Slavin, Stuart J. MD, MEd; Hatchett, Lena PhD; Chibnall, John T. PhD; Schindler, Debra PhD; Fendell, Ginny MSW
Dr. Slavin is associate dean for curriculum and professor of pediatrics, Saint Louis University School of Medicine, Saint Louis, Missouri.
Dr. Hatchett is assistant professor, Neiswanger Institute for Bioethics and Health Policy, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois.
Dr. Chibnall is professor, Department of Neurology and Psychology, Saint Louis University School of Medicine, Saint Louis, Missouri.
Dr. Schindler is education specialist, Saint Louis University School of Medicine, Saint Louis, Missouri.
Ms. Fendell is mental health promotion associate, Washington University in Saint Louis, Saint Louis, Missouri.
Correspondence should be addressed to Dr. Slavin, Saint Louis University School of Medicine, Office of Curricular Affairs, LRC 101, 1402 S. Grand Blvd., St. Louis, MO 63104; telephone: (314) 977-8077; e-mail: firstname.lastname@example.org.
Leaders in academic medicine have recognized the need to better align medical education with the health care needs of society. Cultural competence, end-of-life care, pain management, health literacy, motivational interviewing, obesity, domestic violence, substance abuse, mental health problems, smoking cessation, sexuality, chronic illness, psychosocial issues, preventive counseling, spirituality, ethics/legal issues, professionalism, patient safety, reducing errors, geriatric care, bias in health care providers, teamwork with other health care professionals, and lesbian, gay, bisexual, and transgender issues have all been identified as areas in which physicians should be better trained.
While paying greater attention to these areas is essential, more fundamental changes are required in medical education. A comprehensive, continuous effort to help students, residents, and physicians flourish is necessary to ensure that they will have the orientation to care required to practice effectively in the areas above. If physicians are burned out, depressed, unengaged, or unable to find meaning in their work, they will be less likely to engage in empathic, effective, holistic, patient-centered care. Unfortunately, the mental health landscape in medical schools and medical practice in the United States appears grim. Researchers estimate that 25% of medical students are depressed.1 In a recent study of 4,287 medical students at seven medical schools, 49.6% of respondents reported burnout and 11.2% reported suicidal ideation within the previous year.2 Residents' mental health appears to be no better than that of students. Practicing physicians suffer from similarly high rates of burnout, and the suicide rate for U.S. doctors is higher than that of other professions.
So, what does it mean to flourish? The concept has emerged from work in the positive psychology movement led by Martin Seligman,3 who defines flourishing as an individual state of well-being characterized by positive emotion, engagement, strong relationships, meaning, and achievement. Evidence indicates that not enough medical students, residents, and physicians are truly flourishing. For too many medical students and residents, the medical education continuum is a depressing, dispiriting endeavor. In the preclinical years, information overload, emphasis on memorization, competition for grades, the pressure of performing well on the United States Medical Licensing Examination Step 1, and insufficient time for family, friends, and personal well-being conspire to produce what for many students is a relatively toxic learning environment. In the clinical years of medical school and residency, work hours, the pressure of assuming greater clinical responsibility, the negative effect of the hidden curriculum, and the emotional toll of caring for sick and dying patients can make it difficult for trainees to flourish.
To help students and residents flourish, medical educators must create supportive, nurturing, engaging, and dynamic learning environments. On the basis of the five elements Seligman3 indicates are needed for individuals to flourish, we recommend the following changes to the medical education system to promote students' well-being and flourishing:
* Promote positive emotions. Create comprehensive programs to reduce stressors and promote student wellness; train students in mindfulness and resilience; use appreciative inquiry in support groups across the medical education continuum.
* Facilitate engagement. Develop more opportunities for students to engage in activities outside the classroom and library through longitudinal electives or volunteer opportunities in service and research.
* Encourage development and maintenance of strong relationships. Reduce unneeded competition and promote collaborative learning by instituting pass/fail grading in the preclinical years; institute or improve faculty- and peer-mentoring programs; provide significant opportunities for small-group learning.
* Help students and residents find meaning in their work. Make fundamental changes in teaching and testing to reduce information overload in the preclinical years; help students find meaning in their elective and extracurricular activities; expand healer's arts and medical humanities programs; provide greater opportunities for reflection.
* Encourage and celebrate achievement. Find ways for preclinical students to demonstrate excellence other than through performance on exams; celebrate students' and residents' achievements in community service, clinical care, teaching, and research through approaches including capstone project presentations and service and research awards.
Greater attention also needs to be paid to helping practicing physicians avoid burnout and truly flourish in their practices. Mindfulness-based stress reduction programs have shown some promise in the practice setting. These programs should be expanded, and other approaches to promoting physician well-being and self-care should be encouraged. If physicians approach practice from a position of well-being, engagement, and sense of meaning, they will be well positioned to better meet the complex needs of their patients and society.
1 Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: Causes consequences, and proposed solutions. Mayo Clin Proc. 2005;80:1613–1622.
2 Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149:334–341.
3 Seligman ME. Flourish: A Visionary New Understanding of Happiness and Well-Being. New York, NY: Free Press; 2011.