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Medical students could be healthier and learn better with more humane schedules

Harold Mandel's picture
Medical students

It has been traditionally said that the rigorous schedule of medical students makes them better doctors, but recent research says this is not so. Unfortunately for the medical students it's true that their rates of drug and alcohol abuse, divorce, and suicide have appeared to be unusually high for a long time. Furthermore, medical students are sometimes ruined with allegations by medical professors of having bad attitudes about their professional careers if they complain about their rigorous work schedules and dwindling personal lives. Yet, recent research shows that a kinder, gentler approach to medical students may benefit them greatly.

It's a fact that medical education can have significant negative effects on the well-being of medical students, reports the journal Academic Medicine. As of this time initiatives to improve student mental health have focused primarily on improving their access to mental health providers. It is claimed there are also efforts to lower the stigma to mental health treatment, but this does not appear to actually be true. The careers of medical students who have seen psychiatrists are often catastrophically ruined by the psychiatrists themselves, other physicians, the courts, and the general public due to stigmatization. Of course this is tragic and paints a picture of pushing such bright and motivated young men and women towards suicides instead of productive and rewarding careers and personal lives.

Another approach to this problem is to directly address the root causes of stress which lies within the curriculum itself with an interest in promoting the wellness of medical students. The authors of this research have presented a new paradigm aimed at improving medical student mental health, by focusing on an integrated, multifaceted, preclinical curricular change program at the Saint Louis University School of Medicine. The authors observed that significant and efficient changes to a myriad of factors in the curriculum was associated with improved mental health of medical students. These factors included changes in:

1: Course content

2: Contact hours

3: Scheduling

4: Grading

5: Electives

6: Learning communities

7: Required resilience/mindfulness experiences

The changes were associated with improvements in mental health in many dimensions, including significantly lower levels of:

1: Depression symptoms

2: Anxiety symptoms

3: Stress

Lowering pressure from medical school while teaching students skills aimed at helping them to manage stress and spring back from adversity benefits their mental health and improves their academic achievement, reports Saint Louis University in a review of this study. Stuart Slavin, M.D., M.Ed., associate dean for curriculum at SLU School of Medicine, who is the lead author of the paper, has said the problem of depression among medical school students is significant. Slavin says depression affects between 20 and 30 percent of medical students in the United States and potentially compromises their mental health for years to come.

In this study the well-being of first and second year students is viewed prior to and after changes to Saint Louis University's medical school curriculum that are designed to prevent depression, stress and anxiety. Slavin said, "We've seen dramatic improvement in the mental health of our students." He also said depression rates in first year medical students fell from 27 percent to 11 percent and anxiety went down from 55 percent to 31 percent. Simultaneously, the overall Step 1 board scores of the medical students went up, therefore showing student performance improved. Slavin commented, "Our students know more, and will be in a better situation, emotionally, to care for our patients."

It has been recognized for decades that the number of students who feel depressed or anxious increases during their time in medical school. Initially there was no action to deal with this problem. Than came efforts to get medical students better access to psychiatric and mental health services. Thereafter came the addition of activities in medical school which encouraged wellness and teamwork, such as athletic competitions and optional wellness seminars. The problem of high rates of mental health problems in medical students persisted and so SLU administrators decided to design and implement curricular changes that would directly address these stressors and would produce a less toxic educational experience.

SLU altered its curriculum to remove unnecessary stressors, which was a dramatic paradigm shift from seeing stress as an inevitable part of the path towards becoming a doctor. A class was even now required that teaches strategies to de-stress. Slavin said, "The approach is preventive and the model is very simple. We tried to reduce or eliminate unnecessary stressors in the learning environment itself. At the same time, we helped students develop skills in resilience and mindfulness to better manage stress and find some measure of well-being."

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Changes in the curriculum were dramatic and included:

1: A pass or fail grading system for their pre-clinical courses in the first two years of medical school instead of letter grades or honors/ near honors grading systems

2: Spending fewer hours in the classroom

3: Giving medical students more free time

4: Offers of choice and control over their schedules to explore expanded electives and to engage in newly established learning communities

All of the students now took part in a short, focused course which helps them develop lifelong strategies to cope with stress. Concerns in this class focus medical students on many important factors, including:

1: Better management of energy by taking breaks

2: Encouraging more sleep

3: Encouraging better eating habits

4: Stressing the need for adequate exercise

5: The need to be mindful or to pay close attention to what's happening in the present moment

6: Reframing their perspective to be more realistic

7: Recognizing negativity

8: Controlling their reactions to situations

9: Cultivating a positive and optimistic outlook that is ultimately associated with more happiness and personal satisfaction

The medical students who followed the new curriculum exhibited lower rates of depression symptoms along with less anxiety and stress and they felt more connected to each other than the pre-change group. Slavin has noted, "Physician depression and burnout are significant problems in the United States and may rightly be viewed as a substantial public health problem, particularly given the evidence of the negative impact that mental health can have on clinical care by reducing physician empathy and increasing rates of medical error." He goes on to point out that unfortunately strong evidence has supported that the seeds of these serious mental health problems are planted during medical school.

It has been my observation that Slavin is right on target to highlight the problem of inhumane stressors in medical school often compromising the mental health of medical students. Furthermore, it appears to me that psychiatric intervention does not appear to meet with success to handle this serious problem due to harsh forms of associated stigmatization within the medical community itself and outside of the medical community. This is tragic and often leads to wasted careers and lives, along with devastated relationships within families and other significant people in the lives of medical students. There is of course also the consideration of wasted fortunes due to the huge expense of medical education.

Slavin and his team have demonstrated a courageous effort to throw out the archaic adherence to the idea that the more inhumane the medical experience is the better the final outcome will be. This does not and never made rational sense in dealing with the mental health of medical students, physicians thereafter and the quality of patient care. I am therefore fully in support of the initiatives by Saint Louis University School of Medicine to radically change the way medical students learn. Such revolutionary changes in medical education are long overdue.

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