Kligler, Benjamin MD, MPH; Linde, Brian MD; Katz, Nadine T. MD
There is an extensive literature describing both the challenges to student wellness during medical school and interventions aimed at addressing these challenges.1–3 Similarly, the increased risk of depression during medical school and residency is well documented.4 Although most students are healthy when they begin medical school, some may experience significant changes in healthy lifestyle habits over the course of their studies.5 Medical students’ adjustment to new academic rigors and work demands has been reported to result in mental and physical health declines, as evidenced by increased rates of anxiety, sleep deprivation, depression, and personal distress.6 One key study found that as many as 45% of medical students experience burnout.7 In addition, in an environment where toughness, duty, and self-sacrifice are valued, students may feel enormous pressure to ignore or downplay their health problems for fear of professional repercussions.2
As the evidence of these challenges has mounted, there have been numerous calls for attention to be paid to wellness and self-care during medical school. In 2004, the Association of American Medical Colleges report “Educating Doctors to Provide High Quality Medical Care: A Vision for Medical Education in the United States” highlighted the need for the medical education system to support the health and well-being of its learners.8 That same year, the Institute of Medicine report “Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula” emphasized the importance of physician well-being and the need to teach medical students how to care for themselves.9 The significance of these issues is now so well established that the Liaison Committee on Medical Education requires schools to have student wellness programs (accreditation standard MS-26).10
Few studies, however, have specifically examined how students’ attitudes and practices around wellness change during the third year of medical school, when students face a unique set of challenges. Although many medical students find the basic science years to be stressful and difficult, students’ experiences during these years are not qualitatively different from those most had in college while preparing for medical school. The third year represents a major developmental step in the process of physician identity formation and includes experiences none of the students have had before. For many students, shifting from the relative dependence and immaturity of “passive learning” to their first moments of professional responsibility during clerkships is a huge change. In his landmark report “A Flag in the Wind,” Inui11 eloquently described the challenges of learning to balance the duties and responsibilities of the physician with an understanding and acceptance of one’s own limitations. Studies have documented that third-year students demonstrate higher stress and more depressive feelings than either first-year or fourth-year students.12,13 However, only a few studies have specifically focused on the students’ perspective on the challenges of this watershed year.14,15
In this study, we examined third-year students’ written, year-end reflections on how this major transition affected their own health and wellness. Our aim was to identify major themes emerging from these reflections to improve understanding of the impact of the third year on student wellness and to help educators improve curricular and structural approaches to promoting wellness.
Patients, Doctors, and Communities (PDC) is a yearlong, reflection-oriented course for third-year students at the Albert Einstein College of Medicine of Yeshiva University. The required class, which is taught in small groups of eight students with two faculty facilitators per group, focuses on professionalism, ethics, and prevention.
To explore students’ perspectives on wellness during their third year of medical school, we analyzed responses to the following required essay question on the PDC course’s May 2011 final exam, which was taken at home without a time limit:
As physicians, we value the maintenance of health as well as the treatment of disease. Describe one example in which you think your approach to your own health and wellness has changed since starting medical school. Do you think you pay more or less attention to these issues since before starting clerkships? Before starting medical school? If you’ve changed, why do you think this is? Projecting ahead, do you think you will change your attention on personal wellness in the future?
Of the 174 students enrolled in the course during the 2011–2012 academic year, 82 (47.1%) were male and 92 (52.9%) were female. Their ages ranged from 26 to 37 years. The essay was completed by 173 (99.4%) of the students; the written reflections ranged in length from 504 to 739 words.
The course administrator provided the essays to us for analysis after removing all personal identifiers. We received no unique identifiers, and no course faculty or leaders were involved in any way in the analysis, to protect student confidentiality. This qualitative study was approved by the Albert Einstein College of Medicine of Yeshiva University Committee on Clinical Investigations.
During July to September 2011, we used a constant comparison/interpretive description approach to interpret the essay material; this method identifies thematic patterns describing a phenomenon or body of qualitative material as well as the individual variations within those patterns.16 To develop a set of codes appropriate to begin to characterize themes in the essays, B.K. and three independent coders (B.L. and two others) read a sample of 20 essays, without any preconceived coding categories. We then collaboratively identified our overlapping and unique concepts and reached consensus on an initial set of 19 codes for systematically organizing the data. The three coders proceeded to read a second sample of 20 interviews and applied these initial codes, checking to see that they captured and adequately described all relevant material. This second round resulted in the addition of 3 codes. Using the final set of 22 codes, each of the three coders independently coded the entire dataset, including the 40 essays used to develop the coding scheme. NVivo (QSR International, Doncaster, Australia), a qualitative data analysis program, was used to code the data and to examine the consistency between coders. We found a very high degree of consistency.
Once the coding was completed, we used the immersion/crystallization approach described by Crabtree and Miller17 to look for emergent patterns or themes. In this process, the researcher “immerses” himself or herself in the data by reading and rereading the coded material in great detail, and then he or she temporarily suspends that immersion to “crystallize” the themes that emerge from the data through reflection. In a constant comparison process, the emerging themes are then compared back with the coded data to confirm or disconfirm the researcher’s conclusions. Once the emergent themes were described, B.K. re-read all of the essays, searching for any disconfirming data. The three coders also reviewed the summary of themes and re-read selected essays, searching for exceptions or disconfirming data.
Given the large volume of material analyzed, it is not possible to report on every aspect of our analysis. In keeping with our research question, we report here the four major themes we identified that have the potential to lead to curricular and structural interventions: facing time constraints, becoming a role model, experiencing the impact of information, and developing a professional identity. We describe our findings for each theme below and provide representative excerpts from student essays in Table 1.
Facing time constraints
Almost all students indicated that limited time, especially during the third year of medical school, was a major factor in their struggle to make healthy choices. They reported having less time to shop for and prepare food, exercise, sleep, and spend with friends and family. For some students, this lack of control over their time translated into a larger feeling of lack of control over their lives in general and contributed to feelings of helplessness, low self-esteem, and emotional exhaustion.
Others, though, indicated that the time constraints of the third year of medical school seemed like a positive challenge: They were forced to be more proactive and organized in their health-related choices. Some of these students reported that time pressures had made them more committed to using their time efficiently so that they could exercise or take care of themselves in other ways—in other words, they made having a healthy lifestyle more of a priority. Others described paying more attention to their own health as a way to manage feeling overwhelmed and take back control.
Becoming a role model
Students were acutely aware that they had taken on the responsibility of being a role model for their patients regarding health choices. For example, a number of students commented that patients are unlikely to respond to counseling on obesity from a physician who is obese or on smoking cessation from one who smokes. As students reflected on assuming the physician role in their third year, the effect of this responsibility on their own health choices was prominent in many of their essays: “After all, if we don’t live it, then who are we to preach it?” (or a variation on that concept) was a frequently posed question. Because this concept is never specifically taught in the medical school curriculum, it seems to be an assumption that students almost universally made regarding their responsibility as physicians. Only 1 of the 173 students wrote that physicians’ personal choices regarding health have no bearing on the ability to function effectively as a role model:
The doctor’s job is to inform the patient of what is best for their health and to treat them to the best of their ability, not to be a model of how people should live their lives.
Like the time constraints challenge, the challenge of becoming a role model seemed to affect students in one of two ways. Some students reported that the responsibility motivated them to follow through with healthy behaviors of their own, in order to lead by example. A number of students who quit smoking attributed their success to this motivation. Other students wrote of feeling unable to live up to the responsibility, which added to their distress—the words “hypocrite,” “guilty,” and “irony” were commonly used in their essays. These students indicated that the need to be role models increased their stress, which pushed them toward eating more high-fat/high-sugar foods, increasing alcohol consumption, and making other unhealthy choices. Many students also mentioned the lack of access to healthy food options in the hospital environment as a barrier to making good choices.
Experiencing the impact of information
Many students described the impact of their newfound knowledge about health and disease on their health choices. This new knowledge combined the cognitive understanding of physiology and pathology they gained over their first two years of medical school with the more emotional or visceral experiential knowledge they gained during the third year as they saw patients with the actual manifestations of the pathology. Many students reported that this knowledge served as a source of motivation, even empowerment, for taking control of their own health to prevent the type of outcomes they saw in the hospital. For others, however, this knowledge only contributed to feelings of disempowerment and guilt. Many students mentioned the “disconnect” between knowing what to do and actually doing it. They described how understanding and reflecting on this on a personal level made them slower to judge patients for lifestyle deficiencies because they could understand and empathize with how difficult it can be to make healthy choices.
Developing a professional identity
This theme did not appear as broadly across the essays as did the previous three, but it emerged as a powerful element in the essays of a subset of students. This group wrote and reflected more deeply on how the expectations physicians have for themselves—and that society and medical schools have for them—can interfere with their own health. The challenge of living up to the role of “hero”—never showing weakness, never needing health care—seemed to have a large impact on these students. This challenge appeared to be compounded by the stress of constant evaluation and the accompanying fear of being judged, which one student described as becoming “slaves of our own education/profession.” Many students mentioned the difficulty of leaving the wards to attend appointments with their own doctors and how evaluators and superiors often frown on even this type of self-care. These students commonly expressed doubts about having chosen the right professional path and about whether the sacrifices they felt they were making in the process of becoming physicians would prove to be worthwhile in the long run. However, some students indicated that they experienced this challenge as an opportunity for growth and improved health.
It seems clear from our data and from the previous literature12,13 that the third year of medical school poses a specific set of challenges to student wellness. A number of important issues and opportunities emerged from our findings.
First, it is clear that the challenges that third-year medical students face in dealing with time constraints, becoming role models, and developing professional identities lead to positive growth in some students but cause significant pain and difficulty—characterized by feelings of guilt, anxiety, inadequacy, and loss of autonomy—for others. What qualities or previous experiences tend to predispose a student to being motivated rather than overwhelmed by the challenges posed in the third year (and in residency)? Is there a way to identify students who are at risk of reacting to these pressures with disabling anxiety, depression, or substance use, to provide them with additional support?
Tartas and colleagues18 reviewed the psychological factors predicting success in a medical career, which they defined as “professional competence, satisfaction with medicine as a career, occupational stress and burnout and quality of life.” They found that although academic achievement predicted professional competence, coping styles and “sense of coherence”19—a measure of resilience—most accurately predicted satisfaction and quality of life. Dyrbye and colleagues20 recently developed and validated the Medical Student Well-Being Index (MSWBI), an instrument which incorporates measures of burnout, depression, and physical and mental quality of life to screen for distress. Research is needed to develop additional tools to identify students who may be in need of more support as they move through the stress of the third year, as well as specific strategies to reach out to those students and provide that support.
Second, there is a need for interventions that explicitly address and support the potential positive changes that can be brought about by the challenges of the third year. There seems to be an opportunity to take advantage of an apparently natural learning process that occurs in some students through the combination of increased knowledge, the experience of seeing the results of poor self-care in their patients, and the challenge of acting as role models. Most educational interventions aimed at increasing students’ awareness of and reflection on their own health and health behavior choices have focused on the basic science years rather than on the clinical years, when stress is most acute.5,21,22 We are not aware of an existing third-year curriculum intervention that makes these connections more explicit and incorporates reflection by students as they undergo this growth process. Recent neurodidactical theory on the concept of neural mirroring provides insights into how social experience informs learning, which might be very useful to consider in shaping a curriculum that incorporates the “noncognitive” learning process that plays an important role during the third year.23 Such a curriculum, which uses the experiential challenges of the third year to enhance students’ awareness of their own health choices, might go a long way toward preparing students for the greater challenge of residency and, thus, potentially affect rates of depression and substance use later in training.
Third, many students commented on how reflecting on the challenges they faced in making healthy choices had made them less judgmental and more empathetic toward their patients. Why not capitalize on this experience by introducing a structured “behavior change” experiment for second- or third-year students? At Northwestern,6 second-year students are required to complete a behavior change plan (BCP) in which they identify a personal behavior to change, set a goal, track their progress, and then assess their success. Kushner and colleagues6 reported that 274 (79.9%) of the students who completed BCPs in 2008 or 2009 considered themselves to be healthier after the assignment, and 281 (81.9%) of the students stated that they would use the process again.
Finally, structural solutions are needed to address some of the barriers to wellness that are evident in the essays we analyzed. Many students pointed out the ways in which the medical education system promotes unhealthy behavior—the primary example being the poor quality of the food served in hospitals. One intervention would be to find a way to provide healthier food choices for students on the hospital premises. Students also pointed out the difficulty of leaving the wards to go to their own medical appointments, highlighting the sense of conflict between the need to be seen as dedicated to medicine above all else and the need to follow the health guidelines they are being taught. This finding is consistent with previous studies of medical students’ approaches to their own health.24 One option might be to include one half-day of leave for medical or dental appointments in the schedule of every rotation.
Dunn and colleagues25 proposed an intriguing conceptual model, termed the “coping reservoir,” for understanding medical student well-being. This model might provide a framework for addressing some of the themes that emerged from the essays in our study. The coping reservoir is composed of the student’s personality traits and coping style, and it can be either drained or refilled by various types of experiences. It takes into account the potential positive and negative effects of the stresses of the medical school experience and suggests a strategy for targeting them:
Attention to individual students’ coping reservoirs can help promote well-being and minimize burnout; formal and informal offerings within medical schools can help fill the reservoir. Helping students cultivate the skills to sustain their well-being throughout their careers has important payoffs for the overall medical education enterprise, for promotion of physician resilience and personal fulfillment, and for enhancement of professionalism and patient care.25
Developing a process or set of tools that provides insight into the structure of each student’s coping reservoir could help educators develop interventions that increase the positive potential of the third-year experience (and subsequent experiences in residency) while reducing the negative potential—and with it the incidence of depression, anxiety, suicide, and substance abuse in trainees. Recent studies have examined the impact of a mindfulness intervention on first- and second-year medical students, demonstrating reductions in depression and anxiety in participants21 as well as in total mood disturbance on the Profile of Mood States measure.26 Although the impact of such training on third-year students has not been investigated, this type of intervention is one example of a strategy for attending to students’ “coping reservoirs” early in medical training in a way that might significantly influence their experience of stresses later.
The major limitation of this study is that the essays we analyzed were not written anonymously, which may have influenced how much students divulged. This is somewhat mitigated by the context: The essays were written at the end of a yearlong, small-group class in which there is a heavy emphasis on reflection and in which a substantial degree of trust generally develops between students and the small-group leaders responsible for evaluating them. The fact that the essay was part of a final exam may also have affected the material; students may have written what they believed would be considered “correct” rather than what they actually thought. Finally, although we cannot comment on the generalizability of these findings to students at other medical schools, we think that the relatively large and diverse group of students participating in this course makes it likely that the results are somewhat representative of third-year medical students in general.
This qualitative analysis of third-year medical students’ essays on their own health and wellness-related behaviors yields many insights into the challenges and opportunities presented during the clinical years, specifically around the themes of facing time constraints, becoming a role model, experiencing the impact of information, and developing a professional identity. A number of specific steps could be put into place to address these themes. For example, existing validated tools, such as the MSWBI,18 could be used to identify the students most at risk of experiencing burnout and other health consequences so that medical schools could provide those students with targeted resources and assistance. Mindfulness training or other self-awareness curricula could be offered in the second year,21,26 followed in the third year by a course requiring students to write bimonthly, brief reflections on their personal wellness choices, as in the BCP intervention at Northwestern.6 Healthier food options could be offered in hospital cafeterias, and rotation schedules could include an afternoon off for personal medical care. In the words of one student’s essay, “We have begun to humanize medicine for the patients; I believe that we should start humanizing it for the health care providers.”
Acknowledgments: The authors would like to thank Sophie Brigstocke and Hanniel Levenson for their work on data analysis. They would also like to thank Dr. Jacki Weingarten, course director for the Patients, Doctors, and Communities course, for her support of this project.
Other disclosures: None.
Ethical approval: This study was approved by the Albert Einstein College of Medicine of Yeshiva University Committee on Clinical Investigation.
1. Roberts LW, Warner TD, Trumpower D. Medical students’ evolving perspectives on their personal health care: Clinical and educational implications of a longitudinal study. Compr Psychiatry. 2000;41:303–314
2. Roberts LW, Warner TD, Lyketsos C, Frank E, Ganzini L, Carter D. Perceptions of academic vulnerability associated with personal illness: A study of 1,027 students at nine medical schools. Collaborative Research Group on Medical Student Health. Compr Psychiatry. 2001;42:1–15
3. Lee J, Graham AV. Students’ perception of medical school stress and their evaluation of a wellness elective. Med Educ. 2001;35:652–659
4. Hull SK, DiLalla LF, Dorsey JK. Prevalence of health-related behaviors among physicians and medical trainees. Acad Psychiatry. 2008;32:31–38
5. Ball S, Bax A. Self-care in medical education: Effectiveness of health-habits interventions for first year medical students. Acad Med. 2002;77:911–917
6. Kushner RF, Kessler S, McGaghie WC. Using behavior change plans to improve medical student self-care. Acad Med. 2011;86:901–906
7. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81:354–373
8. Association of American Medical Colleges. Educating Doctors to Provide High Quality Medical Care: A Vision for Medical Education in the United States. Report of the Ad Hoc Committee of Deans. 2004 Washington, DC Association of American Medical Colleges
9. Institute of Medicine, Board on Neuroscience and Behavioral Health. Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. 2004 Washington, DC National Academies Press
11. Inui T A Flag in the Wind: Educating for Professionalism in Medicine. 2003 Washington, DC Association of American Medical Colleges
12. Compton MT, Carrera J, Frank E. Stress and depressive symptoms/dysphoria among US medical students: Results from a large, nationally representative survey. J Nerv Ment Dis. 2008;196:891–897
13. Paro HBMS, Morales NMO, Silva CHM, et al. Health-related quality of life of medical students. Med Educ. 2010;4:227–235
14. Gaufberg EH, Batalden M, Sands R, Bell SK. The hidden curriculum: What can we learn from third-year medical student narrative reflections? Acad Med. 2010;85:1709–1716
15. Haglund ME, aan het Rot M, Cooper NS, et al. Resilience in the third year of medical school: A prospective study of the associations between stressful events occurring during clinical rotations and student well-being. Acad Med. 2009;84:258–268
16. Thorne S, Kirkham SR, O’Flynn-Magee K. The analytic challenge in interpretive description. Int J Qual Methods. 2004;3(1):1–11
17. Crabtree BF, Miller WL Doing Qualitative Research. 1999 Thousand Oaks, Calif SAGE Publications
18. Tartas M, Walkiewicz M, Majkowicz M, Budzinski W. Psychological factors determining success in a medical career: A 10-year longitudinal study. Med Teach. 2011;33:e163–e172
19. Antonovsky A. The structure and properties of the sense of coherence scale. Soc Sci Med. 1993;36:725–733
20. Dyrbye LN, Szydlo DW, Downing SM, Sloan JA, Shanafelt TD. Development and preliminary psychometric properties of a well-being index for medical students. BMC Med Educ. 2010;10:8
21. Hassed C, de Lisle S, Sullivan G, Pier C. Enhancing the health of medical students: Outcomes of an integrated mindfulness and lifestyle program. Adv Health Sci Educ Theory Pract. 2009;14:387–398
22. Finkelstein C, Brownstein A, Scott C, Lan YL. Anxiety and stress reduction in medical education: An intervention. Med Educ. 2007;41:258–264
23. Iacobini M. Imitation, empathy, and mirror neurons. Annu Rev Psychol. 2009;60:653–670
24. Ross J, Cleland S. Medical students’ illness-related cognitions. Med Educ. 2011;45:1241–1250
25. Dunn LB, Iglewicz A, Moutier C. A conceptual model of medical student well-being: Promoting resilience and preventing burnout. Acad Psychiatry. 2008;32:44–53
26. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003;15:88–92