Introduction
Though studying happiness and stress in medical students, since last 8 years; 2 years before, we got curious about relation between stress levels and examination performance of medical students. Giving Google search on title specific topic, "Stress and Examination performance" we found only 12 results. Undergoing still more ‘title specific’ Google search on title "Factors affecting medical students' performance in examination" we found 0 results. THESE led us to work on present research project, albeit, a pilot scale research study.

Stress as described by Hans Selye, results from wear and tear of the body. He further classified stress into eustress and distress (http://www.famousscientists.org/hans-selye/). Eustress refers to the physiological stress that motivates a person to work hard and get desired results of his efforts. Spielberg described stress state as a persons’ response to the stress and stress trait as a persons’ habit to get stressed. The specific signs and symptoms of stress vary widely from person to person (Peter sams, 2008, http://www.articlesbase.com/mental-health-articles/the-effects-of-stress-on-your-body-352097.html).

Stress is known to evoke 3 Freaction (fright, fight and flight), raising the catecholamine levels and helping one win an emergency life threatening situation (Guyton, 2006). In a catch 22 situations like that of chronic stress, where fight is futile and flight is not possible: sympathetico adreno cortical system is activated. This causes release of stress hormones, including corticosteroids (Khurana Indu, 2006).

It is said that we need some stress in our lives to motivate us. With that in mind it seems unhealthy to be either under-stressed or over-stressed. The absence of stress by making one idle, can affect performance, health and well being; whereas the existence of too much stress, leads to many diseases; psychological and behavioural (Kevin Parr, 2010, http://www.articlesbase.com/wellness-articles/how-do-i-know-if-i-am-stressed-out-3055670.html).

Stress activates hypothalamo pituitory adrenal axis and causes release of epinephrine, norepinephrine and corticosteroids (Sujit K. Chaudhuri, 2008). Research studies about cognitive impairment found decreased memory capacity in stressed individuals. Studies employing Magnetic Resonance Imaging (MRI) technology also indicate that chronically stressed persons have selective atrophy in the human brain (Daniel Edelstein, 2000, http://brainconnection.brainhq.com/2000/07/12/tests-stress-problems-for-students/).

Chronic stress induced homeostasis changes and immune reduction, tends to affect the balance between oxidants and antioxidants in the body (Peter sams, http://www.articlesbase.com/mental-health-articles/the-effects-of-stress-on-your-body). Many on-going studies have found that alteration in this balance in favor of oxidants may result in acceleration of the aging process, mutilation of the genetic ‘blue print’ and diseases such as cancer and Alzheimer's disease.

There are many methods to measure sympathetic activity in a person, raised by chronic stress. Measuring galvanic skin resistance and evoked potentials are some such laboratory methods. However these need sophisticated instruments, technical skills, laboratory set up and are time consuming. Measuring cardio respiratory effects caused by raised levels of catecholamines, is one of the clinical method to get idea about existing stress. This needs medical personnel and spare time of both, subject and physician.

The most cost effective, least time consuming and therefore the most commonly used methods to decide stress levels are self report questionnaires. Many of these have been designed to measure stressful states and traits such as anger, anxiety, depression and Type A coronary behavior (http://en.wikipedia.org/wiki/ Yerkes–Dodson_law).

It seems one can precisely judge ones’ own stress level. Medical students being aware of their body and mind can be more trusted in this matter. Self assessment / perception of stress levels can be of great use in research studies.

The Stress Response Curve, as devised by Nixon, P. (1979), shows that as the level of stress increases, the performance level also increases; till the point of eustress, or healthy tension. Near the point of fatigue, an identified area called the comfort zone is seen. This indicates the range of stress levels that we can absolutely manage. Comfort zone stress facilitates reasonably good and sustainable performance levels (Sincero, 2012, https://explorable.com/how-does-stress-affectPerformance?).

Dr. Richard Earle from the Canadian Institute of Stress, located in Toronto, Canada, defines stress as “mobilized energy.” He rates stress levels on the basis of answers about frequency of 20 defined events (signs and symptoms), during last one month. Respondents are rated having low, moderate or overt stress, on the basis of score between 0-20, 20-40 and 40–60 respectively (http://powertochange.com/life/stresslevel). Dr. Earle gave new concept of vitality quotient, as devised by ratio of stressors over satisfiers.

The Holmes and Rahe Stress Scale utilizes 43 different events, allots different scores to these events(stress points) from 15-100, multiplies event by how many times it happened in last 1 year and makes a stress level score. It derives 4 categories, of range 01-50, 51-200, 201-300 and >301; as low, medium, high and severe levels of stress (http://www.lesstress.net/measure-stress.html).

Studies in college are altogether different from that in school. One of the biggest challenges for young people at university is to adjust to the lower degree of predictability (http://www2.warwick.ac.uk/fac/sci/statistics/courses/studying/examstress). Stellar success at A-levels of higher secondary examinations requires both being smart and working hard. But dealing with the variety of not yet familiar exam styles and atmosphere at medical university is an additional challenge. San Diego’s widely circulated students’ independent news letter states that final exams create unnecessary stress, to the students and parents (Marissa Ochoa, 2013, http://www.thedailyaztec.com/?s=Final+Exams+Create+Unnecessary+Stress%2C+&submit=Search).

So much is the stress of examinations that in 2010–2011 Young Minds, a U.K. based charity, received 6332 calls to the helpline. Out of this 6332 calls, 884 calls were of 16–17 year young’s and of those, 39% were about school problems including exam stress (http://www.telegraph.co.uk/education/educationnews/8720513/GCSEs-Pressure-of-exams-leaves-teens-suffering-from-mental-illness.html).

According to statistics from the United Way, 60% of youth visits to the doctor are for stress and anxiety, more so during exam days. Such is the prevalence of stress that CTV Calgary and the United Way of Calgary and Area, have come together to raise awareness about mental health, stress and anxiety among youth: in a three–year initiative called Real Youth (http://calgary.ctvnews.ca/real-youth-tackles-exam-stress-1.835782).

First year medical studies are considered highly difficult. Home sickness, teenage, unknown colleagues, strict (not-so-friendly) aloof teachers, new environment, international language other than mother tongue, and technical terminology; make study of first year of medicine highly stressful. Wide syllabus, no prescribed text books, frequent surprise tests, practical examinations and oral viva voce examinations prove tough to the students. Performance and results of examinations apart from being unpredictable, at times are highly surprising and shocking.

Performance in Examination depends on many factors. In a study of commerce students it was found that examination performance of a student was governed by teaching in the class, his own study and his ability to write in the examination hall (http://www.commerceatease.com/general-guidance/factors-affecting-student-s-performance-in-examination).

According to Britney Cleme, University of Minnesota, Rochester, yoga meditation practice, increases exam marks from 52 to 60%. As per study conducted by R. Holland, [www.elsevierhealth.com/journals/pubh(2006) 120, 249-255], University of East Anglia, Norwich; trainees when provided with adequate trainer contact time, feedback and wide experience, were able to achieve better results (http://www.ppmrn.net.pdf). According to Saima Rasul, [Procedia Social and Behavioral Sciences 15 (2011), 2042-2047], The Islamia University of Bahawalpur, Pakistan; at university level the psychological, physical, socio-economic and educational factors: affected the respondents’ performance in examination, the most (Saima Rasul, 2011, http://www.sciencedirect.com/science/article/pii/S1877042811005969).

Alam (2001) studied academic achievement in relation to socio economic status, anxiety level and achievement motivation. The study revealed significant positive relation between socio economic status and academic achievement; achievement motivation and academic achievement. The study further revealed a negative relationship between anxiety and academic achievement (www.shodhganga.inflibnet.ac.in).

We took up study of self perceived stress levels, and examination results of 50, First Year Bachelor Medicine and Bachelor Surgery (I M.B.B.S.) students in intermediate examinations; during present project.

Material and Methods
50 students of I M.B.B.S. participated in the present study. We asked the participants to note down their stress level, in the range 0–100. Their performance in intermediate examination conducted in + 60 days was studied in correlation with different factors including their stress levels. The examination marks considered were of three written theory papers each of 50 marks and two practical examinations of total 110 marks. The practical examination included amphibian (frog) experiments’ graphs, experiments on human blood parameters and human clinical practicals. At most places in this study, marks are denoted in percentage.

The participants were divided into having scores of 0-20(low stress = no stress), 21-40 (lower average = minimum stress), 41–60 (higher average = borderline high stress), 61-80 (high stress = definite stress) and 81-100(very high stress = dis stress, person in dire need of remedial help). 24%, 24%, 20%, 22%, and 10%, of the participants belonged respectively to the stress score groups of 0-20, 21-40, 41-60, 61-80 and 81-100. Average stress score of these groups was 15.1, 31.3, 52.5, 73.5 and 94.0. Average stress of all participants was 47.2%.

The effects of gender, Body Mass Index (BMI) and stress levels on examination performance were studied.

Results
Girls had higher level of stress than boys (Approximately by 10%). However girls scored better by 6–10% in nearly all examinations carried in + two months (Table 1). It seems girls are more sincere, are more systematic in their studies and are able to handle a little higher stress in a better manner.

Table 1 Gender, average stress levels & “intermediate exam” marks

Though body mass index is a parameter used to grade obesity, we found that persons with higher BMI (26-30) had better performance in all intermediate exams. Perhaps happy people, as per Indian mythology, are well fed and a little obese (Table 2). It seems persons in quest of studies, forget attending to their food habits. Average BMI of the participants was 21.1.

Table 2 BMI levels & “intermediate exam” marks

During the study it was found that body mass index had positive correlation with examination performance.

Stress had negative coefficient correlation with performance in all intermediate exams. This signifies that higher the stress, poor the exam performance. Higher stress had more impact perhaps on theory examinations. Stress seems to affect memorizing, recollecting, organizing, interpreting and writing skills (Table 3).

Table 3 Coefficient correlation of BMI and stress with “intermediate exam” marks

 
We divided participants as per their levels of stress. Persons with stress levels 21–40 had highest performance in the intermediate exams. As the levels of stress increased (more than 40), there was definite decrease in the exam performance (Table 4).

Table 4 Stress levels & “intermediate exam” marks

 
Dividing participants into two major groups of stress levels 01–40 and 41–100, we found that average stress of groups 01–40, 41–100 and all participants were 23.2, 69.4 and 47.2. Persons with stress levels 01–40 had performance marks higher by about 7% compared to participants with stress levels 41–100 (Table 5). This validates The Yerkes-Dodson Law, first described in 1908 by psychologists Robert Yerkes and John Dillingham Dodson. The law suggests that there is a relationship between performance and arousal. Increased arousal can help improve performance, but only up to a certain point. Beyond that point when arousal becomes excessive, performance diminishes (http://psychology.about.com/od/yindex/f/yerkes-dodson-law.html).

Table 5 reported case of abdominal wall leiomyoma in the English literature

 
During talks it was found out that 40% of participants had sleep disturbances. However none were taking psychotropic drugs. Drinking tea or coffee (more than 400 ml/day) was seen in these persons, that was believed to raise alertness and also perhaps caused sleep disturbances.

Discussion
Many students feel stressed due to expectations of family members and their desire to achieve a particular academic goal (http://www.ehow.com/list_7414016_causes-exam-stress_.html). The ChildLine National Exam Stress Survey found 64% of students surveyed saying they never received family support during exams (http://www.mentalhealthy.co.uk/news/321-pressure-of-exams-causing-worrying-levels-of-anxiety-in-students.html). As found out by Liz Smith, the pressure of school exams is having a terrible impact on the mental well-being of teenagers, with family physicians prescribing anti-depressants such as Prozac and Seroxat in high numbers during exam season (Liz Smith, 2004, http://www.wsws.org/en/articles/2004/06/dep-j25.html).

To decrease exam stress experts have various recommendations and advices. The foremost is to set up a study plan and prepare well for the exam (Berens, 2010, http://www.cimaglobal.com/en-gb/Thought-leadership/Newsletters/Velocity-e-magazine/Velocity-2010/Velocity-October-2010/How-to-keep-the-lid-on-exam-nerves/). Also of importance is to get plenty of sleep and eat sensibly (http://www.schools.nsw.edu.au/gotoschool/highschool/stressexams.php).

Research has found that different tasks require different levels of arousal for optimal performance. Difficult or intellectually demanding tasks may require a lower level of arousal to facilitate concentration. Our study with stress levels less than 40, facilitating better performance, validates this (http://en.wikipedia.org/wiki/ Yerkes–Dodson_law).

In our present study, we found that about 52 % of all students had stress higher than 40 and they needed training in de stress measures. These students were offered counseling. They were acquainted with relaxation techniques, laughter therapy, creative arts, pranayam, dhyan and yog.

Conclusion
Performance in examination depends on as many as 14 ‘P’s viz. professor, pupil, past behavior, prejudice, preferences, preparation, persistence, presentation, patience, personality, peace of mind, perfection, pictures and presents.

We studied effect of stress on examination performance. We found high levels of stress in 52% of participants, that affected their performance in examinations, as revealed by lower score of marks.

Since this was a pilot project, we shall like to study effects of stress on exam performance, in stages, in at least 500 participants. We will also like to explore relation between happiness levels and body mass index; on students’ performance in the examinations.

Acknowledgement
We will like to thank The Dean, Sola Medical College, Ahmedabad, Gujarat, India. We are also indebted to the enthusiastic participants of this study.

References
Guyton A. C., 11th edition, 2006, Textbook of Medical Physiology, Saunders, India, Noida, pp 758

Khurana Indu, 1st edition, 2006, Textbook of Medical Physiology, Elsevier, India, New Delhi, pp 777

Sujit K. Chaudhuri, 6th edition, 2008, Concise Medical Physiology, New Central