International Neuropsychiatric Disease Journal

16(2): 17-24, 2021; Article no.INDJ.71811

ISSN: 2321-7235, NLM ID: 101632319

Measuring Anger in Medical, Dental and

Paramedical Post-graduate Students of Sumandeep
Vidyapeeth, Vadodara, Gujarat, India: A Cross-
Sectional Study
Anupsinh H. Chhasatia1 and Lakhan R. Kataria2*
1
Department of Psychiatry, Dr. Kiran C. Patel Medical College and Research Institute, Bharuch,
Gujarat, India.
2
Department of Psychiatry, SBKSMI & RC, Waghodiya, Vadodara, Gujarat, India.

Authors’ contributions

This work was carried out in collaboration between both authors. Both authors read and approved the
final manuscript.

Article Information

DOI: 10.9734/INDJ/2021/v16i230170
Editor(s):
(1) Dr. Takashi Ikeno, National Center of Neurology and Psychiatry, Japan.
Reviewers:
(1) Frederic, Pérez-Álvarez, Hospital Universitari de Girona Doctor Josep Trueta, Spain.
(2) Ilgaitis Prūsis, Riga Technical University, Latvia.
Complete Peer review History: https://www.sdiarticle4.com/review-history/71811

Received 24 May 2021

Accepted 28 July 2021
Original Research Article
Published 31 July 2021

ABSTRACT

Background: Medical, dental and paramedical post-graduate students are an essential part of
multi-specialty teaching institutes where resident doctors are the ones who come in the first contact
with the patients. In this study emotion of residents was measured through their anger. Anger has
negative impacts on daily life, doctor-patient relationships. Throughout the post-graduation program,
students experience stress and burn out.
Aim: The study was conducted with an aim to measure the level of anger amongst the post-
graduate medical, dental and paramedical students at Sumandeep Vidyapeeth University,
Vadodara, Gujarat, India.
Materials and Methods: After obtaining informed and written consent, 349 subjects were assessed
through a semi-structured proforma and clinical anger scale to assess the level of anger. It was a
cross-sectional single interview study. Enrolment of participants done for the tenure of 1 year from
2013 to 2014 and results assessed. At the end of the study, all CAS (clinical anger scale)
parameters compared medical, dental and paramedical groups. Data analyzed through the SPSS
_____________________________________________________________________________________________________

*Corresponding author: E-mail: anup66tia@gmail.com;

 Chhasatia and Kataria; INDJ, 16(2): 17-24, 2021; Article no.INDJ.71811

v16 software package; One way ANOVA and independent t-test was applied.
Results: The overall anger was higher among post-graduate students. Post-graduate medical
students had higher anger compared to paramedical post-graduate students. Female participants
scored significantly lower on clinical anger compared to male participants. Post-graduates doing
MD/MS were having significantly higher anger than post-graduates of MDS (p=0.002), MPT (0.000).
Married participants scored lower on clinical anger compared to unmarried participants.
Conclusion: Overall anger is high in medical post-graduate students which have negative
implications on doctor-patient relationships and patient care can get compromised so it is necessary
to find the ways through which we can lower the anger.

Keywords: Clinical anger scale; resident doctors; frustration; emotions.

ABBREVIATIONS It is usually observed that medical and

paramedical students undergo tremendous
ANOVA : Analysis of Variance stress during various stages of their MBBS
CAS : Clinical Anger Scale course [4] One of the causes of stress has been
CRF : Case Report Form identified is higher medical student year. Another
MD : Doctor of Medicine cause is not being able to indulge in recreational
MDS : Master of Dental Surgery and social activities. Increase in workload and
MPT : Master of Physiotherapy the pressure of learning professional knowledge
MS : Master of Surgery and skills was another factor that was cited to
M.Sc : Master of Science contribute to stress. Exams and continuous
N : Number assessments have also been considered as an
SPSS :Statistical Package for the Social important factor that contributes to psychological
Sciences distress in medical students. Elevated stress
Sr no : Serial Number levels can affect tasks that require divided
attention, working memory, retrieval of
1. INTRODUCTION information from memory, and decision making
[5] A student under optimal stress does bring out
Anger is a complex emotion and occurs as a his or her best; however, extremes of stress can
result of an interaction between one or more result in stress-induced disorders like
eliciting events, the individual’s pre-anger state, depression, insomnia, and hypertension, hence
appraisals of the eliciting events, and available deteriorating performance [6] The occurrence of
coping resources. When anger and anxiety are stress and stress-related anxiety and depression
chronic, people are more susceptible to a range in medical students, trainees, and qualified
of diseases [1] physicians is being increasingly reported in the
literature. Stress is not only a risk factor for
Perceived abuse or harassment during residency several chronic diseases including hypertension,
(post-graduation) has a negative impact on diabetes, and coronary artery disease; it
residents; health and well-being. Postgraduate precipitates several mental ailments, and the
medical and paramedical students are the ones impact on stress in the medical work
who come in first and the direct contact with the environment affects healthcare delivery as well[7]
patients and they are exposed to a great level of
stress and burden for patient care as well as Several studies [4,8,9] in recent years focused
academic performance. They have to bear the on the incidence of stress and stress-related
stress and manage their professional as well as illnesses such as anxiety and depression among
personal life. A high level of dropout rate has students, trainees, and qualified physicians.
also been observed during the post-graduation Indeed, some research indicates the unique
[2] academic challenges of medical studies, the rigor
of the educational program, and emotionally
The modern age is ‘The Age of Stress’ and tense experiences, such as dealing with illness,
stress-related diseases, which pose a serious disease, and dying that make medical students
challenge to not only medical professionals but to more vulnerable to stress and anxiety than
the whole concerned diasporas. Despite the students of other disciplines [7] Up to one-third of
leaps and bounds in medical sciences, we are practicing clinicians could be expected to be
surrounded by a very silent but dangerous foe, suffering from burnout if assessed cross-
lifestyle diseases [3] sectionally [10]

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 Chhasatia and Kataria; INDJ, 16(2): 17-24, 2021; Article no.INDJ.71811

Clinical anger was conceptualized as a and correlate the level of anger with (a) EI and
syndrome that consists of several symptoms that (b) empathy in medical post-graduates. No
can vary in their intensity and strength and that correlation was found between age and clinical
can produce severe health risks [11]. The anger. 10.6% of subjects reported clinical anger
chronic, pervasive aspects of clinical anger were in a range of moderate to severe on CAS. [14]
presumed to include affective, cognitive,
physiological, and behavioral manifestations There is a paucity of studies in the Indian setting
(e.g., fatigue, irritability, rage). Individuals who that has focused on post-graduate medical and
are high in clinical anger were expected to report paramedical students’ psych. They are an
affective feelings of anger about their present life, integral part of any medical teaching institute and
themselves, their future, others, and things in their health can have an impact on patient care
general. In addition, it was anticipated that they as well as their own life. Anger is one of the
would report that their clinical anger interferes dangerous aspects of life which can harm
with their social relations, their ability to make anyone including medical and paramedical
decisions, and their capacity to pursue effective professionals as well as students.
work relations and accomplishments. In addition,
people afflicted with this affective disorder were That is why there is a need to understand the
expected to report appetite, health, thinking, and level of anger among different medical and post-
sexual interference from their syndrome of graduate medical students so that we can help
clinical anger. In brief, clinical anger was defined them to cope with that anger and it can help to
as a syndrome that consists of debilitating, improve patient care.
global, and chronic symptoms of anger and
includes affective (e.g., rage, irritability), cognitive During the residency program, postgraduate
decision interference, physiological (e.g., students undergo a great level of stress which
fatigue), social (e.g., interpersonal dysfunctions), has a negative impact on the quality of patient
and behavioral (e.g. ineffective work relations care and their coping abilities. The need for this
and accomplishments) manifestations [12]. study emerged to identify how medical and
paramedical postgraduate students go through
A total of 305 medical residents, of both genders, burnout during their 2 or 3 years of program and
of different specialties, from clinical and surgical how can we help them to overcome from the
areas of a Brazilian university hospital, were burden and how they themselves can help them
evaluated using the following standardized self- and we can have an idea about the kind of
report instruments: Burnout Syndrome Inventory, intervention required to reduce their burden and
Social Skills Inventory, and the Patient Health improve their life as well as patient care as they
Questionnaire-4. This study was aimed to verify are the upcoming new professionals in the
the rates of burnout, anxiety, and depression growing world as the time passes by. The study
presented by resident physicians, as well as the was conducted with an aim to study the level of
associations of these problems with social skills, anger amongst post-graduate students of
as potential protective factors. High rates of Sumandeep Vidyapeeth, Vadodara, Gujarat,
burnout and mental health problems were India.
verified and social skills were negatively
associated with burnout dimensions such as 2. MATERIALS AND METHODS
emotional exhaustion, emotional detachment,
and dehumanization, but positively associated This was a cross-sectional, single interview study
with personal accomplishment. [13] conducted on medical, dental and paramedical
post-graduate students of Sumandeep
A study was conducted between January 2008 Vidyapeeth University to find out the clinical
and August 2009 on 150 medical post-graduate anger amongst them. The sample collection for
students by the psychiatry department of a the study was between February 2013 and July
tertiary care medical hospital in Mumbai. 2014 and data analyzed within one month of total
Subjects were assessed randomly through semi- recruitment.
structured proforma and various scales, including
the Emotional Quotient Self Assessment Postgraduate students of medical and
Checklist, Multi-Dimensional Emotional Empathy, Paramedical (Dental, Physiotherapy and
and Clinical Anger Scale. This study aimed to Nursing) were selected randomly from
assess emotional intelligence focusing Sumandeep Vidyapeeth University. A total of
specifically on empathy, study the level of anger, around 500 postgraduates from medical and

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 Chhasatia and Kataria; INDJ, 16(2): 17-24, 2021; Article no.INDJ.71811

Paramedical disciplines were given the forms but statements per group) and to select the single
only 349 were recruited in the study as others did statement that best described how they felt(e.g.,
not return the forms and forms were left unfilled. item 1 : A = I do not feel angry, B = I feel angry,
A semi-structured self-prepared questionnaire C= I am angry most of the time now, and D= I am
mentioning demographic details and CAS so angry all the time that I can’t stand it). Each
(Clinical Anger Scale) was given. cluster of statements was scored on a 4-point
Likert scale, with A=0, B=1, C=2, D=3. The four
2.1 Inclusion Criteria statements in each cluster varied in symptom
intensity, with more intense clinical anger
 Participants who gave informed and associated with statement D. Subjects’
written consent responses on CAS were summed so that higher
 Participants who returned the filled forms scores corresponded to greater clinical anger (21
within one week items; range 0-63). Score range: Minimal clinical
 Participants aged 24 and above were anger (0-13), Mild clinical anger (14-19),
included Moderate clinical anger (20-28), and severe
 Participants who were part of clinical anger (29-63). [12]
sumandeep vidyapeeth University
2.4 Statistical Analysis
2.2 Exclusion Criteria
Data were pooled and statistical analysis was
done with SPSS v16 software package using
 Participants who did not give informed
multivariate analysis with analysis of covariance
written consent
test.
 Participants who did not return filled
forms within one week.
3. RESULTS
2.3 Methodology
In the present study 189(54.2%) were males
while 160(45.8%) were females. The mean age
A cross-sectional (randomized selection of
of postgraduate students was 25.5(SD 2.3)
subjects) study was done and post-graduate
years. 29.22% were married while the rest was
medical, dental and paramedical students were
widowed or separated or unmarried. 57.3% were
included in the study. Demographic details of all
medical post-graduate students while 42.7 %
the subjects were captured in a predesigned
were paramedical post-graduate students.
CRF (Case Report Form). All the subjects were
given the Clinical Anger Scale (CAS).
Table 2 shows that only <40% of subjects were
having minimal clinical anger while almost 40%
Clinical Anger Scale (CAS), an objective self-
of subjects were having moderate to severe
report instrument, was designed to measure the
clinical anger.
psychological symptoms presumed to have
relevance for the understanding and to treat
Table 3 shows that there was no significant
clinical anger. Twenty-one sets of statements
difference found in clinical anger between
were prepared for this purpose. In writing these
postgraduates of MD/MS and
group of items, the format from one of beck’s
M.Sc.Postgraduates doing MD/MS were having
early instruments was used to design the Clinical
significantly higher anger compared to
Anger Scale (Beck,1963,1967;Beck et al.,1961).
postgraduates of MDS (p=0.002), MPT
The symptoms of anger measured by the CAS
(p=0.000).
items involved: anger now, anger about the
future, anger about failure, anger about things,
More than 50% of subjects pursuing MDS were
angry-hostile feelings, annoying others, angry
having minimal clinical anger while only 9.8%
about self, angry misery, wanting to hurt others,
were having severe clinical anger. 70% of
shouting at people, irritated now, social
subjects pursuing MPT were having minimal
interference, decision interference, alienating
clinical anger while only 2 subjects (6.7%) were
others, work interference, sleep interference,
having severe clinical anger. Amongst the
fatigue, appetite interference, health interference,
students doing M.Sc 41.4% were having minimal
thinking interference, thinking interference, and
clinical anger while 29.30% were having severe
sexual interference. Subjects were asked to read
clinical anger. 32.50% of postgraduate students
each of the 21 groups of statements(4
pursuing MD/MS were having moderate clinical

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 Chhasatia and Kataria; INDJ, 16(2): 17-24, 2021;; Article no.INDJ.71811
no.INDJ

anger while 17% were having severe clinical higher anger compare to paramedical post-
post
anger. graduate students (p=0.000). Postgraduate
students doing MS have significantly higher
Females scored significantly lower on clinical clinical anger compared to post-graduate
post
anger compared to males (p=0.004). Medical students pursuing MD (p=0.000).
post-graduate students were having
ng significantly

Table 1. Socio demographic

d details of participants

Socio demographic details Sample size 349 (100%)

Age Range 22-44
Mean 25.5
Standard Deviation 2.3
Sex Male 189 (54.2%)
Female 160(45.8%)
Marital Married 102 (29.22%)
status Unmarried 247 (70.78%)
Domicile Gujarat 244 (69.9%)
state Others 105 (30.1%)
Habitat Rural (R) 22 (6.3%)
Urban (U) 327 (93.7%)
Group MDS 61 (17.5%)
MPT 30 (8.6%)
M.Sc 58 (16.6%)
MD/MS Degree 176(50.5%) 200 (57.3%)
Diploma 24 (6.9%)
Academic 1st 148 (42.4%)
nd
Year 2 129 (37%)
rd
3 72 (20.6%)

Age (mean)
26.38
26.5
25.78
26
25.3
25.5

25 24.5 Age (mean)

24.5 * = SD

24

23.5
MDS (2.69*) MPT (3.72*) M.Sc (1.03*) MD/MS (1.80*)

Graph 1. Age distribution across the sample discipline wise

The mean age of postgraduate students was 25.5 years

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Table 2. Clinical Anger Scale, distribution of clinical anger across the sample

Clinical Anger N Percentage (%)

Minimal 137 39.3
Mild 70 20
Moderate 83 23.8
Severe 59 16.9

Table 3(a). Discipline wise distribution of clinical anger

Discipline Clinical Anger on CAS

Minimal Mild Moderate Severe
N (%) N (%) N (%) N (%)
MDS 31 (50.9%) 16 (26.2%) 8 (13.1%) 6 (9.8%)
MPT 21 (70%) 7 (23.3%) 0 (0%) 2 (6.7%)
M.Sc 24 (41.4%) 7 (12.1%) 10 (17.2%) 17 (29.3%)
MD/MS 61 (30.5%) 40 (20%) 65 (32.5%) 34 (17%)

Table 3(b). Discipline wise distribution of clinical anger

Discipline wise comparison P value

MPT .444
MDS M.Sc .029
MD/MS .002
MDS .444
MPT M.Sc .001
MD/MS .000
MDS .029
M.Sc M.Sc .001
MD/MS .999
MDS .002
MD/MS MPT .000
M.Sc .999

4. DISCUSSION have positive as well as negative impacts on the

daily life and behavior of people including
The present study showed higher clinical anger resident doctors. Here in this study emotion of
among post-graduate students. Clinical anger residents was measured through their level of
was more among the postgraduate medical anger.
students compared to paramedical postgraduate
students. Anger was more among the unmarried Though less in number, most of the studies have
subjects compared to married subjects and it been done on undergraduate medical and dental
was higher among the males than females.In the students [15]. Very few studies have been done
present study, less than 40% of subjects had to measure anger amongst resident doctors,
minimal clinical anger. In comparison, almost especially in India [16]. No research has been
40% of subjects had moderate to severe clinical done till now on paramedical post-graduate
anger, similar to the study done by Faye Abhijeet students to measure their anger even though
et al. [14]. they are a critical part of all health universities
and multi-specialty hospitals.
Medical, dental and paramedical post-graduate
students are an essential part of multi-specialty In the present study, it was found that subjects
teaching institutes where resident doctors are the from the surgical branch were having significantly
ones who come in the first contact with the higher anger which is similar to the finding of the
patients and the behavior of both residents and study by Azimi et al. [17] and Abhijeet et al. [14].
patients depends on each other. Emotions of
residents play an important role in patient-doctor In the medical field, however, burnout is often
relationships and to maintain the same. Emotions seen in health care workers. Self-motivation is

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 Chhasatia and Kataria; INDJ, 16(2): 17-24, 2021; Article no.INDJ.71811

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© 2021 Chhasatia and Kataria; This is an Open Access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any
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