering with school	0.42	0.04	0.29	0.09	0.02	0.11	−0.10	0.03
56	Interruptions	0.46	−0.09	0.05	0.27	0.17	0.08	−0.06	0.06
57	Failing exams	0.80	0.00	−0.06	0.22	−0.19	0.01	0.06	−0.09
58	Yard work or outside home maintenance	−0.03	−0.07	−0.14	0.34	0.31	0.16	−0.05	0.20
59	Too many classes	0.71	0.10	0.07	−0.01	0.08	−0.11	0.00	−0.02
60	Planning meals	−0.05	−0.08	−0.02	0.04	0.77	0.06	−0.01	0.05
61	Making mistakes on exams	0.91	−0.08	−0.08	0.04	−0.17	−0.01	0.08	−0.01
62	Car maintenance	0.17	0.20	−0.10	0.15	0.20	0.09	−0.01	0.07
63	Thinking about having children	−0.01	0.08	0.05	0.01	−0.05	0.51	0.12	0.13
64	Household appliances and belongings breaking down	−0.03	0.05	0.00	0.34	0.20	0.20	0.01	0.03
65	Taking exams	0.94	−0.09	−0.05	−0.06	−0.13	0.02	0.03	−0.02
66	Smoking too much	0.11	−0.04	0.11	0.23	−0.18	0.05	0.29	−0.05
67	Concerns about being owed money	−0.05	0.22	0.08	0.43	−0.08	−0.03	0.10	−0.01
68	Concerns about meeting high standards	0.40	0.10	0.14	−0.07	0.14	0.13	−0.06	−0.09
69	Menstrual (period) problems	−0.08	0.17	0.21	−0.04	−0.06	0.12	0.33	−0.05
70	Pollution	0.02	0.00	0.12	0.51	0.03	0.05	0.03	−0.10
71	Concerns about owing money	−0.05	0.72	−0.01	0.08	0.04	0.05	−0.12	−0.07
72	Fighting with lover	0.04	0.00	−0.04	0.09	0.02	0.76	0.07	−0.03
73	Not getting enough sleep	0.48	−0.02	−0.04	0.00	0.34	0.03	−0.03	0.04
74	Class schedules	0.46	0.22	0.00	0.03	0.27	−0.10	0.00	−0.09
75	Washing dirty dishes	−0.03	−0.08	−0.08	0.08	0.57	0.19	0.16	0.02
76	Transportation problems	−0.03	0.14	0.01	0.28	0.35	−0.02	−0.16	0.12
77	Not getting enough rest and relaxation	0.55	0.05	−0.04	0.01	0.28	0.04	−0.01	0.08
78	Wasting time	0.54	−0.12	−0.02	0.05	0.07	0.04	0.24	0.04
79	Use of alcohol	0.02	−0.14	0.01	0.06	0.30	0.16	0.15	−0.13
80	Lifestyle sacrifice due to not enough money	0.11	0.71	0.05	−0.04	−0.10	0.08	−0.02	0.05
81	Not enough time for physical activities	0.28	0.24	0.00	−0.03	0.14	0.15	0.08	0.06
82	Misplacing or losing things	0.20	0.04	0.03	0.36	0.13	0.12	0.02	−0.01
83	Traffic ticket	0.03	−0.05	0.02	0.70	0.04	0.01	−0.01	0.00
84	Paying bills	0.09	0.49	−0.05	0.15	0.20	0.06	−0.01	−0.04
85	Visitors or company	0.01	−0.04	0.15	0.11	0.19	0.09	0.03	0.11
86	Care of pet	0.04	−0.06	−0.04	0.02	0.22	0.13	−0.02	0.02
87	Affected by problems with spouse or lover	0.08	0.01	0.04	−0.02	0.05	0.76	0.02	0.00
88	Affected by problems with children	−0.03	−0.07	0.12	0.02	0.04	−0.01	−0.04	0.82
89	Affected by problems with other family member(s)	0.00	0.04	0.45	0.17	-0.11	0.12	0.10	0.14
90	Affected by problems with friends	0.09	−0.06	0.60	0.22	−0.08	0.08	−0.15	0.10
91	Home maintenance	−0.10	0.07	0.07	0.10	0.33	0.02	0.17	0.15
92	Weight gain	0.07	0.11	−0.01	0.04	0.07	−0.04	0.75	0.00
93	Not enough personal energy	0.28	0.05	0.24	0.01	0.23	0.01	0.13	0.00
94	Concerns about bodily functions	0.07	−0.01	0.39	0.01	0.06	−0.04	0.29	0.00
95	Parking tickets	0.08	−0.05	0.01	0.75	−0.03	−0.06	−0.02	−0.09
96	Problems getting along with fellow students	0.17	0.03	0.64	−0.05	−0.11	−0.06	0.00	0.07
97	Preparing meals	0.02	−0.13	0.01	−0.05	0.69	0.08	−0.02	0.04
98	Not enough time to spend with spouse or lover	0.28	0.13	−0.12	−0.09	−0.02	0.59	−0.09	0.12
99	Not enough time to spend with children	0.10	0.19	−0.08	−0.10	−0.10	0.02	−0.04	0.66
100	Not enough time to spend with other family member(s)	0.23	0.10	0.24	−0.01	−0.06	0.10	0.13	0.11
101	Not enough time to spend with friends	0.36	0.01	0.25	0.01	0.25	−0.05	−0.16	0.14
% of variance explained (total: 44%)		21%	5%	4%	3%	3%	3%	3%	2%
α		0.94	0.87	0.83	0.85	0.80	0.79^b	0.75	NA

^a Bolded factor scores denote the subscale(s) in which an item is included. Factor 1 is the Academic and Time Pressures subscale, factor 2 is the Financial subscale, factor 3 is the Social subscale, factor 4 is the External Influences subscale, factor 5 is the Day-to-Day Functioning subscale, combination of factors 6 and 8 is the Relationships With Immediate Family subscale, and factor 7 is the Health subscale.

^b Cronbach α for Relationships With Immediate Family subscale.

Abbreviation: NA, not applicable.

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Table 1.

Factor Scores Produced by Promax Rotation of the First 8 Principal Components From the Medical Education Hassles Scale-R, 7 Subscales Derived From Exploratory Factor Analysis, Percent of Variance Explained by Each Factor, and Cronbach α for the Subscales

Item		Factor^a
Item		1	2	3	4	5	6	7	8
1	Finding a place to study	0.30	−0.16	0.19	−0.05	0.15	0.02	0.04	0.05
2	Condition of the streets	−0.13	0.01	0.12	0.16	0.16	0.15	0.15	−0.09
3	Relating to professors	0.21	0.02	0.27	-0.11	0.01	0.03	0.10	0.07
4	Concern about accidents	−0.05	0.07	0.14	0.31	0.06	−0.09	0.14	0.29
5	Not enough money for entertainment and recreation	−0.04	0.70	−0.11	−0.01	−0.01	0.07	0.15	−0.01
6	Concerns about money for emergencies	−0.02	0.70	-0.14	0.02	−0.08	0.07	0.15	0.08
7	Filling out forms	0.15	0.02	−0.07	0.02	0.32	−0.07	−0.06	0.08
8	Physical illness	0.26	−0.08	0.14	0.10	0.14	−0.07	0.14	0.10
9	Prejudice and discrimination from others	0.17	−0.01	0.43	0.17	−0.09	−0.11	0.09	0.06
10	Use of drugs	0.03	0.01	0.25	0.11	−0.12	0.01	0.10	−0.08
11	Concern with contraception	−0.04	0.05	−0.01	0.11	−0.05	0.28	0.28	0.17
12	Heavy work load	0.71	0.02	0.03	−0.18	0.11	−0.06	0.01	0.08
13	Shopping for groceries	0.00	0.05	0.04	−0.04	0.59	−0.05	0.06	−0.06
14	Instructor giving poor lecture	0.53	−0.08	0.07	0.13	-0.07	−0.01	0.05	−0.09
15	Being lonely	0.09	−0.07	0.46	−0.07	0.21	−0.15	0.12	−0.19
16	Cutting down on electricity, water, etc	−0.14	0.41	0.13	−0.06	0.09	0.13	0.11	−0.05
17	Too many responsibilities	0.32	0.18	0.07	−0.07	0.37	−0.11	0.05	0.09
18	Not enough time to develop sexual relationships	0.05	−0.07	0.46	−0.04	0.19	−0.06	0.08	−0.01
19	Physical appearance	0.04	0.04	0.24	−0.04	0.30	0.06	0.29	−0.06
20	Troublesome neighbors	−0.10	−0.01	0.13	0.26	0.20	0.11	-0.01	−0.06
21	Concerns about weight	0.04	0.04	−0.04	−0.01	0.12	−0.04	0.79	−0.03
22	Not enough money for tuition and books for medical school	−0.06	0.82	−0.07	0.00	−0.02	0.02	−0.04	−0.05
23	Change in the weather	−0.12	0.20	-0.03	0.24	0.37	−0.14	0.01	0.01
24	Having to wait	0.02	0.03	0.14	0.45	0.21	0.01	−0.12	0.00
25	Friends or relatives too far away	0.16	0.12	0.26	−0.12	0.22	−0.16	0.13	−0.05
26	Worry if made right decision in coming to medical school	0.08	0.22	0.45	−0.08	0.12	−0.18	−0.16	−0.11
27	Feeling exploited by medical school system	0.23	0.34	0.28	−0.09	−0.19	−0.04	−0.03	−0.03
28	Lack of understanding about school commitments from spouse or lover	−0.06	0.16	0.08	−0.08	0.05	0.74	−0.10	−0.13
29	Lack of understanding about school commitments from children	−0.01	0.03	−0.03	−0.06	0.08	−0.11	−0.04	0.72
30	Lack of understanding about school commitments from other family member(s)	−0.11	0.04	0.60	0.02	−0.06	0.05	−0.03	0.05
31	Lack of understanding about school commitments from friend	−0.02	0.03	0.50	0.07	0.05	0.10	−0.21	−0.11
32	Not enough time for entertainment and recreation	0.36	0.27	0.09	−0.11	0.25	0.07	−0.11	0.00
33	Buying clothes	−0.09	0.41	0.09	0.07	0.29	−0.17	0.08	0.00
34	Difficulty finding parking	0.06	0.01	−0.12	0.58	0.00	0.02	−0.06	0.02
35	Traffic	0.02	0.03	−0.08	0.66	0.18	−0.08	−0.07	−0.10
36	Sexual problems	−0.01	−0.12	0.53	−0.02	0.02	0.18	−0.06	−0.04
37	Not enough money for clothing	−0.15	0.69	0.12	0.09	−0.02	−0.06	0.08	−0.04
38	Not enough time to do the things you need to do	0.39	0.25	0.05	−0.11	0.33	−0.02	−0.05	−0.01
39	Not enough money for food	−0.02	0.63	0.06	0.08	−0.18	0.09	0.05	−0.02
40	Cramming	0.79	−0.08	−0.03	0.03	−0.02	0.03	−0.02	−0.01
41	No sleep	0.60	−0.07	0.01	0.04	0.13	0.09	−0.05	0.07
42	Inconsiderate smoker(s)	0.17	0.13	−0.03	0.54	−0.10	−0.13	0.07	0.02
43	Making mistakes	0.64	−0.01	0.03	0.03	0.09	0.05	0.00	−0.11
44	Doing laundry	0.08	−0.07	−0.18	0.10	0.66	−0.02	0.05	−0.11
45	Crime	−0.02	0.07	0.05	0.72	0.01	−0.06	0.01	−0.01
46	Not enough money for housing	0.02	0.71	−0.09	0.01	−0.06	0.07	0.02	0.11
47	Weight loss	0.11	0.07	−0.11	-0.12	0.06	0.04	0.70	0.03
48	Flirting	−0.01	−0.11	0.36	-0.12	0.22	0.10	0.16	−0.18
49	Problems interacting with spouse or lover	−0.05	0.05	0.14	-0.09	0.09	0.77	0.01	−0.14
50	Problems interacting with children	−0.08	−0.13	0.05	-0.07	0.02	0.03	0.09	0.75
51	Problems interacting with other family member(s)	−0.09	−0.03	0.58	0.17	−0.13	0.10	0.06	0.08
52	Problems interacting with friends	0.03	−0.02	0.71	−0.04	−0.06	0.00	−0.04	0.06
53	Doing poorly on exams	0.88	−0.03	−0.01	0.12	−0.24	0.03	0.03	−0.09
54	Noise	0.28	−0.01	0.06	0.40	0.10	−0.02	0.01	−0.11
55	Personal problems interfering with school	0.42	0.04	0.29	0.09	0.02	0.11	−0.10	0.03
56	Interruptions	0.46	−0.09	0.05	0.27	0.17	0.08	−0.06	0.06
57	Failing exams	0.80	0.00	−0.06	0.22	−0.19	0.01	0.06	−0.09
58	Yard work or outside home maintenance	−0.03	−0.07	−0.14	0.34	0.31	0.16	−0.05	0.20
59	Too many classes	0.71	0.10	0.07	−0.01	0.08	−0.11	0.00	−0.02
60	Planning meals	−0.05	−0.08	−0.02	0.04	0.77	0.06	−0.01	0.05
61	Making mistakes on exams	0.91	−0.08	−0.08	0.04	−0.17	−0.01	0.08	−0.01
62	Car maintenance	0.17	0.20	−0.10	0.15	0.20	0.09	−0.01	0.07
63	Thinking about having children	−0.01	0.08	0.05	0.01	−0.05	0.51	0.12	0.13
64	Household appliances and belongings breaking down	−0.03	0.05	0.00	0.34	0.20	0.20	0.01	0.03
65	Taking exams	0.94	−0.09	−0.05	−0.06	−0.13	0.02	0.03	−0.02
66	Smoking too much	0.11	−0.04	0.11	0.23	−0.18	0.05	0.29	−0.05
67	Concerns about being owed money	−0.05	0.22	0.08	0.43	−0.08	−0.03	0.10	−0.01
68	Concerns about meeting high standards	0.40	0.10	0.14	−0.07	0.14	0.13	−0.06	−0.09
69	Menstrual (period) problems	−0.08	0.17	0.21	−0.04	−0.06	0.12	0.33	−0.05
70	Pollution	0.02	0.00	0.12	0.51	0.03	0.05	0.03	−0.10
71	Concerns about owing money	−0.05	0.72	−0.01	0.08	0.04	0.05	−0.12	−0.07
72	Fighting with lover	0.04	0.00	−0.04	0.09	0.02	0.76	0.07	−0.03
73	Not getting enough sleep	0.48	−0.02	−0.04	0.00	0.34	0.03	−0.03	0.04
74	Class schedules	0.46	0.22	0.00	0.03	0.27	−0.10	0.00	−0.09
75	Washing dirty dishes	−0.03	−0.08	−0.08	0.08	0.57	0.19	0.16	0.02
76	Transportation problems	−0.03	0.14	0.01	0.28	0.35	−0.02	−0.16	0.12
77	Not getting enough rest and relaxation	0.55	0.05	−0.04	0.01	0.28	0.04	−0.01	0.08
78	Wasting time	0.54	−0.12	−0.02	0.05	0.07	0.04	0.24	0.04
79	Use of alcohol	0.02	−0.14	0.01	0.06	0.30	0.16	0.15	−0.13
80	Lifestyle sacrifice due to not enough money	0.11	0.71	0.05	−0.04	−0.10	0.08	−0.02	0.05
81	Not enough time for physical activities	0.28	0.24	0.00	−0.03	0.14	0.15	0.08	0.06
82	Misplacing or losing things	0.20	0.04	0.03	0.36	0.13	0.12	0.02	−0.01
83	Traffic ticket	0.03	−0.05	0.02	0.70	0.04	0.01	−0.01	0.00
84	Paying bills	0.09	0.49	−0.05	0.15	0.20	0.06	−0.01	−0.04
85	Visitors or company	0.01	−0.04	0.15	0.11	0.19	0.09	0.03	0.11
86	Care of pet	0.04	−0.06	−0.04	0.02	0.22	0.13	−0.02	0.02
87	Affected by problems with spouse or lover	0.08	0.01	0.04	−0.02	0.05	0.76	0.02	0.00
88	Affected by problems with children	−0.03	−0.07	0.12	0.02	0.04	−0.01	−0.04	0.82
89	Affected by problems with other family member(s)	0.00	0.04	0.45	0.17	-0.11	0.12	0.10	0.14
90	Affected by problems with friends	0.09	−0.06	0.60	0.22	−0.08	0.08	−0.15	0.10
91	Home maintenance	−0.10	0.07	0.07	0.10	0.33	0.02	0.17	0.15
92	Weight gain	0.07	0.11	−0.01	0.04	0.07	−0.04	0.75	0.00
93	Not enough personal energy	0.28	0.05	0.24	0.01	0.23	0.01	0.13	0.00
94	Concerns about bodily functions	0.07	−0.01	0.39	0.01	0.06	−0.04	0.29	0.00
95	Parking tickets	0.08	−0.05	0.01	0.75	−0.03	−0.06	−0.02	−0.09
96	Problems getting along with fellow students	0.17	0.03	0.64	−0.05	−0.11	−0.06	0.00	0.07
97	Preparing meals	0.02	−0.13	0.01	−0.05	0.69	0.08	−0.02	0.04
98	Not enough time to spend with spouse or lover	0.28	0.13	−0.12	−0.09	−0.02	0.59	−0.09	0.12
99	Not enough time to spend with children	0.10	0.19	−0.08	−0.10	−0.10	0.02	−0.04	0.66
100	Not enough time to spend with other family member(s)	0.23	0.10	0.24	−0.01	−0.06	0.10	0.13	0.11
101	Not enough time to spend with friends	0.36	0.01	0.25	0.01	0.25	−0.05	−0.16	0.14
% of variance explained (total: 44%)		21%	5%	4%	3%	3%	3%	3%	2%
α		0.94	0.87	0.83	0.85	0.80	0.79^b	0.75	NA

^a Bolded factor scores denote the subscale(s) in which an item is included. Factor 1 is the Academic and Time Pressures subscale, factor 2 is the Financial subscale, factor 3 is the Social subscale, factor 4 is the External Influences subscale, factor 5 is the Day-to-Day Functioning subscale, combination of factors 6 and 8 is the Relationships With Immediate Family subscale, and factor 7 is the Health subscale.

^b Cronbach α for Relationships With Immediate Family subscale.

Abbreviation: NA, not applicable.

Procedures

The MEHS-R was administered during student orientation before the onset of classes each year and then 9 to 11 times throughout the first year. Administration times were selected to balance data collection between periods of examinations, vacation, and routine medical school activity (weeks with neither major examinations nor vacations). Data were analyzed, and confidentiality was maintained by the investigators.

Statistical Analysis

Exploratory Factor Analysis

Principal components analysis with promax rotation was performed on hassles data collected from participants at the first medical school during orientation to statistically identify common themes in the MEHS-R. Principal components were retained through examination of the scree plot, eigenvalues (>1), and the cumulative percentage of the total variance explained (at least 40%).

The factors were converted to subscales of the MEHS-R. Items belonging to each subscale were determined by examining the factor scores resulting from the promax rotation and the content of the item in relation to other items in the subscale. The oblique promax rotation procedure was selected because the factors were expected to be correlated considering the nature of the items included in the MEHS-R. Each subscale was then labeled according to the construct defined by the items included in the subscale. Initially, an item was included in the subscale for which it had the highest factor score. If the highest factor score for an item was less than 0.30, the item was considered for elimination from the subscale. If the difference between the 2 highest factor scores was less than 0.07, the item was considered for inclusion in both subscales. Subscales were formed using unit weights and summing the items included for the scale. The internal consistency of the resulting subscales was measured using Cronbach α, and the independence of subscales was examined using Pearson product moment correlation coefficients.

Confirmatory Factor Analysis

Confirmatory factor analysis was used to investigate the generalizability of the factor structure found in the exploratory factor analysis to times other than orientation and to other medical schools. Four analyses were performed on data collected at the first medical school during periods of examinations, vacation, and routine medical school activity; and on data collected at the second medical school. To account for the dependence between surveys stemming from the use of multiple measurements from each student, a general linear mixed model was fit for each item using an unstructured covariance matrix block for each student. The residuals resulting from the general linear mixed models were used in the confirmatory factor analyses. The confirmatory factor analyses were conducted using the CALIS procedure in SAS (SAS Institute, Inc). The Bentler comparative fit index and Bentler and Bonett nonnormed fit index were calculated to assess the factor model fit. Values of 0.90 or higher were considered to indicate that the model fit was good, and values of 0.70 or higher were considered to indicate that the model fit was adequate. Significance tests of the nonstandardized factor loadings were performed to determine whether the factor loading was significantly greater than zero. A factor loading that is not significant may indicate the item is not related to the subscale. A standardized factor loading of less than 0.20 may also indicate lack of a relationship between the item and the subscale.

Generalizability of Factor Structure to Demographic Subgroups

To examine whether the structure of subscales could be generalized to subsets of the first-year medical student population, confirmatory factor analyses were conducted on data from the following subgroups of participants at the first medical school: males, females, married students, single students, whites, and ethnic minorities.

Results

Of 553 potential participants, 506 first-year medical students (92%)—438 from the first medical school and 68 from the second—volunteered to participate in the study. A majority of the participants were male (70%), single (69%), and white (78%). Four participants declined to identify their marital status, and 5 declined to identify their ethnicity. The mean (SD) age at enrollment was 24.8 (2.9) years.

Exploratory Factor Analysis on the MEHS-R

Of the 438 participants from the first medical school, data from 1 participant were excluded because of incomplete questionnaires. The first 26 principal components had eigenvalues greater than 1.0 (Figure). Eight principal components were retained, which individually explained between 2% and 21% of the total variance of the 101 items and together explained 42% of the total variance. The factor scores resulting from the promax rotation of the first 8 principal components are presented in Table 1. Interfactor correlations ranged from 0.08 to 0.39.

Figure.

Scree plot of eigenvalues from first 26 principal components from exploratory factor analyses of the Medical Education Hassles Scale-R. Principal components analysis with promax rotation was performed on hassles data collected from participants at the first medical school during orientation to statistically identify common themes in the MEHS-R. Principal components were retained through examination of the scree plot, eigenvalues (>1), and the cumulative percentage of the total variance explained (at least 40%).

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Of the 101 items, there were 14 for which the maximum factor score was less than 0.30. Hassle items about the condition of the streets, use of drugs, car maintenance, visitors or company, and care of pet had no factor loadings greater than 0.25; thus, these items were omitted from all subscales. Physical illness was not conceptually related to the other items in the subscale and was also omitted. The remaining items under consideration with factor loadings between 0.25 and 0.30 (relating to professors, concern with contraception, troublesome neighbors, friends or relatives too far away, smoking too much, not enough time for physical activities, not enough personal energy, and not enough time to spend with other family member[s]) were conceptually related to the other items that loaded on the same factor and were, therefore, included in that subscale.

There were 9 items for which the difference between the 2 highest factor scores was less than 0.07 (Table 1). Based on the content of each item, those items determined to be appropriate for inclusion in both subscales were concern with contraception (factors 6 and 7), too many responsibilities (factors 1 and 5), physical appearance (factors 5 and 7), yard work or outside home maintenance (factors 4 and 5), transportation problems (factors 4 and 5), and not enough time to spend with other family member(s) (factors 1 and 3). The other 3 items (relating to professors, feeling exploited by medical school system, and not enough time to do the things you need to do) were included only in the subscale with the highest factor loading.

After the items included in each subscale were identified, it was determined that factors 6 and 8 were conceptually related, in that both were directly related to relationships within the nuclear living group. Consequently, the items associated with these 2 factors were combined into 1 subscale. Each subscale was then titled based on the nature of the items included in the subscale. The items included in each subscale are identified in bold in Table 1. Items related to factor 1 were combined as the Academic and Time Pressures subscale, which consisted of hassles from heavy workload, cramming, making mistakes, interruptions, schedules, and taking examinations. Items related to factor 2 were combined as the Financial subscale, which included concerns about money, a lack of funds, and lifestyle sacrifices because of lack of funds. Items related to factor 3 were combined as the Social subscale, which consisted of hassles students experienced in relating to others, such as professors, friends, and relatives, and not having enough time to develop relationships. Items related to factor 4 were combined as the External Influences subscale, which related to hassles in the community, such as neighbors, traffic, parking, pollution, transportation, crime, and noise. Items related to factor 5 were combined as the Day-to-Day Functioning subscale, which measured hassles that concern daily tasks and responsibilities, such as doing laundry, yard work, planning and preparing meals, and shopping. Items related to factors 6 and 8 were combined as the Relationships With Immediate Family subscale, which included items associated with one's immediate family, spouse/partner, and children. Items related to factor 7 were combined as the Health subscale, which included items related to physical appearance and health, such as weight loss or gain, smoking, contraception, and physical appearance.

The Cronbach α for the 7 subscales were at least 0.75 (Table 1), which is within the acceptable range. The Pearson product moment correlation coefficients between the subscales ranged from 0.33 (Social and Relationships With Immediate Family subscales) to 0.66 (Academic and Time Pressures and Social subscales).

Confirmatory Factor Analysis on the MEHS-R

The fit statistics from the 4 confirmatory factor analyses of the 7 subscales for the MEHS-R are presented in Table 2. Both the Bentler comparative fit index and the Bentler and Bonett nonnormed fit index indicated the 7-factor model fit the data adequately for the examination and routine medical school activity periods. Additionally, the Bentler comparative fit index was 0.70 for the data from the vacation period. However, neither of the fit indices indicated adequate fit to the data from the second medical school. The tests for the nonstandardized factor loadings were statistically significant for all items with the exception of too many responsibilities, yard work or outside home maintenance, and transportation problems from the Day-to-Day Functioning subscale. The following items had standardized factor loadings less than 0.20: concern with contraception and smoking too much from the Health subscale; too many responsibilities, yard work or outside home maintenance, and transportation problems from the Day-to-Day Functioning subscale; and not enough time to spend with other family member(s) from the Academic and Time Pressures subscale. The correlations between the subscales ranged from 0.15 (Academic and Time Pressures and Relationships With Immediate Family subscales) to 0.83 (External Influences and Social subscales).

Table 2.

Fit Statistics From the Confirmatory Factor Analysis of Subscales (7-Factor Model) for the Medical Education Hassles Scale-R (MEHS-R)^a

MEHS-R Administration^b	No. of Participants	No. of Measurements	Fit Index
MEHS-R Administration^b	No. of Participants	No. of Measurements	CFI	NNFI
First Medical School
Examination period	436	1322	0.73	0.72
Vacation period	429	919	0.70	0.69
Routine medical school activity period	436	1072	0.73	0.73
Second Medical School	68	712	0.64	0.63

^a To remove the variability from repeated measurements from the same student, these analyses were performed on the residuals obtained from a repeated measures analysis of variance of each item.

^b The MEHS-R was administered 9-10 times after orientation at the first medical school, which were classified as examination, vacation, or routine medical school activity periods for separate analyses, and 11 times at the second medical school, which were combined in 1 analysis.

Abbreviations: CFI, Bentler comparative fit index; NNFI, Bentler and Bonett nonnormed fit index.

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Table 2.

Fit Statistics From the Confirmatory Factor Analysis of Subscales (7-Factor Model) for the Medical Education Hassles Scale-R (MEHS-R)^a

MEHS-R Administration^b	No. of Participants	No. of Measurements	Fit Index
MEHS-R Administration^b	No. of Participants	No. of Measurements	CFI	NNFI
First Medical School
Examination period	436	1322	0.73	0.72
Vacation period	429	919	0.70	0.69
Routine medical school activity period	436	1072	0.73	0.73
Second Medical School	68	712	0.64	0.63

^a To remove the variability from repeated measurements from the same student, these analyses were performed on the residuals obtained from a repeated measures analysis of variance of each item.

^b The MEHS-R was administered 9-10 times after orientation at the first medical school, which were classified as examination, vacation, or routine medical school activity periods for separate analyses, and 11 times at the second medical school, which were combined in 1 analysis.

Abbreviations: CFI, Bentler comparative fit index; NNFI, Bentler and Bonett nonnormed fit index.

Generalizability of Factor Structure to Demographic Subgroups

Confirmatory factor analyses of the subscales for the MEHS-R 7-subscale model were performed on 6 subgroups of the study participants, and the fit statistics from these factor analyses are presented in Table 3. The Bentler comparative fit index and the Bentler and Bonett nonnormed fit index indicated the models used adequately fit the data for all but the analysis of the MEHS-R on the ethnic minorities subgroup.

Table 3.

Fit Statistics from the Confirmatory Factor Analysis of Subscales for the Medical Education Hassles Scale-R (MEHS-R) for Demographic Subgroups^a

Demographic Subgroup	No. of Participants	No. of Measurements	Fit Index
Demographic Subgroup	No. of Participants	No. of Measurements	CFI	NNFI
Males	318	2808	0.74	0.73
Females	120	1061	0.71	0.70
Married	143	1290	0.70	0.70
Single	291	2567	0.74	0.74
White	348	3092	0.75	0.74
Ethnic minorities	85	746	0.67	0.66

^a To remove the variability from repeated measurements from the same student, these analyses were performed on the residuals obtained from a repeated measures analysis of variance of each item.

Abbreviations: CFI, Bentler comparative fit index; NNFI, Bentler and Bonett nonnormed fit index.

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Table 3.

Fit Statistics from the Confirmatory Factor Analysis of Subscales for the Medical Education Hassles Scale-R (MEHS-R) for Demographic Subgroups^a

Demographic Subgroup	No. of Participants	No. of Measurements	Fit Index
Demographic Subgroup	No. of Participants	No. of Measurements	CFI	NNFI
Males	318	2808	0.74	0.73
Females	120	1061	0.71	0.70
Married	143	1290	0.70	0.70
Single	291	2567	0.74	0.74
White	348	3092	0.75	0.74
Ethnic minorities	85	746	0.67	0.66

^a To remove the variability from repeated measurements from the same student, these analyses were performed on the residuals obtained from a repeated measures analysis of variance of each item.

Abbreviations: CFI, Bentler comparative fit index; NNFI, Bentler and Bonett nonnormed fit index.

Discussion

The goal of the present study was to identify and group related items on the MEHS-R questionnaire into common subscales. These subscales would potentially make the MEHS-R a more powerful research tool for identifying sources of acute stress during medical education. Furthermore, identification of specific sources of stress could lead to more focused intervention programs that reduce the negative effect of stress on the health of medical students.

Exploratory factor analysis performed on the data from the MEHS-R supported formation of subscales that were similar to the categories identified by Wolf et al¹⁶ in development of the MEHS (ie, interpersonal relationships, health habits, financial status, chores, viewpoints on the outside world, and personal habits). Of the 7 subscales identified for the MEHS-R, 5 had a strong correspondence with the Wolf et al¹⁶ categories (our Relationships With Immediate Family vs their interpersonal relationships, Health vs health habits, Financial vs financial status, Day-to-Day Functioning vs chores, and External Influences vs viewpoints on the outside world). Wolf et al^5,16 did not indicate which items were included in the MEHS to address each category, but the items included in the Social subscale may overlap to some extent with the items identified in their personal habits category. In addition, our subscale with the highest internal consistency, Academic and Time Pressures, was consistent with the findings of Wolf et al¹⁶ that the hassle items most often endorsed were academic concerns.

In the present study, the decision to omit 6 items from all subscales and to include 7 other items in 2 subscales was based on statistical findings and examination of the content of the items included in each subscale. Of the 6 items that were omitted from all subscales, 4 (condition of the streets, use of drugs, visitors or company, and care of pet) were seldom cited by students in the study and had extremely low factor loadings. The other 2 items, car maintenance and physical illness, had low to extremely low factor loadings or did not appear to relate to the other items in the subscale for which the item had the highest factor loading. Unexpectedly, physical illness as a hassle was associated with issues of academics and time pressures rather than other health issues. Thus, it appears that illness is viewed more as an interference with school than it is a health concern.

For the most part, confirmatory factor analysis supported placement of items in the 7 designated subscales. The 6 exceptions included 5 of the items that conceptually fit into 2 subscales each. For both the concern with contraception and smoking too much items, only 1 of the 4 samples had a standardized factor loading less than 0.20, and the nonstandardized factor loadings were statistically significant for all 4 samples. The lack of stability for the remaining 4 items might have several different sources. Yard work and outside home maintenance, transportation problems, and not having enough time to spend with family members were infrequently cited by students. Consequently, the stability of the factor loadings for these 3 items may have suffered from a lack of variability in the responses. An additional potential reason for the exceptions identified in the confirmatory factor analysis might be the circumstances associated with sampling times. The exploratory factor analysis was performed on data obtained at orientation, while the confirmatory factor analyses were performed on data obtained after students were established in their new environment or, in the case of the second medical school, on data pooled over multiple data collection times that were heavily weighted by nonorientation data. Hence, items such as too many responsibilities, yard work and outside home maintenance, and transportation problems, which could be associated with day-to-day issues when moving to a new environment, may be perceived somewhat differently over time. Similarly, not having enough time to spend with family members may have been an issue of time pressure when extended family was nearby during orientation but was no longer related to time pressure once they were gone.

The results of the confirmatory factor analysis using data from the second medical school demonstrate the need to expand examining the generalizability of the MEHS-R subscales beyond a single medical school. Because the subscales were developed based on first-year osteopathic medical students attending 2 rural medical schools, the generalizability to urban medical schools and to clinical years may be limited. Additionally, the generalizability of the results to specific ethnic minority subgroups could not be examined because of the small sample sizes in these subgroups. The utility of the MEHS-R subscales could be increased by further studies that include students attending urban medical schools, students during their clinical rotations, and larger samples of students who identify as ethnic minorities.

Conclusion

Although Wolf et al^5,16,17 reported total scores in their studies, the subscale scores for the MEHS-R identified in the present study have demonstrated utility as a research tool for examining the types of acute stress experienced by medical students at orientation.⁹ Analysis of the types of stress experienced by medical students allows medical schools to determine the areas in which stress reduction interventions would have the greatest impact. The present study also suggested that the subscales from the MEHS-R can be generalized to diverse groups, such as those related to gender, marital status, and ethnic background, to allow for more targeted interventions to reduce acute stress, potentially leading to increases in students’ well-being and reductions in the prevalence of burnout in medical students.¹⁸

Acknowledgments

We appreciate the editorial support provided by Deborah Goggin, MA, ELS, from Research Support at A.T. Still University. We also appreciate the insightful comments from the manuscript reviewers.

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Figure.

Scree plot of eigenvalues from first 26 principal components from exploratory factor analyses of the Medical Education Hassles Scale-R. Principal components analysis with promax rotation was performed on hassles data collected from participants at the first medical school during orientation to statistically identify common themes in the MEHS-R. Principal components were retained through examination of the scree plot, eigenvalues (>1), and the cumulative percentage of the total variance explained (at least 40%).

View Original | Slide (.ppt)

Table 1.

Factor Scores Produced by Promax Rotation of the First 8 Principal Components From the Medical Education Hassles Scale-R, 7 Subscales Derived From Exploratory Factor Analysis, Percent of Variance Explained by Each Factor, and Cronbach α for the Subscales

Item		Factor^a
Item		1	2	3	4	5	6	7	8
1	Finding a place to study	0.30	−0.16	0.19	−0.05	0.15	0.02	0.04	0.05
2	Condition of the streets	−0.13	0.01	0.12	0.16	0.16	0.15	0.15	−0.09
3	Relating to professors	0.21	0.02	0.27	-0.11	0.01	0.03	0.10	0.07
4	Concern about accidents	−0.05	0.07	0.14	0.31	0.06	−0.09	0.14	0.29
5	Not enough money for entertainment and recreation	−0.04	0.70	−0.11	−0.01	−0.01	0.07	0.15	−0.01
6	Concerns about money for emergencies	−0.02	0.70	-0.14	0.02	−0.08	0.07	0.15	0.08
7	Filling out forms	0.15	0.02	−0.07	0.02	0.32	−0.07	−0.06	0.08
8	Physical illness	0.26	−0.08	0.14	0.10	0.14	−0.07	0.14	0.10
9	Prejudice and discrimination from others	0.17	−0.01	0.43	0.17	−0.09	−0.11	0.09	0.06
10	Use of drugs	0.03	0.01	0.25	0.11	−0.12	0.01	0.10	−0.08
11	Concern with contraception	−0.04	0.05	−0.01	0.11	−0.05	0.28	0.28	0.17
12	Heavy work load	0.71	0.02	0.03	−0.18	0.11	−0.06	0.01	0.08
13	Shopping for groceries	0.00	0.05	0.04	−0.04	0.59	−0.05	0.06	−0.06
14	Instructor giving poor lecture	0.53	−0.08	0.07	0.13	-0.07	−0.01	0.05	−0.09
15	Being lonely	0.09	−0.07	0.46	−0.07	0.21	−0.15	0.12	−0.19
16	Cutting down on electricity, water, etc	−0.14	0.41	0.13	−0.06	0.09	0.13	0.11	−0.05
17	Too many responsibilities	0.32	0.18	0.07	−0.07	0.37	−0.11	0.05	0.09
18	Not enough time to develop sexual relationships	0.05	−0.07	0.46	−0.04	0.19	−0.06	0.08	−0.01
19	Physical appearance	0.04	0.04	0.24	−0.04	0.30	0.06	0.29	−0.06
20	Troublesome neighbors	−0.10	−0.01	0.13	0.26	0.20	0.11	-0.01	−0.06
21	Concerns about weight	0.04	0.04	−0.04	−0.01	0.12	−0.04	0.79	−0.03
22	Not enough money for tuition and books for medical school	−0.06	0.82	−0.07	0.00	−0.02	0.02	−0.04	−0.05
23	Change in the weather	−0.12	0.20	-0.03	0.24	0.37	−0.14	0.01	0.01
24	Having to wait	0.02	0.03	0.14	0.45	0.21	0.01	−0.12	0.00
25	Friends or relatives too far away	0.16	0.12	0.26	−0.12	0.22	−0.16	0.13	−0.05
26	Worry if made right decision in coming to medical school	0.08	0.22	0.45	−0.08	0.12	−0.18	−0.16	−0.11
27	Feeling exploited by medical school system	0.23	0.34	0.28	−0.09	−0.19	−0.04	−0.03	−0.03
28	Lack of understanding about school commitments from spouse or lover	−0.06	0.16	0.08	−0.08	0.05	0.74	−0.10	−0.13
29	Lack of understanding about school commitments from children	−0.01	0.03	−0.03	−0.06	0.08	−0.11	−0.04	0.72
30	Lack of understanding about school commitments from other family member(s)	−0.11	0.04	0.60	0.02	−0.06	0.05	−0.03	0.05
31	Lack of understanding about school commitments from friend	−0.02	0.03	0.50	0.07	0.05	0.10	−0.21	−0.11
32	Not enough time for entertainment and recreation	0.36	0.27	0.09	−0.11	0.25	0.07	−0.11	0.00
33	Buying clothes	−0.09	0.41	0.09	0.07	0.29	−0.17	0.08	0.00
34	Difficulty finding parking	0.06	0.01	−0.12	0.58	0.00	0.02	−0.06	0.02
35	Traffic	0.02	0.03	−0.08	0.66	0.18	−0.08	−0.07	−0.10
36	Sexual problems	−0.01	−0.12	0.53	−0.02	0.02	0.18	−0.06	−0.04
37	Not enough money for clothing	−0.15	0.69	0.12	0.09	−0.02	−0.06	0.08	−0.04
38	Not enough time to do the things you need to do	0.39	0.25	0.05	−0.11	0.33	−0.02	−0.05	−0.01
39	Not enough money for food	−0.02	0.63	0.06	0.08	−0.18	0.09	0.05	−0.02
40	Cramming	0.79	−0.08	−0.03	0.03	−0.02	0.03	−0.02	−0.01
41	No sleep	0.60	−0.07	0.01	0.04	0.13	0.09	−0.05	0.07
42	Inconsiderate smoker(s)	0.17	0.13	−0.03	0.54	−0.10	−0.13	0.07	0.02
43	Making mistakes	0.64	−0.01	0.03	0.03	0.09	0.05	0.00	−0.11
44	Doing laundry	0.08	−0.07	−0.18	0.10	0.66	−0.02	0.05	−0.11
45	Crime	−0.02	0.07	0.05	0.72	0.01	−0.06	0.01	−0.01
46	Not enough money for housing	0.02	0.71	−0.09	0.01	−0.06	0.07	0.02	0.11
47	Weight loss	0.11	0.07	−0.11	-0.12	0.06	0.04	0.70	0.03
48	Flirting	−0.01	−0.11	0.36	-0.12	0.22	0.10	0.16	−0.18
49	Problems interacting with spouse or lover	−0.05	0.05	0.14	-0.09	0.09	0.77	0.01	−0.14
50	Problems interacting with children	−0.08	−0.13	0.05	-0.07	0.02	0.03	0.09	0.75
51	Problems interacting with other family member(s)	−0.09	−0.03	0.58	0.17	−0.13	0.10	0.06	0.08
52	Problems interacting with friends	0.03	−0.02	0.71	−0.04	−0.06	0.00	−0.04	0.06
53	Doing poorly on exams	0.88	−0.03	−0.01	0.12	−0.24	0.03	0.03	−0.09
54	Noise	0.28	−0.01	0.06	0.40	0.10	−0.02	0.01	−0.11
55	Personal problems interfering with school	0.42	0.04	0.29	0.09	0.02	0.11	−0.10	0.03
56	Interruptions	0.46	−0.09	0.05	0.27	0.17	0.08	−0.06	0.06
57	Failing exams	0.80	0.00	−0.06	0.22	−0.19	0.01	0.06	−0.09
58	Yard work or outside home maintenance	−0.03	−0.07	−0.14	0.34	0.31	0.16	−0.05	0.20
59	Too many classes	0.71	0.10	0.07	−0.01	0.08	−0.11	0.00	−0.02
60	Planning meals	−0.05	−0.08	−0.02	0.04	0.77	0.06	−0.01	0.05
61	Making mistakes on exams	0.91	−0.08	−0.08	0.04	−0.17	−0.01	0.08	−0.01
62	Car maintenance	0.17	0.20	−0.10	0.15	0.20	0.09	−0.01	0.07
63	Thinking about having children	−0.01	0.08	0.05	0.01	−0.05	0.51	0.12	0.13
64	Household appliances and belongings breaking down	−0.03	0.05	0.00	0.34	0.20	0.20	0.01	0.03
65	Taking exams	0.94	−0.09	−0.05	−0.06	−0.13	0.02	0.03	−0.02
66	Smoking too much	0.11	−0.04	0.11	0.23	−0.18	0.05	0.29	−0.05
67	Concerns about being owed money	−0.05	0.22	0.08	0.43	−0.08	−0.03	0.10	−0.01
68	Concerns about meeting high standards	0.40	0.10	0.14	−0.07	0.14	0.13	−0.06	−0.09
69	Menstrual (period) problems	−0.08	0.17	0.21	−0.04	−0.06	0.12	0.33	−0.05
70	Pollution	0.02	0.00	0.12	0.51	0.03	0.05	0.03	−0.10
71	Concerns about owing money	−0.05	0.72	−0.01	0.08	0.04	0.05	−0.12	−0.07
72	Fighting with lover	0.04	0.00	−0.04	0.09	0.02	0.76	0.07	−0.03
73	Not getting enough sleep	0.48	−0.02	−0.04	0.00	0.34	0.03	−0.03	0.04
74	Class schedules	0.46	0.22	0.00	0.03	0.27	−0.10	0.00	−0.09
75	Washing dirty dishes	−0.03	−0.08	−0.08	0.08	0.57	0.19	0.16	0.02
76	Transportation problems	−0.03	0.14	0.01	0.28	0.35	−0.02	−0.16	0.12
77	Not getting enough rest and relaxation	0.55	0.05	−0.04	0.01	0.28	0.04	−0.01	0.08
78	Wasting time	0.54	−0.12	−0.02	0.05	0.07	0.04	0.24	0.04
79	Use of alcohol	0.02	−0.14	0.01	0.06	0.30	0.16	0.15	−0.13
80	Lifestyle sacrifice due to not enough money	0.11	0.71	0.05	−0.04	−0.10	0.08	−0.02	0.05
81	Not enough time for physical activities	0.28	0.24	0.00	−0.03	0.14	0.15	0.08	0.06
82	Misplacing or losing things	0.20	0.04	0.03	0.36	0.13	0.12	0.02	−0.01
83	Traffic ticket	0.03	−0.05	0.02	0.70	0.04	0.01	−0.01	0.00
84	Paying bills	0.09	0.49	−0.05	0.15	0.20	0.06	−0.01	−0.04
85	Visitors or company	0.01	−0.04	0.15	0.11	0.19	0.09	0.03	0.11
86	Care of pet	0.04	−0.06	−0.04	0.02	0.22	0.13	−0.02	0.02
87	Affected by problems with spouse or lover	0.08	0.01	0.04	−0.02	0.05	0.76	0.02	0.00
88	Affected by problems with children	−0.03	−0.07	0.12	0.02	0.04	−0.01	−0.04	0.82
89	Affected by problems with other family member(s)	0.00	0.04	0.45	0.17	-0.11	0.12	0.10	0.14
90	Affected by problems with friends	0.09	−0.06	0.60	0.22	−0.08	0.08	−0.15	0.10
91	Home maintenance	−0.10	0.07	0.07	0.10	0.33	0.02	0.17	0.15
92	Weight gain	0.07	0.11	−0.01	0.04	0.07	−0.04	0.75	0.00
93	Not enough personal energy	0.28	0.05	0.24	0.01	0.23	0.01	0.13	0.00
94	Concerns about bodily functions	0.07	−0.01	0.39	0.01	0.06	−0.04	0.29	0.00
95	Parking tickets	0.08	−0.05	0.01	0.75	−0.03	−0.06	−0.02	−0.09
96	Problems getting along with fellow students	0.17	0.03	0.64	−0.05	−0.11	−0.06	0.00	0.07
97	Preparing meals	0.02	−0.13	0.01	−0.05	0.69	0.08	−0.02	0.04
98	Not enough time to spend with spouse or lover	0.28	0.13	−0.12	−0.09	−0.02	0.59	−0.09	0.12
99	Not enough time to spend with children	0.10	0.19	−0.08	−0.10	−0.10	0.02	−0.04	0.66
100	Not enough time to spend with other family member(s)	0.23	0.10	0.24	−0.01	−0.06	0.10	0.13	0.11
101	Not enough time to spend with friends	0.36	0.01	0.25	0.01	0.25	−0.05	−0.16	0.14
% of variance explained (total: 44%)		21%	5%	4%	3%	3%	3%	3%	2%
α		0.94	0.87	0.83	0.85	0.80	0.79^b	0.75	NA

^a Bolded factor scores denote the subscale(s) in which an item is included. Factor 1 is the Academic and Time Pressures subscale, factor 2 is the Financial subscale, factor 3 is the Social subscale, factor 4 is the External Influences subscale, factor 5 is the Day-to-Day Functioning subscale, combination of factors 6 and 8 is the Relationships With Immediate Family subscale, and factor 7 is the Health subscale.

^b Cronbach α for Relationships With Immediate Family subscale.

Abbreviation: NA, not applicable.

View Large

Table 1.

Factor Scores Produced by Promax Rotation of the First 8 Principal Components From the Medical Education Hassles Scale-R, 7 Subscales Derived From Exploratory Factor Analysis, Percent of Variance Explained by Each Factor, and Cronbach α for the Subscales

Item		Factor^a
Item		1	2	3	4	5	6	7	8
1	Finding a place to study	0.30	−0.16	0.19	−0.05	0.15	0.02	0.04	0.05
2	Condition of the streets	−0.13	0.01	0.12	0.16	0.16	0.15	0.15	−0.09
3	Relating to professors	0.21	0.02	0.27	-0.11	0.01	0.03	0.10	0.07
4	Concern about accidents	−0.05	0.07	0.14	0.31	0.06	−0.09	0.14	0.29
5	Not enough money for entertainment and recreation	−0.04	0.70	−0.11	−0.01	−0.01	0.07	0.15	−0.01
6	Concerns about money for emergencies	−0.02	0.70	-0.14	0.02	−0.08	0.07	0.15	0.08
7	Filling out forms	0.15	0.02	−0.07	0.02	0.32	−0.07	−0.06	0.08
8	Physical illness	0.26	−0.08	0.14	0.10	0.14	−0.07	0.14	0.10
9	Prejudice and discrimination from others	0.17	−0.01	0.43	0.17	−0.09	−0.11	0.09	0.06
10	Use of drugs	0.03	0.01	0.25	0.11	−0.12	0.01	0.10	−0.08
11	Concern with contraception	−0.04	0.05	−0.01	0.11	−0.05	0.28	0.28	0.17
12	Heavy work load	0.71	0.02	0.03	−0.18	0.11	−0.06	0.01	0.08
13	Shopping for groceries	0.00	0.05	0.04	−0.04	0.59	−0.05	0.06	−0.06
14	Instructor giving poor lecture	0.53	−0.08	0.07	0.13	-0.07	−0.01	0.05	−0.09
15	Being lonely	0.09	−0.07	0.46	−0.07	0.21	−0.15	0.12	−0.19
16	Cutting down on electricity, water, etc	−0.14	0.41	0.13	−0.06	0.09	0.13	0.11	−0.05
17	Too many responsibilities	0.32	0.18	0.07	−0.07	0.37	−0.11	0.05	0.09
18	Not enough time to develop sexual relationships	0.05	−0.07	0.46	−0.04	0.19	−0.06	0.08	−0.01
19	Physical appearance	0.04	0.04	0.24	−0.04	0.30	0.06	0.29	−0.06
20	Troublesome neighbors	−0.10	−0.01	0.13	0.26	0.20	0.11	-0.01	−0.06
21	Concerns about weight	0.04	0.04	−0.04	−0.01	0.12	−0.04	0.79	−0.03
22	Not enough money for tuition and books for medical school	−0.06	0.82	−0.07	0.00	−0.02	0.02	−0.04	−0.05
23	Change in the weather	−0.12	0.20	-0.03	0.24	0.37	−0.14	0.01	0.01
24	Having to wait	0.02	0.03	0.14	0.45	0.21	0.01	−0.12	0.00
25	Friends or relatives too far away	0.16	0.12	0.26	−0.12	0.22	−0.16	0.13	−0.05
26	Worry if made right decision in coming to medical school	0.08	0.22	0.45	−0.08	0.12	−0.18	−0.16	−0.11
27	Feeling exploited by medical school system	0.23	0.34	0.28	−0.09	−0.19	−0.04	−0.03	−0.03
28	Lack of understanding about school commitments from spouse or lover	−0.06	0.16	0.08	−0.08	0.05	0.74	−0.10	−0.13
29	Lack of understanding about school commitments from children	−0.01	0.03	−0.03	−0.06	0.08	−0.11	−0.04	0.72
30	Lack of understanding about school commitments from other family member(s)	−0.11	0.04	0.60	0.02	−0.06	0.05	−0.03	0.05
31	Lack of understanding about school commitments from friend	−0.02	0.03	0.50	0.07	0.05	0.10	−0.21	−0.11
32	Not enough time for entertainment and recreation	0.36	0.27	0.09	−0.11	0.25	0.07	−0.11	0.00
33	Buying clothes	−0.09	0.41	0.09	0.07	0.29	−0.17	0.08	0.00
34	Difficulty finding parking	0.06	0.01	−0.12	0.58	0.00	0.02	−0.06	0.02
35	Traffic	0.02	0.03	−0.08	0.66	0.18	−0.08	−0.07	−0.10
36	Sexual problems	−0.01	−0.12	0.53	−0.02	0.02	0.18	−0.06	−0.04
37	Not enough money for clothing	−0.15	0.69	0.12	0.09	−0.02	−0.06	0.08	−0.04
38	Not enough time to do the things you need to do	0.39	0.25	0.05	−0.11	0.33	−0.02	−0.05	−0.01
39	Not enough money for food	−0.02	0.63	0.06	0.08	−0.18	0.09	0.05	−0.02
40	Cramming	0.79	−0.08	−0.03	0.03	−0.02	0.03	−0.02	−0.01
41	No sleep	0.60	−0.07	0.01	0.04	0.13	0.09	−0.05	0.07
42	Inconsiderate smoker(s)	0.17	0.13	−0.03	0.54	−0.10	−0.13	0.07	0.02
43	Making mistakes	0.64	−0.01	0.03	0.03	0.09	0.05	0.00	−0.11
44	Doing laundry	0.08	−0.07	−0.18	0.10	0.66	−0.02	0.05	−0.11
45	Crime	−0.02	0.07	0.05	0.72	0.01	−0.06	0.01	−0.01
46	Not enough money for housing	0.02	0.71	−0.09	0.01	−0.06	0.07	0.02	0.11
47	Weight loss	0.11	0.07	−0.11	-0.12	0.06	0.04	0.70	0.03
48	Flirting	−0.01	−0.11	0.36	-0.12	0.22	0.10	0.16	−0.18
49	Problems interacting with spouse or lover	−0.05	0.05	0.14	-0.09	0.09	0.77	0.01	−0.14
50	Problems interacting with children	−0.08	−0.13	0.05	-0.07	0.02	0.03	0.09	0.75
51	Problems interacting with other family member(s)	−0.09	−0.03	0.58	0.17	−0.13	0.10	0.06	0.08
52	Problems interacting with friends	0.03	−0.02	0.71	−0.04	−0.06	0.00	−0.04	0.06
53	Doing poorly on exams	0.88	−0.03	−0.01	0.12	−0.24	0.03	0.03	−0.09
54	Noise	0.28	−0.01	0.06	0.40	0.10	−0.02	0.01	−0.11
55	Personal problems interfering with school	0.42	0.04	0.29	0.09	0.02	0.11	−0.10	0.03
56	Interruptions	0.46	−0.09	0.05	0.27	0.17	0.08	−0.06	0.06
57	Failing exams	0.80	0.00	−0.06	0.22	−0.19	0.01	0.06	−0.09
58	Yard work or outside home maintenance	−0.03	−0.07	−0.14	0.34	0.31	0.16	−0.05	0.20
59	Too many classes	0.71	0.10	0.07	−0.01	0.08	−0.11	0.00	−0.02
60	Planning meals	−0.05	−0.08	−0.02	0.04	0.77	0.06	−0.01	0.05
61	Making mistakes on exams	0.91	−0.08	−0.08	0.04	−0.17	−0.01	0.08	−0.01
62	Car maintenance	0.17	0.20	−0.10	0.15	0.20	0.09	−0.01	0.07
63	Thinking about having children	−0.01	0.08	0.05	0.01	−0.05	0.51	0.12	0.13
64	Household appliances and belongings breaking down	−0.03	0.05	0.00	0.34	0.20	0.20	0.01	0.03
65	Taking exams	0.94	−0.09	−0.05	−0.06	−0.13	0.02	0.03	−0.02
66	Smoking too much	0.11	−0.04	0.11	0.23	−0.18	0.05	0.29	−0.05
67	Concerns about being owed money	−0.05	0.22	0.08	0.43	−0.08	−0.03	0.10	−0.01
68	Concerns about meeting high standards	0.40	0.10	0.14	−0.07	0.14	0.13	−0.06	−0.09
69	Menstrual (period) problems	−0.08	0.17	0.21	−0.04	−0.06	0.12	0.33	−0.05
70	Pollution	0.02	0.00	0.12	0.51	0.03	0.05	0.03	−0.10
71	Concerns about owing money	−0.05	0.72	−0.01	0.08	0.04	0.05	−0.12	−0.07
72	Fighting with lover	0.04	0.00	−0.04	0.09	0.02	0.76	0.07	−0.03
73	Not getting enough sleep	0.48	−0.02	−0.04	0.00	0.34	0.03	−0.03	0.04
74	Class schedules	0.46	0.22	0.00	0.03	0.27	−0.10	0.00	−0.09
75	Washing dirty dishes	−0.03	−0.08	−0.08	0.08	0.57	0.19	0.16	0.02
76	Transportation problems	−0.03	0.14	0.01	0.28	0.35	−0.02	−0.16	0.12
77	Not getting enough rest and relaxation	0.55	0.05	−0.04	0.01	0.28	0.04	−0.01	0.08
78	Wasting time	0.54	−0.12	−0.02	0.05	0.07	0.04	0.24	0.04
79	Use of alcohol	0.02	−0.14	0.01	0.06	0.30	0.16	0.15	−0.13
80	Lifestyle sacrifice due to not enough money	0.11	0.71	0.05	−0.04	−0.10	0.08	−0.02	0.05
81	Not enough time for physical activities	0.28	0.24	0.00	−0.03	0.14	0.15	0.08	0.06
82	Misplacing or losing things	0.20	0.04	0.03	0.36	0.13	0.12	0.02	−0.01
83	Traffic ticket	0.03	−0.05	0.02	0.70	0.04	0.01	−0.01	0.00
84	Paying bills	0.09	0.49	−0.05	0.15	0.20	0.06	−0.01	−0.04
85	Visitors or company	0.01	−0.04	0.15	0.11	0.19	0.09	0.03	0.11
86	Care of pet	0.04	−0.06	−0.04	0.02	0.22	0.13	−0.02	0.02
87	Affected by problems with spouse or lover	0.08	0.01	0.04	−0.02	0.05	0.76	0.02	0.00
88	Affected by problems with children	−0.03	−0.07	0.12	0.02	0.04	−0.01	−0.04	0.82
89	Affected by problems with other family member(s)	0.00	0.04	0.45	0.17	-0.11	0.12	0.10	0.14
90	Affected by problems with friends	0.09	−0.06	0.60	0.22	−0.08	0.08	−0.15	0.10
91	Home maintenance	−0.10	0.07	0.07	0.10	0.33	0.02	0.17	0.15
92	Weight gain	0.07	0.11	−0.01	0.04	0.07	−0.04	0.75	0.00
93	Not enough personal energy	0.28	0.05	0.24	0.01	0.23	0.01	0.13	0.00
94	Concerns about bodily functions	0.07	−0.01	0.39	0.01	0.06	−0.04	0.29	0.00
95	Parking tickets	0.08	−0.05	0.01	0.75	−0.03	−0.06	−0.02	−0.09
96	Problems getting along with fellow students	0.17	0.03	0.64	−0.05	−0.11	−0.06	0.00	0.07
97	Preparing meals	0.02	−0.13	0.01	−0.05	0.69	0.08	−0.02	0.04
98	Not enough time to spend with spouse or lover	0.28	0.13	−0.12	−0.09	−0.02	0.59	−0.09	0.12
99	Not enough time to spend with children	0.10	0.19	−0.08	−0.10	−0.10	0.02	−0.04	0.66
100	Not enough time to spend with other family member(s)	0.23	0.10	0.24	−0.01	−0.06	0.10	0.13	0.11
101	Not enough time to spend with friends	0.36	0.01	0.25	0.01	0.25	−0.05	−0.16	0.14
% of variance explained (total: 44%)		21%	5%	4%	3%	3%	3%	3%	2%
α		0.94	0.87	0.83	0.85	0.80	0.79^b	0.75	NA

^a Bolded factor scores denote the subscale(s) in which an item is included. Factor 1 is the Academic and Time Pressures subscale, factor 2 is the Financial subscale, factor 3 is the Social subscale, factor 4 is the External Influences subscale, factor 5 is the Day-to-Day Functioning subscale, combination of factors 6 and 8 is the Relationships With Immediate Family subscale, and factor 7 is the Health subscale.

^b Cronbach α for Relationships With Immediate Family subscale.

Abbreviation: NA, not applicable.

Table 2.

Fit Statistics From the Confirmatory Factor Analysis of Subscales (7-Factor Model) for the Medical Education Hassles Scale-R (MEHS-R)^a

MEHS-R Administration^b	No. of Participants	No. of Measurements	Fit Index
MEHS-R Administration^b	No. of Participants	No. of Measurements	CFI	NNFI
First Medical School
Examination period	436	1322	0.73	0.72
Vacation period	429	919	0.70	0.69
Routine medical school activity period	436	1072	0.73	0.73
Second Medical School	68	712	0.64	0.63

^a To remove the variability from repeated measurements from the same student, these analyses were performed on the residuals obtained from a repeated measures analysis of variance of each item.

^b The MEHS-R was administered 9-10 times after orientation at the first medical school, which were classified as examination, vacation, or routine medical school activity periods for separate analyses, and 11 times at the second medical school, which were combined in 1 analysis.

Abbreviations: CFI, Bentler comparative fit index; NNFI, Bentler and Bonett nonnormed fit index.

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Table 2.

Fit Statistics From the Confirmatory Factor Analysis of Subscales (7-Factor Model) for the Medical Education Hassles Scale-R (MEHS-R)^a

MEHS-R Administration^b	No. of Participants	No. of Measurements	Fit Index
MEHS-R Administration^b	No. of Participants	No. of Measurements	CFI	NNFI
First Medical School
Examination period	436	1322	0.73	0.72
Vacation period	429	919	0.70	0.69
Routine medical school activity period	436	1072	0.73	0.73
Second Medical School	68	712	0.64	0.63

^a To remove the variability from repeated measurements from the same student, these analyses were performed on the residuals obtained from a repeated measures analysis of variance of each item.

^b The MEHS-R was administered 9-10 times after orientation at the first medical school, which were classified as examination, vacation, or routine medical school activity periods for separate analyses, and 11 times at the second medical school, which were combined in 1 analysis.

Abbreviations: CFI, Bentler comparative fit index; NNFI, Bentler and Bonett nonnormed fit index.

Table 3.

Fit Statistics from the Confirmatory Factor Analysis of Subscales for the Medical Education Hassles Scale-R (MEHS-R) for Demographic Subgroups^a

Demographic Subgroup	No. of Participants	No. of Measurements	Fit Index
Demographic Subgroup	No. of Participants	No. of Measurements	CFI	NNFI
Males	318	2808	0.74	0.73
Females	120	1061	0.71	0.70
Married	143	1290	0.70	0.70
Single	291	2567	0.74	0.74
White	348	3092	0.75	0.74
Ethnic minorities	85	746	0.67	0.66

^a To remove the variability from repeated measurements from the same student, these analyses were performed on the residuals obtained from a repeated measures analysis of variance of each item.

Abbreviations: CFI, Bentler comparative fit index; NNFI, Bentler and Bonett nonnormed fit index.

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Table 3.

Fit Statistics from the Confirmatory Factor Analysis of Subscales for the Medical Education Hassles Scale-R (MEHS-R) for Demographic Subgroups^a

Demographic Subgroup	No. of Participants	No. of Measurements	Fit Index
Demographic Subgroup	No. of Participants	No. of Measurements	CFI	NNFI
Males	318	2808	0.74	0.73
Females	120	1061	0.71	0.70
Married	143	1290	0.70	0.70
Single	291	2567	0.74	0.74
White	348	3092	0.75	0.74
Ethnic minorities	85	746	0.67	0.66

^a To remove the variability from repeated measurements from the same student, these analyses were performed on the residuals obtained from a repeated measures analysis of variance of each item.

Abbreviations: CFI, Bentler comparative fit index; NNFI, Bentler and Bonett nonnormed fit index.

Tool for Predicting Medical Student Burnout From Sustained Stress Levels: Factor Analysis of the Medical Education Hassles Scale-R

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