A high prevalence of depression and burnout among U.S. medical students has been documented.1–3 A recent systematic review and meta-analysis estimates the prevalence of depression among medical students to be 27%, which is threefold greater than age-similar norms.1 Additional data suggest that the prevalence of depression increases as medical students progress through their education. As many as 11% of medical students report experiencing suicidal ideation, and few seek help to address mood disorders.1,4–6 Similarly, in a national study of medical students, 56% of respondents reported substantial symptoms of burnout, which is much higher than the average of 36% in a representative sample of U.S. college graduates of similar age.7 Medical students with depression or burnout are more likely than their peers to struggle academically, have professionalism lapses, show lower empathy, and develop thoughts of suicide or dropping out of medical school.3,4,8–10 Practical solutions to address depression and burnout are urgently needed, but few intervention and longitudinal studies have been conducted to date. Because of the lack of research, there is little evidence available to guide intervention strategies aimed at reducing medical students’ risk of distress.3,11–15
Personality, social support, fatigue, coping mechanisms, life stressors outside medicine, educational debt, and exercise habits are likely related to the risk of distress among medical students.3,16–19 Mindfulness-based stress management training, adaptive coping skills, and social support help reduce the risk of anxiety, stress, and depressive symptoms.18,20–22 Individual-level strategies associated with lower risk of burnout in physicians include finding meaning in work, engaging in recreation and hobbies, spending time with family and friends, maintaining a positive outlook, and avoiding a mentality of delayed gratification.23–25
Many of the factors that contribute to depression and burnout in medical students are, however, outside students’ control and originate from the learning environment.1,3,11,12,26 During the early years of medical school, cadaveric dissection, a first death experience, patient and family suffering, shortage of personal time, and lack of control are common stressors identified by students.19 In clinical settings, faculty and resident authoritarian or even abusive behaviors may decrease medical student well-being.3,18,27,28 Grading schema are an independent predictor of burnout: Preclinical students in pass/fail curricula have lower odds of burnout than students in curricula not graded pass/fail.29–31 Hours of instruction, practice setting (i.e., inpatient, outpatient, intensive care unit), and the volume of patients seen in the clinic or followed in the hospital, however, are not associated with medical student burnout.28,29
Educational approaches that include unobtrusive monitoring of medical student well-being as well as coaching and feedback, reflecting on ethical challenges, exposing students to positive role models, and encouraging social connections may help promote well-being.3,11,14,17 Learning communities are a strategy some medical schools, particularly larger schools, use to strengthen relationships and social support. One study suggests that medical students experienced less stress, anxiety, and depression following implementation of learning communities.13
Multiple strategies have been proposed to facilitate medical student well-being, including implementing a well-being curriculum (e.g., self-care, mindfulness, debt management), self-care competencies, and pass/fail grading in preclinical courses.1,3,11,12,26 Schools have also been encouraged to promote social support (e.g., organize students into learning communities, organize social activities), facilitate physical activity (e.g., subsidize fitness facilities), provide access to self-assessment tools for students to monitor their level of well-being, improve access to care for mental health concerns, and strengthen programmatic evaluation and faculty development.3,5,16,17,32 Although individual institutional efforts to promote student well-being have been described,13,29,33 there are no consolidated data on such strategies across multiple institutions.
To address this gap, we surveyed a convenience sample of 32 MD-granting and DO-granting U.S. medical schools participating in the American Medical Association’s (AMA’s) Accelerating Change in Medical Education Consortium. This consortium began in 2013 when 11 grant-receiving medical schools came together to explore ways to better prepare physicians to deliver care in 21st-century health systems. In 2016, the consortium expanded to 32 grant-receiving schools, each committed to educational innovation.34 The purpose of our survey was to describe the strategies these schools use to promote student well-being, including their approach to program evaluation, their allocation of resources, and any dedicated infrastructure.
In 2016, 15 individuals from 10 consortium member institutions recognized a shared interest in student well-being and formed the Student Wellness interest group.34 This interest group developed a survey based on recent narrative reviews and published recommendations,1,3,11,12,26 a limited literature review, and focused discussions with content experts (including several associate deans of student affairs). Our literature review, conducted in September 2016, was intended to identify articles published after a recent narrative review3 and, thus, was limited to peer-reviewed, English-language articles published in 2016 focusing on burnout, stress, or depression among U.S. medical students. (Our search of Ovid MEDLINE used the Medical Subject Headings [MeSH] terms medical student, burnout, professional, depression, and stress, psychological.) After synthesizing the information and a series of conference calls, interest group members reached consensus that the survey should gather information on well-being curricula; activities intended to promote emotional, physical, financial, and social well-being; evaluation strategies; resources and infrastructure allocated to support well-being; grading in preclinical courses; and learning communities. Survey items were developed by M.B.S., S.R., A.P.K., A.H., and M.R., and piloted with seven educators from the interest group. After this pilot testing, the term emotional well-being was changed to emotional/spiritual well-being, and the definition of learning communities was clarified to encompass longitudinal societies, colleges, docent teams, houses, and mentorship groups. The final well-being inventory survey instrument is available as Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A630.
In October 2016, an AMA representative sent an e-mail describing the survey and its intent to the principal investigators at each of the 32 schools participating in the AMA’s Accelerating Change in Medical Education initiative. These principal investigators were asked to forward the e-mail, which included the survey link, to colleagues at their institution involved in medical student well-being. Multiple individuals could contribute to a school’s response depending on their specific involvement with, and knowledge of, student well-being at their institution. In situations in which individuals from the same school provided conflicting information, one of the authors (M.D.) reached out to them for additional clarification, and discrepancies were resolved by consensus. Informed consent was implied by return of the survey. Responses were collected through a secure online portal, and summary descriptive statistics were compiled. School-related data (i.e., number of students enrolled and their gender, public or private status, and in-state tuition) were collected through public sources. The University of Illinois at Chicago’s IRB reviewed the study and determined it to be exempt.
Of the 32 consortium medical schools, 27 (84%) responded. Descriptive data for the responding institutions are provided in Table 1. The percentage of women enrolled and the mean in-state tuition at the responding institutions were generally similar to those of other U.S. medical schools.35–38
Curricula and activities
More than half of the responding schools (16/27; 59%) reported having a student well-being curriculum. Most of these schools (13/16; 81%) indicated that this curriculum took place on a weekday between 8 am and 12 pm or 1 pm and 5 pm (Figure 1). The well-being curriculum was scheduled at least monthly at most of these schools (12/16; 75%); at the others, it was scheduled quarterly (1/16; 6%) or yearly (3/16; 19%). More than half (9/16; 56%) reported a combination of optional and mandatory attendance. Nearly one-third (5/16; 31%) stated that attendance was optional for all activities, and few (2/16; 13%) indicated that attendance was always mandatory.
The types of emotional/spiritual, physical, financial, and social well-being activities offered by schools are shown in Table 2. Most schools reported providing mindfulness meditation training (25/27; 93%), supporting student-defined organizations (26/27; 96%), encouraging physical activity through organized events (23/27; 85%), holding lectures related to finances (20/27; 74%), and hosting social events (26/27; 96%). Several institutions emphasized the importance of offering an assortment of social activities that appeal to diverse groups of students, including activities that welcome partners, focus on parenting, highlight talents of faculty and peers, and offer relaxed ways to connect with staff from the dean’s office.
Examples of well-being curricula and activities are provided in Table 3. For instance, one school sponsored a “My Stories” program, where medical students share with each other their stories of recovery, struggles, and/or failure. Another institution held monthly discussion groups for third- and fourth-year medical students, led by the coordinator of the licensed clinical social worker program and a social work practicum student, providing a safe environment for students to discuss stressors such as clinical rotations, challenges to personal life and health, human suffering, and the pressure of constant evaluation.
Schools encouraged physical activity among students by applying a health behavior change framework, organizing athletic competitions, and making treadmill desk stations readily available. One institution incorporated healthy role modeling and community service by organizing “Walk With a Doc” sessions, consisting of brief presentations for community members on specific health topics followed by a walk shared with physicians, medical students, and patients.
To address financial well-being, one institution connected career advisors with financial aid counselors in an active partnership to facilitate discussions with students about career choices and medical school debt. Another institution sponsored a food security program for students and hosted a web page providing students with information on how to live on a fixed budget.
Nearly one-quarter of the responding schools (6/27; 22%) reported having a formal competency related to well-being. Two MD-granting schools indicated that they use the Physician Competency Reference Set developed by the Association of American Medical Colleges (AAMC), which includes competencies related to appropriate help-seeking behaviors and adaptive coping skills.39 DO-granting schools reported relying on the American Association of Colleges of Osteopathic Medicine’s professionalism and personal self-care competency, which expects students to engage in self-care, appropriately seek care from a professional outside their family, ensure that their mental and physical health does not have a negative impact on patient care or welfare, identify sources of personal stress and take steps to intervene, and have the ability to recognize the physiologic and psychologic consequences of stress.40
The most common strategies used to evaluate well-being curricula and activities were student participation rates (26/27; 96%) and student satisfaction as reported on surveys or course evaluations (22/27; 81%). Some schools used focus groups (13/27; 48%) or faculty attitudinal surveys (8/27; 30%). More than half of the schools (16/27; 59%) assessed student well-being through data collected from surveys administered locally, by external vendors, or nationally (e.g., school-specific well-being data from the AAMC’s Medical School Year Two Questionnaire and Medical School Graduation Questionnaire).
Infrastructure and resources
Among the responding schools, 22/27 (82%) identified an individual or group of individuals specifically charged with overseeing student well-being. The titles associated with this role included “assistant dean of students,” “associate director of student affairs,” “director of student well-being,” “student well-being advocate,” and “executive director of university health and counseling services.” These individuals had dedicated time set aside for well-being activities at most schools (18/22; 82%), but the amount of time varied widely: They had more than 50% dedicated time at approximately one-third of institutions (51%–75% time at 2/18 [11%]; > 75% time at 4/18 [22%]); 26%–50% dedicated time at more than one-quarter (5/18; 28%); and 25% or less dedicated time at more than one-third (7/18; 39%).
Most schools (22/27; 82%) reported having a student well-being committee. Three (14%) of these 22 schools reported student-only participation, while the other 19 (86%) reported both student and faculty membership. The student well-being committees served to provide information to students, organize activities, offer peer mentoring and support, act as a liaison between students and student affairs deans, and provide input on student health and counseling programs.
Reported budgets for student well-being activities ranged from $0 to $35,000/year (median $0; average $2,963). Four schools (4/22; 18%) indicated that they allocate funds for well-being initiative grants. For example, one school’s student well-being committee awarded multiple grants of up to $250 for student-initiated well-being activities. At one school, funds were used to incentivize participation in optional well-being activities: The school challenged students to collect passport-like stamps at well-being activities, and these stamps were used as raffle tickets for well-being-related prizes.
Seven (26%) of the responding institutions indicated that they spend funds to provide students access to anonymous self-assessment tools, including the Medical Student Well-Being Index, ULifeLine, and Student Health 101. In addition to providing students with mechanisms to gain insight into their personal well-being, these tools provide resources for students and (in some cases) aggregate, deidentified reports to schools on participation rates, resources reviewed, and well-being scores.
Many schools (20/27; 74%) reported using pass/fail grading in the preclinical years. Twenty-two schools (81%) had learning communities. Most of the learning communities included students from multiple years and required student participation in advising/mentoring and in team-building and career-planning activities (Table 4). Learning communities also often provided structure for students to build their doctoring skills and discuss medical professionalism and ethics.
In this study of U.S. medical schools, more than half of the 27 responding institutions had a well-being curriculum for medical students, and most offered a variety of well-being activities. Despite the allocation of curricular time and/or resources to support an individual charged with overseeing medical student well-being, budgets for well-being activities were typically small, self-care competencies were largely absent, and program evaluation was generally limited to student participation rates and reports of satisfaction. Although 59% of schools reported assessing student well-being, only 26% of schools provided students access to self-assessment tools that would provide them with insight into their own level of well-being.41 In terms of structural approaches, nearly 75% of schools used pass/fail grading during the preclinical years, and 81% used learning communities designed to promote social support and mentorship and address stressors (e.g., ethical dilemmas, career choice).
Our findings are generally encouraging. Most of the surveyed schools allocated some curricular time to well-being at regular intervals and offered activities with the potential to promote self-care, physical activity, social support, and debt management. Mounting evidence suggests that well-being curricula and activities can have a measurable effect on well-being. For example, intervention studies of mindfulness-based stress reduction have demonstrated reduction in burnout and stress and improved mood and empathy in medical student or physician volunteers.20,21,42–50 Medical students who adhere to Centers for Disease Control and Prevention exercise guidelines have a lower risk of burnout,16 and participation in incentivized team-based physical activity interventions results in higher quality of life.51 Social support also promotes well-being. In a longitudinal, single-institution study of third-year medical students, high degrees of social function protected against depression.18
Institutional structures that reduce competition and time pressures (e.g., pass/fail grading in the preclinical years) and enhance social support (e.g., learning communities) are supported by the literature on medical student well-being14,15,29–31 and were common (though not universal) in our study cohort. In another multi-institutional study across 12 medical schools that explored curricular factors influencing preclinical students’ well-being (i.e., grading, hours spent in lectures and small groups, hours of clinical experiences, hours and number of exams, and weeks of vacation), the predominant factor associated with burnout, stress, and serious thoughts of dropping out was the grading schema.29 Students in a preclinical curriculum not graded pass/fail had increased odds of burnout, higher stress scores, and higher odds of seriously considering dropping out of school. Pass/fail grading in preclinical courses has been shown to enhance students’ well-being and satisfaction with their medical education and personal life, while having no detrimental impact on learning as measured by United States Medical Licensing Examination Step 1 scores and clerkship grades.30,31
Some of our findings are discour aging, however. Few schools had an operationally defined well-being competency or used rigorous strate gies to evaluate their approach to optimizing student well-being. Implementing dedicated competencies and rigorously evaluating their impact would help ensure that time and resources are appropriately allocated, as well as help determine whether strategies to improve student well-being are making a difference. Similar to professionalism, once well-being competencies are defined and implemented, evidence-based curricula, implementation strategies, and evaluation methods must follow.
Also, few schools provided students access to a self-assessment instrument to measure well-being. Experienced physicians struggle to accurately self-assess their level of well-being, which contributes to a lack of timely help seeking.41 Providing individualized feedback on well-being helps promote behavior change and help seeking.41,52 Like residency programs,53 medical schools should consider providing access to and encouraging the iterative use of self-assessment tools to improve self-awareness and identify areas for improvement in the context of well-being.
This study has several limitations. Although the survey asked about learning communities and pass/fail grading in the preclinical years, other aspects of the learning environment likely to influence student well-being were not explored. Those aspects include curriculum overcrowding, faculty and resident well-being, organization of clinical rotations, faculty incentives for teaching, faculty development (e.g., feedback skills), mistreatment policies and procedures, and curriculum evaluation.3,27,28 In addition, our findings may not be generalizable to all U.S. medical schools because only consortium schools were surveyed. Although generalizability is supported by inclusion of geographically diverse private and public MD- and DO-granting medical schools with tuition and student gender typical of U.S. medical schools, additional studies are warranted to further explore medical schools’ approaches to optimizing student well-being. As we relied on principal investigators to identify the appropriate individual(s) at their institution to complete the survey, sampling bias may have occurred. This may, however, have been mitigated by enabling multiple individuals at an institution to respond.
To our knowledge, this is the first study to describe strategies to support student well-being across multiple U.S medical schools. We found that schools have implemented a broad range of well-being curricula and activities, but resources, oversight, and evaluation strategies vary. Because distress in medical school is a predictor of distress in residency,54 strengthening the approaches used to evaluate the efficacy of schools’ student well-being strategies is an important next step in alleviating learner distress and ultimately improving student well-being.
Acknowledgments: The authors wish to acknowledge additional members of the Student Wellness interest group, including Tonya Fancher, MD, MPH, associate dean, Workforce Innovation and Community Engagement, Division of General Medicine, University of California, Davis, School of Medicine; Beat Steiner, assistant dean for clinical education, University of North Carolina School of Medicine; Ann Poncelet, MD, professor of clinical neurology and William G. Irwin Endowed Chair, University of California, San Francisco; Martha Elks, MD, PhD, senior associate dean of educational affairs, Morehouse School of Medicine; and Sue Cox, MD, executive vice dean for academics and chair of medical education, Dell Medical School, University of Texas at Austin.
1. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: A systematic review and meta-analysis. JAMA. 2016;316:22142236.
2. 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;81:354373.
3. Dyrbye L, Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ. 2016;50:132149.
4. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149:334341.
5. Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA. 2010;304:11811190.
6. Chew-Graham CA, Rogers A, Yassin N. “I wouldn’t want it on my CV or their records”: Medical students’ experiences of help-seeking for mental health problems. Med Educ. 2003;37:873880.
7. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89:443451.
8. Thomas MR, Dyrbye LN, Huntington JL, et al. How do distress and well-being relate to medical student empathy? A multicenter study. J Gen Intern Med. 2007;22:177183.
9. Dyrbye LN, Massie FS Jr, Eacker A, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA. 2010;304:11731180.
10. Dyrbye LN, Thomas MR, Power DV, et al. Burnout and serious thoughts of dropping out of medical school: A multi-institutional study. Acad Med. 2010;85:94102.
11. Slavin SJ. Medical student mental health: Culture, environment, and the need for change. JAMA. 2016;316:21952196.
12. Slavin SJ, Chibnall JT. Finding the why, changing the how: Improving the mental health of medical students, residents, and physicians. Acad Med. 2016;91:11941196.
13. Slavin SJ, Schindler DL, Chibnall JT. Medical student mental health 3.0: Improving student wellness through curricular changes. Acad Med. 2014;89:573577.
14. Dyrbye L, Shanafelt T. Nurturing resiliency in medical trainees. Med Educ. 2012;46:343.
15. Dyrbye LN, Shanafelt TD. Commentary: Medical student distress: A call to action. Acad Med. 2011;86:801803.
16. Dyrbye LN, Satele D, Shanafelt TD. Healthy exercise habits are associated with lower risk of burnout and higher quality of life among U.S. medical students. Acad Med. 2017;92:10061011.
17. Howe A, Smajdor A, Stöckl A. Towards an understanding of resilience and its relevance to medical training. Med Educ. 2012;46:349356.
18. 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;84:258268.
19. Kligler B, Linde B, Katz NT. Becoming a doctor: A qualitative evaluation of challenges and opportunities in medical student wellness during the third year. Acad Med. 2013;88:535540.
20. Finkelstein C, Brownstein A, Scott C, Lan YL. Anxiety and stress reduction in medical education: An intervention. Med Educ. 2007;41:258264.
21. Shapiro SL, Shapiro DE, Schwartz GE. Stress management in medical education: A review of the literature. Acad Med. 2000;75:748759.
22. Dyrbye LN, Shanafelt TD, Werner L, Sood A, Satele D, Wolanskyj AP. The impact of a required longitudinal stress management and resilience training course for first-year medical students. J Gen Intern Med. 2017;32:13091314.
23. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358367.
24. Shanafelt TD. Enhancing meaning in work: A prescription for preventing physician burnout and promoting patient-centered care. JAMA. 2009;302:13381340.
25. Shanafelt TD, Oreskovich MR, Dyrbye LN, et al. Avoiding burnout: The personal health habits and wellness practices of US surgeons. Ann Surg. 2012;255:625633.
26. McKenna KM, Hashimoto DA, Maguire MS, Bynum WE 4th. The missing link: Connection is the key to resilience in medical education. Acad Med. 2016;91:11971199.
27. Cook AF, Arora VM, Rasinski KA, Curlin FA, Yoon JD. The prevalence of medical student mistreatment and its association with burnout. Acad Med. 2014;89:749754.
28. Dyrbye LN, Thomas MR, Harper W, et al. The learning environment and medical student burnout: A multicentre study. Med Educ. 2009;43:274282.
29. Reed DA, Shanafelt TD, Satele DW, et al. Relationship of pass/fail grading and curriculum structure with well-being among preclinical medical students: A multi-institutional study. Acad Med. 2011;86:13671373.
30. Rohe DE, Barrier PA, Clark MM, Cook DA, Vickers KS, Decker PA. The benefits of pass–fail grading on stress, mood, and group cohesion in medical students. Mayo Clin Proc. 2006;81:14431448.
31. Bloodgood RA, Short JG, Jackson JM, Martindale JR. A change to pass/fail grading in the first two years at one medical school results in improved psychological well-being. Acad Med. 2009;84:655662.
32. Dyrbye LN, Schwartz A, Downing SM, Szydlo DW, Sloan JA, Shanafelt TD. Efficacy of a brief screening tool to identify medical students in distress. Acad Med. 2011;86:907914.
33. Drolet BC, Rodgers S. A comprehensive medical student wellness program—Design and implementation at Vanderbilt School of Medicine. Acad Med. 2010;85:103110.
34. Skochelak SE, Stack SJ. Creating the medical schools of the future. Acad Med. 2017;92:1619.
35. Association of American Medical Colleges. AAMC FACTS. Table B-1.2: Total enrollment by U.S. medical school and sex, 2012–2013 through 2016–2017. https://www.aamc.org/download/321526/data/factstableb1-2.pdf
. Accessed August 17, 2017. [Updated version available.].
36. American Association of Colleges of Osteopathic Medicine. 2016–17 osteopathic medical college total enrollment by gender and race/ethnicity. https://www.aacom.org/docs/default-source/data-and-trends/2016-17_TEnroll_Gender_RE_COM%20.pdf?sfvrsn=12
. Accessed December 10, 2018.
37. Association of American Medical Colleges. Academic year 2016–2017 data. In: Tuition and Student Fees for First-Year Students: Summary Stastistics for Academic Years 2012–2013 Through 2018–2019. https://www.aamc.org/data/tuitionandstudentfees
. Accessed December 10, 2018.
38. American Association of Colleges of Osteopathic Medicine. 2016–2017 data. In: Osteopathic College Tuition and Fees (1st Year) 2018–19 and historical. https://www.aacom.org/reports-programs-initiatives/aacom-reports/tuition-fees-and-financial-aid
. Accessed December 10, 2018.
39. Association of American Medical Colleges. Physician Competency Reference Set. https://www.aamc.org/initiatives/cir/developers/348808/aboutpcrs.html
. Accessed December 10, 2018.
40. American Association of Colleges of Osteopathic Medicine. Osteopathic Core Competencies for Medical Students. https://www.aacom.org/docs/default-source/core-competencies/corecompetencyreport2012.pdf?sfvrsn=4
. Published August 2012. Accessed December 10, 2018.
41. Shanafelt TD, Kaups KL, Nelson H, et al. An interactive individualized intervention to promote behavioral change to increase personal well-being in US surgeons. Ann Surg. 2014;259:8288.
42. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003;15:8892.
43. Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. J Behav Med. 1998;21:581599.
44. Warnecke E, Quinn S, Ogden K, Towle N, Nelson MR. A randomised controlled trial of the effects of mindfulness practice on medical student stress levels. Med Educ. 2011;45:381388.
45. de Vibe M, Solhaug I, Tyssen R, et al. Mindfulness training for stress management: A randomised controlled study of medical and psychology students. BMC Med Educ. 2013;13:107.
46. Erogul M, Singer G, McIntyre T, Stefanov DG. Abridged mindfulness intervention to support wellness in first-year medical students. Teach Learn Med. 2014;26:350356.
47. Jain S, Shapiro SL, Swanick S, et al. A randomized controlled trial of mindfulness meditation versus relaxation training: Effects on distress, positive states of mind, rumination, and distraction. Ann Behav Med. 2007;33:1121.
48. 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;14:387398.
49. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. Lancet. 2016;388:22722281.
50. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302:12841293.
51. Weight CJ, Sellon JL, Lessard-Anderson CR, Shanafelt TD, Olsen KD, Laskowski ER. Physical activity, quality of life, and burnout among physician trainees: The effect of a team-based, incentivized exercise program. Mayo Clin Proc. 2013;88:14351442.
52. Moutier C, Norcross W, Jong P, et al. The suicide prevention and depression awareness program at the University of California, San Diego School of Medicine. Acad Med. 2012;87:320326.
53. Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements. https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_2017-07-01.pdf
. Effective July 1, 2017. Accessed December 10, 2018.
54. Tyssen R, Vaglum P, Grønvold NT, Ekeberg O. Factors in medical school that predict postgraduate mental health problems in need of treatment. A nationwide and longitudinal study. Med Educ. 2001;35:110120.