Over the past decade, recognition has grown of the mental health challenges facing our nation’s medical students, residents, and physicians.1,2 The literature on this topic is rapidly expanding as the problem continues to be explored and described, yet the number of intervention studies addressing it still lags. A tremendous challenge remains ahead for the medical education community and health care overall—how to take collective, widespread action to effectively address this complex, multifaceted problem.
One of the earliest longitudinal efforts to improve medical student well-being, and perhaps the only one that has tracked mental health outcomes continuously, is the decade-long medical student well-being initiative at Saint Louis University School of Medicine (SLU SOM).3 In this Invited Commentary, I describe my experience leading that effort—the obstacles, the challenges, the successes, and the failures—to help inform more nascent efforts beginning to take shape across the medical education continuum and in practice.
The Origin of the SLU SOM Well-Being Initiative
In 2006, two years into my tenure as associate dean for curriculum at SLU SOM, I became acutely aware of the poor mental health of medical students. A 2005 review paper by Dyrbye and colleagues4 had described high rates of distress, depression, and burnout in medical students; however, I thought that the poor mental health outcomes described in that study and elsewhere in the literature seemed implausible at our school. Since my arrival at SLU SOM, I had worked to create an atmosphere of respect, openness, and compassion, and it seemed to be appreciated by the students. They appeared very happy overall, and their satisfaction with the school’s administration and their overall education, as measured by the Association of American Medical Colleges (AAMC) Graduation Questionnaire,5 had soared. I thought that being open and accessible to students and promoting a culture of respect and warmth was perhaps all we needed to do to avert the poor mental health outcomes associated with medical school described in the literature. Rather than trust that notion, however, we decided to measure our students’ mental health with validated depression and anxiety scales. The results were devastating; our rates matched those in the literature. Our students’ mental health was very good at orientation but deteriorated across their four years of medical school.
The only possible conclusion was that we were harming our students’ mental health, and I, as curriculum dean, was ultimately responsible. With a mission statement that included the words “education of the whole person—mind, body, spirit, and heart,” the status quo was not acceptable. We either needed to abandon our mission statement or change the way we were teaching and caring for our students. We opted for the latter and embarked that day on a path to do something about it. As we began our work, I knew that financial resources would be constrained as the curricular affairs budget was already stretched thin and an influx of new funds seemed unlikely. We would also need to make the plans palatable to the course directors and the faculty on two curriculum committees and the Executive Committee at what was a fairly traditional and conservative medical school.
The Well-Being Model and Interventions
We developed a simple model with three components to guide our efforts3:
- Reduce unnecessary stressors and enhance the learning environment,
- Teach students skills to better manage their stress and provide and encourage them to use a range of psychological and emotional support resources, and
- Create more opportunities for students to find meaning in their work.
We proposed the first set of interventions in 2008; they focused entirely on the curriculum and the learning environment in the preclerkship years, addressing stressors and deficiencies students had identified in focus groups and surveys. These interventions included:
- Change from a four-tier to a two-tier (pass/fail) grading system,
- Cut curriculum hours in all courses by 10%, in conjunction with efforts to get faculty to reduce the amount of detail taught, and
- Institute longitudinal electives and theme-based learning communities.
These proposed changes received significant opposition from some faculty as well as from some students, but ultimately, using evidence from the literature to support the proposal, the changes were approved unanimously by the two curriculum committees and the Executive Committee mentioned above and instituted in 2009.
The following year, a six-hour mindfulness and resilience curriculum for first-year students was implemented. It was initially met with some resistance and resentment from students who felt it was too “soft” and “touchy-feely.” An exercise in which students were given chocolate to eat mindfully was, rather sadly, met with particular derision from some.
In 2011, the dean pressured the directors of the human anatomy course to ease the course’s content load and harsh grading system. The human anatomy course was also moved from the first slot to the second slot in the students’ first year, to ease the transition to medical school.
The following year, because of evidence of continued student stress related to academic achievement, we implemented a “true” pass/fail system, where student performance in preclerkship courses was not used to determine eligibility for Alpha Omega Alpha Honor Medical Society induction or provided to residency program directors during the residency application process.
In 2013, a complete restructuring of the four-year curriculum was approved. The major features of the revised curriculum were a decrease of nine weeks in the length of, and greater integration of the material in, the preclerkship curriculum; a change to a completely block curriculum in which students had only one major course at a time; and substantial changes to fourth-year requirements. Notably, the initial draft curriculum was developed by 4 fourth-year students on a two-week medical education elective I supervised. The proposal, after input from course directors, faculty, and students, and review and modification by a curriculum task force, was approved unanimously by the three committees mentioned above.
The following year, in concert with our behavioral health providers, students were given the option of taking part in a confidential assessment for depression and anxiety at four points during their preclerkship years. Those who screened positive for depression or anxiety received follow-up e-mails from counselors asking if they wanted to come in to talk. Approximately 90% of students opted to participate in these assessments.
During the 2015–2016 academic year, because of evidence of mounting pressure associated with the United States Medical Licensing Exam Step 1, we provided more intentional and expansive emotional and academic support for second-year students in the months before the exam.
Finally, two areas of the curriculum evolved in important ways over the years. First, the required component of the resilience curriculum for first-year students was trimmed down from six hours to an hour and a half. The topics and tools introduced in the first year were revisited and reinforced in presentations at key transition points—during the run-up to the Step 1 exam, during orientation week preceding the clerkship year, and just before graduation during the fourth-year required capstone course. These presentations were supplemented by occasional, brief in-class messages and “pep talks” I gave as well as in e-mails I sent to the class listserves on an as-needed basis. As part of the well-being curriculum, we also focused more on cognitive distortions and destructive mind-sets, such as maladaptive perfectionism. As all these changes were made, the initial resistance seemed to dissipate, and it perhaps even disappeared entirely.
Second, we changed the timing and scheduling of exams in the preclerkship years. Most exams were moved to Fridays, and no new material could be given to students in the 24 hours before the exam, allowing time for students to consolidate their learning. All preclerkship modules also came to include quizzes and/or midmodule exams to provide students with critical feedback to help guide their studying.
We saw striking improvements in the mental health of our medical students over the years of this well-being initiative.6 The percentage of the Class of 2018 (which was exposed to all of the well-being changes) that reported moderate to severe symptoms of depression (as measured by the Center for Epidemiologic Studies Depression scale) at the end of their first year was 4% and at the end of their second year was 6%. In comparison, the percentage of the Classes of 2012 and 2013 (which preceded the initiative) that reported these symptoms at the end of their first year was 27% and at the end of their second year was 31%. The percentage of the Class of 2018 that reported moderate to high levels of anxiety (as measured by the state portion of the State Trait Anxiety Inventory) at the end of their first year was 14% and at the end of their second year was 31%. In comparison, the percentage of the Classes of 2012 and 2013 that reported these symptoms at the end of their first year was 55% and at the end of their second year was 60%. These decreases occurred despite evidence nationally of rising stress and distress associated with the Step 1 exam over these years.
These improvements in mental health outcomes in preclerkship students appear to be unprecedented. Strikingly, despite the reduction in curriculum hours and the change to pass/fail grading we implemented, academic performance, as measured by Step 1 exam mean scores and passing rate, also improved.
Although the impact of our well-being initiative on the mental health of our preclerkship students was very positive, the impact on our clerkship students was not. We still saw spikes in depression and anxiety rates in students during their clerkship year.
Reflections and Impressions
The SLU SOM well-being initiative was remarkably effective despite significant constraints in terms of financial resources and staffing. The annual budget for the entire initiative was less than $3,000 per year, and no new staff or faculty were added. What led to its effectiveness then?
The following are my personal impressions based on my experience, which may be informative not just for well-being efforts across the medical educational continuum and practice but also for efforts in other educational settings.
Poor mental health in medical students (and in students across the education continuum outside of medical school) is a multifactorial problem that, to a great degree, stems from the learning environment. Our initiative was likely successful because of its multifaceted, learning-environment-focused approach.
We developed a deep understanding of the lived experiences of our students and regularly assessed their collective mental health. Surveys, town halls, focus groups, one-on-one meetings, and conversations in the hallway helped us gain a deeper understanding of the needs of those we were charged with nurturing and guiding. I think the success of our interventions in many ways hinged on this philosophy. Also, without regular mental health assessments, we could not have been confident of the efficacy of the interventions. I cannot conceive how others in medical education and clinical practice can be similarly confident of the efficacy of their programs without regular mental health assessments of those they serve.
Educators have historically focused much more on how students are taught than on how much. We recognized early on that our students suffered from information overload, excessive class time, and unreasonable academic demands, so we reduced that load and the pressure on our students. In backing off, academic outcomes did not suffer, as might be expected, but rather they improved as did the mental health of our students.
Our required resilience curriculum was modest in duration and scope, respecting the time pressures that students face. We took an invitational rather than prescriptive approach and encouraged students to choose those tools, strategies, and activities that they thought could benefit them. I believe that if we had been more prescriptive and our required well-being curriculum had been significantly longer, it would not have been as effective.
During their education before medical school, many students develop cognitive distortions, such as all-or-nothing thinking and catastrophization, as well as problematic mind-sets, such as maladaptive perfectionism, which may contribute to the negative impact of the learning environment on their well-being. Our well-being curriculum took primary aim at those mind-sets, providing students with cognitive behavioral tools and approaches while shining a light on common distortions and problematic mind-sets to ensure that students knew they were not alone in experiencing less-than-ideal cognitive processes.
Seemingly disparate efforts appeared to work synergistically to produce change in the learning environment and in students’ mind-sets and priorities. The reduction in required class hours; creation of longitudinal electives and learning communities; institution of pass/fail grading; and encouragement of students to care more about learning, experience, growth, and meaning and less about test scores, all combined to create a spirit of collaboration, innovation, and joy. In such an atmosphere and with more freedom and autonomy, student engagement expanded dramatically as students themselves led the development of a wide range of programs and activities including a homeless foot care “clinic,” a doula training program, preventive health programs for a local school for immigrant children, and a collaborative biomedical incubator program called MEDLaunch, which they created with business, law, and engineering students.
We treated our students with respect and compassion. We listened to them. We supported them, and we were responsive to their reasonable requests. On the AAMC Graduation Questionnaire, students rate the Office of Curriculum on factors including accessibility, awareness of students’ concerns, and responsiveness to students’ concerns. In 2017, nationally, 32.8% of students were very satisfied with their school on these measures. At SLU SOM, 76.1% of students were. Students are also asked to rate their “satisfaction with programs/activities that promote effective stress management, a balanced lifestyle, and overall well-being.” Nationally, 33.3% of students were very satisfied, while at SLU SOM, 81.2% were. These rates did not reflect satisfaction with our well-being programming alone; rather, they reflected satisfaction with our overall approach to the students, our care and concern for them, our policies, and our procedures.
We provided our students with a supportive, responsive, respectful, and caring learning environment, and they flourished. I cannot see how the same should not be the goal in every educational setting.
We were not successful in all areas, however. The mental health of our students still deteriorated during their clerkship year, and the primary driver of that change appeared to be exposure to unhappy residents and faculty. I believe that medical student mental health in the clinical years will not improve until the mental health of their supervisors does. In my mind, programs to improve faculty and resident mental health and morale are critical to creating a clinical learning environment to support medical students, and implementing such changes should be of the highest priority.
Ultimately, and crucially, we recognized the importance of finding meaning and its intersection with students’ mental health. The outcome that I am perhaps most proud of is the following. On the AAMC Graduation Questionnaire, students are asked if they agree or disagree (on a five-point Likert scale from strongly agree to strongly disagree) with the following statement: “My medical school has done a good job of fostering and nurturing my development as a person.” In 2017, nationally, 33.8% of students strongly agreed, while at SLU SOM, 65.0% did. Our initial goal was to improve students’ well-being, but I now believe that we accomplished much more, and from that, well-being ensued. Students felt listened to, valued, and respected. They found purpose and meaning. They grew not just as future doctors but as people. I firmly believe that the same is possible elsewhere.
Acknowledgments: The author wishes to thank the following for their contributions to the well-being initiative at Saint Louis University School of Medicine—Greg Smith, PhD, John Chibnall, PhD, Ginny Fendell, LCSW, Michael Railey, MD, and Debra Schindler, PhD. The author also would like to thank Philip Alderson, MD, former dean of Saint Louis University School of Medicine, for his support of the well-being initiative and its goals. Finally, he would like to thank the students at Saint Louis University School of Medicine who were truly cocreators of the culture, curriculum, and environment described in this paper.