‘Stress’ was most definitely the hook that drew me into world of endocrinology in the first place. The year was 1996, and I had just completed my BSc in Pharmacology at King’s College London. I had decided to embark on a PhD, primarily to avoid facing the real world and getting a proper job.

I spent a summer looking for PhD opportunities in London, but was becoming disheartened due to the sheer number of projects which focused on obscure proteins acting in tissues of which I had never heard. Then, as the summer was drawing to a close, a beacon was lit in the shape of a project offered by Julia Buckingham at Charing Cross and Westminster Medical School. It had the simple title ‘Stress-induced infertility’.

The project appealed to me for two reasons. First, it appeared to be a project that involved whole body physiology and, secondly, I felt I had a clear understanding of the term ‘stress’. Having secured the PhD, I then spent the next 3 years working on the action of some obscure protein in a tissue of which I’d never heard. This was my first lesson in the art of marketing!

STUDENTS AND STRESS

However, my initial engagement with the concept of stress is certainly mirrored in the students who entered university in 2018. If you enter the terms ‘stress’ and ‘secondary education’ into a Google search, you will receive over 100 million results. The majority of these focus on exam stress and its impact on performance and mental health. Anyone involved in education at all will know that students are obsessed with performance in assessments above anything else. As a result, students are incredibly interested in the subject of stress before they even enter university.

Prior knowledge is an essential component of the learning process, so we have a student body that should be very receptive to any teaching concerning stress. That prior knowledge can be clearly demonstrated if you ask early years students to define stress (see Figure).

AN EXPERT’S DEFINITION

How would an expert define stress? From a teaching perspective, I’ve always liked an adaptation of Hooke’s Law (1658):

‘The magnitude of an external force, or stress, produces a proportional amount of defamation, or strain, in a malleable metal an organism.’

As you can see from the Figure, even amongst ‘raw’ university students you will find definitions that are fairly accurate (and others less so).

TEACHING STRESS

So, how much do we teach our students about stress? I entered the term ‘stress’ into the search engine of our lecture capture software for the 2017‒2018 academic year and received 757 hits! Those are 757 individual lectures across the course that relate to stress in some way.

Much of that teaching develops a deep understanding of the endocrinology of stress. Some examples include the link between stress and disease, such as the importance of the mineralocorticoid and glucocorticoid receptor balance in the hippocampus and how this determines the supportive or destructive role of cortisol in this tissue, which is linked to the potential development of depression.

Or there’s the difference in the typical male and female behavioural responses to stress, whereby cortisol is known to activate the amygdala (fear centre) and promote ‘flight’. The ‘flight’ response can be diminished by testosterone which switches the behavioural stress response towards a more aggressive ‘fight’ response, but can also be modified by oxytocin to induce a more ‘affiliative’ response (the ‘tend and befriend’ model).

There are many other examples that demonstrate how the endocrinology of stress is taught throughout our syllabus.

RESEARCHING STRESS

This year we introduced a 3-week research experience for our second year medics. This felt like a great opportunity to come full circle: creative ownership of a project focused on stress is what had driven my interest and passion for this subject over two decades ago. Once again stress was the perfect educational tool…

The project title was ‘Stress has a negative impact on exam performance’, which has personal relevance for all students (I’d learnt my marketing lesson many years before). In addition, non-invasive biomarkers for stress exist, meaning students could test this hypothesis with limited resources.

Ten groups of three students were given the task to design and test their own stress protocols. The creative element of the project engaged students in a manner I had not previously witnessed in all my years of teaching. A testing phase allowed students to modify stress protocols that included cold pressor stress, mild electric shock stress and a wide range of social stressors including the most powerful stressor tested – public singing!

LESSONS LEARNT

The experimental phase produced an interesting set of results. When asked how the project had changed their attitude to endocrinology, I received many student comments similar to the following.

‘In my efforts (research) to make sense of the results generated by this investigation, I came across numerous intriguing mechanisms that play a part in the stress response. A particularly fascinating example is the prospect that one’s personal disposition may contribute to whether or not hypothalamic-pituitary-adrenal axis activation occurs. This research experience has taken me past superficial assumptions about the endocrine system and has offered me a glimpse of the true depth and wonders of endocrinology.’

I felt extremely proud that our students had entered university with some understanding of stress, which we had substantially developed with extensive teaching on the subject. Finally, a deep understanding of the endocrinology of stress had been promoted, through creative engagement with stress in an experimental setting. A true educational panacea!

However, it appears that no panacea is absolute, as evidenced by the following response.

‘It hasn’t. The only relevance was coming up with a physiological explanation for the stress response. Other than that endocrinology was fairly obsolete. (Sorry!)’

For now, I’ll file that one under ‘how to stress an endocrinologist’.

Chris John, Reader in Pharmacology, Head of BSc Biomedical Science, Director BSc Pharmacology, Section of Investigative Medicine, Hammersmith Campus, Imperial College London