Medical student wellness: Critical next steps
By: Mara K. Rice-Stubbs
Mara Rice-Stubbs is a medical student at the University of Pittsburgh. Before attending medical school, she served as a critical care nurse. She is the recipient of the 2018 Allegheny County Medical Society Foundation scholarship and the 2018 Foundation Education Award.
When I express interest in physician wellness, I am often asked, “So you tell people to meditate?” Promoting wellness is one of the most misunderstood concepts in medicine today, despite a fixed false belief that it is simple.
So what then is wellness? Wellness is developing the flexibility and discipline to perform within the Yerkes-Dodson optimal stress zone, pushing yourself when you least want to and recognizing when your mind and body need rest. It is learning to overcome the internal resistance to do the things you least want to do when it is in the service of creating a life you value. It’s developing the foresight to optimize strategies for peak performance, while recognizing recovery is an essential component of excellence.
Wellness can be viewed as enhancing protective factors to minimize burnout in the face of profound stress. Wellness is a trainable skillset within the individual; at the same time, optimizing the environment in which the student operates is inextricably linked to wellness. An effective wellness program addresses both environmental challenges while promoting individual strengths.
A recent meta-analysis revealed that one-third of medical students suffer from depression.1 Medical schools are working to improve access to mental health services. The University of Pittsburgh School of Medicine has a clinical psychologist and psychiatrist available to all students confidentially and without charge.2
The traditional view of a physician is one of a flawless machine that functions with little sleep, poor nutrition and feels no stress under strenuous conditions that demand perfection. This creates the expectation that recovery time is a luxury, leading to burnout.
Like a triathlete who rests after a strenuous race, developing a personalized recovery plan for both daily stresses and exceptionally stressful periods is vital to maintaining long-term stamina. To that end, the University of Pittsburgh has also incorporated two “flex days” (personal days) per academic year, which build in recovery time from training exhaustion and life events. The wellness crisis has generated some positive change in medical school training, but the response remains inadequate to fully address the crisis.
From a systems perspective, the most pressing issue to address is the doubling time of medical knowledge for medical students. Doubling time is the timeframe it takes for a twofold increase in the amount of medical knowledge science acquires.
In 1950, the doubling time of medical knowledge was 50 years.3 By 2020, the projected doubling time of medical knowledge is estimated to be 73 days.3 The result is an overwhelming body of knowledge that medical professionals are now responsible to master.
In addition to this growing body of knowledge, medical students are caught between learning for the STEP exam and learning for the wards. While STEP exams focus on foundational knowledge, medical courses are taught by experts in their isolated fields (both MDs and PhDs) who believe it is their responsibility to cover the entirety of their field. Without the clinical acumen to identify the most important concepts presented in order to focus study efforts, medical students are drowning in a sea of knowledge with no land in sight.
There is growing awareness of the misuse of stimulants by students to facilitate their attempt to become the machine our culture has valued. Poor sleep quality is significantly associated with lower GPA among medical students.4 The fact students must turn to stimulants in order to further minimize sleep in an attempt to memorize an ever-expanding quantity of material is further evidence that the current system is broken. Medical schools continue to add content, requirements and assignments. Perhaps it is time to revisit our curriculum from the perspective of what can be eliminated.
Despite the medical field’s obsession with bundles, wellness is an individualized effort and is a more complex issue than can be addressed by a checklist. In an effort to tailor wellness programs to the individual, some schools are utilizing faculty coaches to assist students. While this certainly helps personalize the approach, physicians are not equipped with the right skillset to effect change for student wellness.
Instead, every medical school should have a dedicated clinical psychologist with extensive training in the fundamentals of wellness to formulate an effective wellness program within the context of the culture of the school. Such clinical psychologists have the knowledge of how to teach others about their own wellness and guide students through the behavior change process. Furthermore, they are capable of analyzing their interventions to create an evidence-based approach to student wellness.
The complexities of teaching and implementing wellness is beyond the scope of the average physician, whether we have the humility to accept that. The value of a clinical psychologist to the performance and well-being of medical students is underutilized and would likely provide the answers desperately needed.
The mental health crisis among medical students has been gaining recognition and the real crux of the issue is “where do we go from here?” From a systems perspective, reigning in the content that has resulted from our exponential medical knowledge is most important to give students some sense of control over their studies. In order to develop effective strategies for everything from study skills to stress management, our clinical psychology colleagues should be leading the way.
1 Puthran R, Zhang MW, Tam WW, & Ho RC. (2016) Prevalence of depression amongst medical students: a meta-analysis. Med Educ. 50(4), 456-468.
2 Karp, J & Levine, A. (2018) Mental Health Services for Medical Students – Time to Act. The New England Journal of Medicine, 379, 1196-1198.
3 Densen P. (2011) Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 122, 48-58.
4 Maheshwari, G & Shaukat, F. (2019) Impact of Poor Sleep Quality on the Academic Performance of Medical Students, Cureous. 11(4), e4357.