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Innovation Reports

REACH: A Required Curriculum to Foster the Well-Being of Medical Students

Ferguson, Catherine C. MD1; Ark, Tavinder K. PhD2; Kalet, Adina L. MD3

Author Information
doi: 10.1097/ACM.0000000000004715
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Abstract

Problem

The presence, breadth, and consequences of medical student unwellness are well documented. Levels of depression, stress, anxiety, suicidality, and burnout in medical students are reported as at or above those of their age-matched peers, and few students seek help on their own. 1 Learner distress may negatively impact the quality and safety of patient care, the adequacy of the workforce, and learners’ professionalism, academic performance, and personal health. 2 To address the personal and professional development of medical students, it is imperative to develop holistic strategies to help this group of learners not only avoid psychological distress but also flourish. 3 In this report, we describe the philosophy, structure, and content of the REACH (Recognize, Empathize, Allow, Care, Hold each other up) curriculum, provide a preliminary evaluation of the first 2 years of implementation, and discuss our plans to study the impact of this mandatory well-being curriculum on learners.

Approach

Curriculum principles

At the Medical College of Wisconsin (MCW), we sought to create an integrated well-being curriculum to prepare learners for the emotional life of being a physician. The longitudinal REACH curriculum emphasizes self-care as a competency on par with the competencies taught in the basic and clinical sciences. 3 Because of the nature of physicians’ work, physicians-in-training will be witness to, attend to, and often absorb the suffering of other human beings. Therefore, the REACH curriculum uses a framework, core concepts, and discrete skills from the field of trauma stewardship. As described by Lipsky and Burk, 4 trauma stewardship comprises a set of skills or practices through which “individuals, organizations, and societies tend to the hardship, pain, or trauma experienced by humans” and develop the “deep sense of awareness needed to care for ourselves while caring for others.” Throughout the curriculum, we introduce and give students the opportunity to practice the skills that allow physicians to tend to our patients’ suffering without assuming their pain as our own.

Building on effective medical student well-being interventions described in the literature (mindfulness-based training, shame resilience seminars, facilitated small-group discussions), we also incorporate storytelling to demonstrate the power of vulnerability, show how to navigate ambiguity, and destigmatize help-seeking. 5,6

Needs assessment and pilot curriculum

A voluntary needs assessment survey of MCW medical students was conducted in 2016 (response rate = 44.3% [405/915]). The results were comparable to state-level data, 7 with 29% of the MCW respondents reporting they had experienced a mental health condition while in medical school and 12% reporting they had screened positive for depression. The prevalence of suicidal ideation in the prior 2 weeks was 7.8%.

A 1-year pilot of a well-being curriculum called the MCW Resilience Project was conducted in 2017–2018 with the 82 first-, second-, and third-year medical students (13% of all students across the 3 classes) enrolled in the Quality Improvement/Patient Safety Scholarly Concentration, a course where select core concepts around burnout and resilience were already being taught. Participant feedback highlighted that teaching practical skills, normalizing difficulty, role-modeling, and providing time for reflection were the most useful components of the pilot curriculum.

REACH curriculum: Goals, learning objectives, and content

Following the successful pilot, the senior associate dean for medical education freed up a total of 13.5 hours of instructional time for didactic and small-group sessions focused on well-being without adding time to the overall curriculum. The new REACH curriculum, based on the MCW Resilience Project, was implemented in 2018–2019 as a requirement for all first- and second-year students. The REACH curriculum director (C.C.F.) designs, administers, and teaches it with support from the MCW Kern Institute for the Transformation of Medical Education. The small-group facilitators—45 faculty, trainees, and staff—are volunteers.

The REACH curriculum goals are that students will (1) appreciate the connection between individual well-being and the quality and safety of the care provided by physicians and trainees to patients; (2) learn the core concepts and practical skills that allow sustained work with suffering people; and (3) contribute to the cultivation of an equitable, inclusive, and hopeful institutional culture that supports all students to thrive. Chart 1 presents the learning objectives for the didactic and small-group sessions for the cohort of students who began the 2-year curriculum in the 2019–2020 academic year. (These objectives are similar to those covered in 2018–2019, and differences are described below.)

CH1
Chart 1:
Learning Objectives for the REACH Curriculum’s Didactic and Small-Group Sessions for Medical College of Wisconsin (MCW) Students Beginning the 2-Year Curriculum in 2019–2020

The REACH curriculum content is drawn from mindfulness-based interventions, cognitive behavioral therapy, and positive psychology research evidence. The skills and core concepts woven throughout the REACH curriculum include embracing vulnerability, mindfulness, and meditation; engaging with technology responsibly; setting healthy boundaries; cultivating self-compassion; and understanding the differences between empathy and compassion. The content and structure of the curriculum are iteratively refined. For example, in 2020, in response to the murder of George Floyd by a police officer and the COVID-19 pandemic, we added a didactic session on having difficult conversations (replaced a session on sustaining relationships in medical school) and a didactic session on secondary trauma in the face of a pandemic (replaced a session on generosity burnout). In 2021, in response to student feedback, we added 2 didactic sessions focused on anxiety and coping with patient death.

Educational strategies

In 2018–2019 and 2019–2020, the REACH curriculum included an orientation session, 4 didactic sessions and 3 facilitated small-group sessions in the second semester of the first year of a 4-year traditional 2 + 2 curriculum, and 3 didactic sessions and 3 facilitated small-group sessions in the first semester of the second year. In 2020–2021, the 2 additional didactic sessions mentioned above extended the curriculum into a third semester. In 2021–2022, the curriculum was extended to all 4 semesters in the first 2 years.

Each lecture is 60 minutes and integrated into a basic science course (e.g., neuroanatomy), replacing 60 minutes of that course’s content. The 75-minute small-group sessions are integrated into Clinical Apprenticeship, an early clinical learning course.

Each small group is composed of medical students (10 in 2018–2020; reduced to 8 in 2020–2021, based on student feedback) and 2 facilitators (a clinical faculty member and a behavioral health expert, i.e., psychiatrist, psychologist, psychiatry resident/fellow, or student support staff member). To ensure representation of a broad set of life experiences in the small-group discussions, student assignments to groups are balanced by gender, racial/ethnic diversity, traditional/nontraditional medical student status, legal state of residence, undergraduate college/university, and undergraduate major. Before each session, facilitators receive detailed session guides. Students are assigned small-group prework, including short videos (e.g., TED Talks), podcasts, and/or short readings.

Storytelling is used by educators in both didactic and small-group sessions as a pedagogical tool to promote understanding of how the REACH core concepts and skills relate to the experience of being a physician and to create an environment in which students feel comfortable sharing their personal stories. Telling stories is a means of “giving cognitive and emotional coherence to experience, and constructing and negotiating social identity,” 8 and it can be a useful medium for the development of emotional understanding. The curriculum director (C.C.F.) infuses storytelling into the didactic sessions, connecting each of the core concepts covered to a personal story (e.g., the concept of self-compassion, a story about receiving negative patient feedback). Facilitators are encouraged to share their personal stories during the small-group discussions to illustrate how they have used specific skills or practices (successfully or unsuccessfully) to enhance their own well-being. This storytelling provides a way for instructors to model vulnerability, a key component of teaching medical students about shame resilience. 5

Assessment and evaluation methods

During the first 2 years of implementation (2018–2019 and 2019–2020), we evaluated the REACH curriculum by fielding a midcurriculum survey (administered between the first and second year) and a postcurriculum survey (at the completion of the curriculum) that included closed questions (5- to 6-point Likert-type response options) and open-ended questions. The students were asked whether the REACH curriculum met their expectations and to rate the value of the didactic lectures and small-group sessions. In 2019–2020, we added open-ended questions about the ongoing use of specific skills taught in the REACH curriculum. The Medical College of Wisconsin Institutional Review Board approved the study of this curriculum.

Outcomes

The REACH curriculum was implemented in the general MCW curriculum in 2018–2019, and more than 700 students across 3 MCW campuses have completed the REACH curriculum as of the time of writing in March 2022. Overall, most students who responded to the mid- and postcurriculum surveys in 2018–2019 and 2019–2020 reported that the REACH curriculum material was important, that the curriculum met their expectations for a quality medical school course, and that they would recommend other schools incorporate a similar curriculum (Table 1).

T1
Table 1:
Medical Student Satisfaction With the REACH Curriculum, Medical College of Wisconsin, 2018–2019 and 2019–2020 Surveys

In the 2019–2020 postcurriculum survey (response rate of 51% [101/197]), respondents identified the following as skills that the REACH curriculum helped them develop: self-care (84% [85/101]), mindfulness (76% [76/101]), and help-seeking (71% [72/101]). Respondents also reported that REACH helped them develop connections with faculty and with others different from themselves (71% [72/101]), confidence about tackling unfamiliar problems (67% [67/101]), and connections with other students (65% [65/101]). Only a few (3% [4/101]) indicated that “nothing” from the REACH curriculum helped them.

Of the 343 mid- and postcurriculum surveys completed in 2018–2019 and 2019–2020, 83% (288/343) included responses to 1 or more of the open-ended questions. Several students commented that their REACH small-group facilitators volunteered to meet with them outside of class to offer career advice and support. The representative comments from students in Table 2 provide examples of ways in which the REACH curriculum goals were met.

T2
Table 2:
Representative Student Comments on the REACH Curriculum, Organized by Curriculum Goal, Medical College of Wisconsin, 2018–2019 and 2019–2020 Surveysa

Next Steps

Our initial outcomes show that a mandatory, integrated, and longitudinal well-being curriculum is feasible and both acceptable and relevant to medical students. Similar to the experience of Pipas et al, 9 our students appeared to perceive the REACH small-group sessions as a safe space to talk with peers, faculty, and staff about topics not discussed elsewhere in the curriculum. They also appeared to appreciate the honesty and vulnerability with which the instructors and facilitators shared personal stories about what it feels like to be a doctor and how they work with the difficult emotions that arise from caring for others.

A small number of students felt that participation in REACH should not be mandatory; in their comments on the surveys, some indicated they would prefer to spend that class time engaging in their chosen well-being activities, and others felt that organizational issues were to blame for student unwellness. Such concerns—along with lack of effectiveness, cognitive dissonance, unaddressed moral injury, and toxic positivity—have been identified by Dajani et al as perceived “unintended consequences of wellness initiatives” in undergraduate medical education. 10 Given the patient care implications of medical student and physician well-being, we believe that all students should have access to the tools they need to care for themselves while caring for others. We are committed to mitigating any potential harm of the REACH curriculum through the study of its short- and long-term impacts and through continuous improvement.

We acknowledge that the REACH curriculum is not, in and of itself, sufficient to address learner distress. Significant systemic changes in medical education and the medical practice environment are needed to shift the culture of medicine toward honoring the humanity of its professionals and its learners. At the MCW, other changes designed to improve student well-being occurred alongside the implementation of the REACH curriculum, including a shift to pass/fail grading, improved access to mental health services, and the addition of a student behavioral health and resource navigator.

We learned several valuable lessons while implementing the REACH curriculum. Incorporating the small groups into our existing Clinical Apprenticeship course gave students the opportunity to reflect on their early clinical experiences and strengthened the connection between their own well-being and caring for patients. Basic science instructors’ willingness to give up 60 minutes of instructional time for the didactic sessions reinforced the importance of the REACH content. Finally, instructors’ and facilitators’ willingness to demonstrate the values espoused by the curriculum and to meet with students to discuss the material outside of scheduled course time enhanced student buy-in. Ongoing feedback from our facilitators suggests that they find participation rewarding and that interacting with students in this way adds to their own sense of well-being.

Our next steps will include a rigorous exploration of how the REACH curriculum impacts student well-being in the near and long term. We plan to examine the relationships between student-reported well-being metrics, academic and clinical performance data, and professional identity formation using a variety of strategies, including latent profile analysis. We are also prototyping electronic dashboards that will allow students to interact dynamically with their own well-being data, which we hope will promote timely help-seeking and behavior change. 3

Our preliminary findings suggest our approach to teaching well-being to first- and second-year medical students builds community, normalizes personal struggle and help-seeking, and creates a safer space for students to learn the often-overlooked skills they need to care for themselves while learning to care for others.

Acknowledgments:

The authors thank the faculty, trainees, and staff members at the Medical College of Wisconsin (MCW) who have generously shared their time as REACH small-group facilitators. The authors also thank the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and the MCW Office of Academic Affairs, whose support made the REACH curriculum possible.

References

1. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149:334–341.
2. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: National Academies Press; 2019.
3. Dyrbye LN, Sciolla AF, Dekhtyar M, et al. Medical school strategies to address student well-being: A national survey. Acad Med. 2019;94:861–868.
4. Lipsky LvD, Burk C. Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others. Oakland, CA: Berrett-Koehler Publishers; 2009.
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6. Wasson LT, Cusmano A, Meli L, et al. Association between learning environment interventions and medical student well-being: A systematic review. JAMA. 2016;316:2237–2252.
7. Van Remortel B, Dolan E, Cipriano D, McBride P. Medical student wellness in Wisconsin: Current trends and future directions. WMJ. 2018;117:211–213.
8. Collins F. The use of traditional storytelling in education to the learning of literacy skills. Early Child Dev Care. 1999;152:77–108.
9. Pipas CF, Damianos JA, Montalbano L, Matous AL, Hua J, Shoop GH. A curriculum to promote a culture of wellness among medical students and faculty. PRiMER. 2020;4:13.
10. Dajani T, Bryant V, Sackett D, Allgood JA. “Your wellness program is interfering with my well-being”: Reducing the unintended consequences of wellness initiatives in undergraduate medical education [version 1]. MedEdPublish. 2021;10:146.
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