The Problem with Mandatory Wellness

Introduction

“Medical School is bad for your health” – a direct quote from orientation on my very first day of classes. Along with this statement came a myriad of statistics highlighting the risk of burnout, depression, anxiety, and suicide for medical students, residents, and physicians. My excitement for my first day started to be replaced by a feeling that I was not so comfortable with, like catching a fish that is too big for you to handle – exciting, but you don’t want to lose the hook! “Wellness”, “resiliency”, and “looking after yourself first” were touted as the way to reel in this fish. I resolved to continue my exercise regime, make time for friends and family, and try to keep a level head with all the exams, late nights, and long hours ahead. Then came the hours and hours of mandatory wellness sessions.

Background

Wellness among medical students is an increasingly well researched topic with studies discussing the rates of burnout, depression, and anxiety in medical students; or information on the efficacy of a wellness intervention^​1–8​. Other articles include descriptions of successful medical school wellness curriculums and discussions around sources of student stress^​9,10​. With such a complex and serious topic, medical schools across the world are implementing wellness curriculums to help students cope with their training. Often, these wellness activities are mandatory sessions that include activities such as figure drawing, photography or creative writing^​11​.

These interventions are supported by a variety of studies. An article by Mangione et al. in 2018^​12​ presents an interesting case for including arts and humanities wellness sessions in a medical school curriculum. The study found that students who engage in activities that incorporate the arts and humanities have higher levels of empathy and lower levels of burnout than those who do not. Since these traits are so important to a developing medical professional, it followed that if mandatory arts and humanities wellness sessions are included in the curriculum, other students will be able to experience the benefits of these activities. However, as a student who has participated in mandatory arts and humanities sessions, when I ask my classmates what they think about the programming, many find themselves frustrated that their time is being wasted doing something that they do not enjoy or want to participate in.

After reviewing the Mangione article, I found several flaws that may explain this negative student perception. First, the article utilized a convenience sampling technique, where students self-selected to complete the survey. Students who regularly participate in arts and humanities hobbies are likely to be more interested in completing such a questionnaire. I interpret the results of this study to show that students who participate in hobbies that they enjoy have lower levels of burnout than those who do not. If this study was restructured to survey all students who were institutionally mandated to attend arts and humanities instruction, I suspect that the results would show an inverse correlation.  Forcing students to participate in activities that they do not enjoy would increase burnout and decrease empathy. Indeed, a recent systematic review^​5​ stated that “the limitations of wellness interventions include the fact that some students may not find a particular wellness programme (sic) to be beneficial, and some may see wellness activities as yet another obligation, which could conceivably further burnout levels.”

Wellness and Learner Autonomy

From my personal experience, frustration and apathy are a result of students being forced to participate in prescribed activities during what could be free time. There is, however, value in blocking off time for wellness. Instead of signing students up for arts and humanities, ask the student what could be done to enable them to spend time doing the activities that they love. For example, if a student enjoys soccer, find ways to remove the barriers that are preventing them from enjoying their sport – reduce the cost of registering for a league or provide the scheduling flexibility to make attending practice or games easier. Help this student build a social network by connecting them with other people who share the same interests – from both inside and outside of the medical school.

Each person has a different way of coping with the stressors of medical school. I believe that medical school should support learners in doing whatever helps them to maintain their mental health and empathy. In other words, a well medical student is one that has the autonomy to make choices regarding which wellness activities they will participate in. They may like to run, cycle, play squash or flag football, go for coffee with friends, draw figures, paint, do pottery, go for hikes, or any other of the thousands of fun activities that humans enjoy daily. It is ironic that a profession that emphasizes patient autonomy so strongly refrains from giving students the autonomy to determine which wellness activities are most congruent with their interests and goals.

A Wellness Curriculum

To understand the role of medical schools in student wellness, one must first understand what aspects of students’ lives change in medical school. The academic workload and professional commitments required by medical training leave fewer hours in the day for wellness. Additionally, medical school recruits a breed of students willing to devote their life 100% to achieve their career goals. Although some students have personal qualities that make them less prone to burnout^​13​, many students find themselves swallowed up by the amount of studying and work they have to do. Since time is scarce, shouldn’t we be focusing on what gives us the most bang for our buck?

Throughout their medical training, students will experience stress in their professional and personal lives. Professionally, students are most worried about times of transition, such as beginning the next phase of training, as well as intellectual and physical challenges like learning demands and increased working hours^​9​. Other stressors include uncertainty about study behaviour, progress and aptitude, assessment practices and the availability of learning materials^​8​. A formalized wellness curriculum delivered through didactic lectures or small group activities has the potential to address each of these concerns. For example, the transition between pre-clerkship and clerkship represents a significant source of stress for medical students. During orientation to clerkship, many of these stressors could be addressed by having a successful upper-year student describe how they achieved work-life balance on each rotation, which resources they used to study for each exam, what their studying schedule looked like, and how they managed their finances. They could also discuss any valuable strategies that they learned throughout clerkship and facilitate a question and answer period. A wellness curriculum focused on addressing these concerns could be effective at targeting stressors that affect a broad range of students. However, a more individualized program is required for the unique aspects of student’s lives.

Support and Mentorship

Although one study found that students are more stressed about their professional commitments than their personal lives, events such as divorce, death in the family or significant psychiatric diagnoses^​9​ places a student in a situation where they may require help. When such an event takes place in a student’s life, medical schools should be able to fast-track these individuals to counselors, psychiatrists, or other support programs if they are wanted or required.

In addition to personal support programs, strong mentorship can assist learners to work through difficult experiences and support them through medical school’s intellectual challenges. There are a variety of mentorship program formats available in the literature^​6,9​ that can support student wellness. To start, make sure that every student has access to senior students and clinicians who they feel safe to ask questions to. I would recommend pre-selecting faculty members from each department who are interested in mentorship and then set aside time for them to interact with students. From my experience, it can be very difficult to find a physician mentor as such informal relationships can be difficult to navigate. Although it can be challenging to organize, the positive mentoring experiences I have had have been paramount to my wellness and success. An idea that I’d like to see tried out is a speed-mentoring workshop, where students rotate through a group of mentors, spending 10-15 minutes at each station.  Beyond Faculty mentorship, facilitating mentorship from senior students can be incredibly helpful. I have asked my senior-student mentor hundreds of questions about topics that are causing me stress, and have answered just as many from a student in the year below me.

Conclusion

It is frustrating to be frequently reminded to practice wellness without someone providing the support that would help to do so. The road to student wellness needs to incorporate support, mentorship, and the autonomy of the unique and diverse students populating modern medical schools. The resources required to improve the wellness of medical students are available, they just need to be refocused to make them productive.

Twitter: @alexsenger

Special thanks to Dr. Brent Thoma and Dr. Zafrina Poonja for help with content and editing.

Photo by Robert D. E. Henderson

Staff Review

In recent years, it has been encouraging to see how the importance of wellness in medicine has been highlighted. With it has followed several different possible interventions to try and mitigate the risk of burnout, anxiety, and depression. While many different strategies have been suggested and access to supports have been highlighted, I believe the next steps should be taken towards system level changes. We should also be optimizing students, residents, and physicians to recognize burnout early, and equipping them with resiliency strategies so that individuals may choose what works best for them. The implementation of different wellness programs and sessions in medical schools is promising and definitely a step forward. However, I think we should be mindful of the programs that are being implemented, and ensure students are not becoming overwhelmed by an intervention that is supposed to diffuse stress, not increase it. It’s all about finding that balance!

Dr. Zafrina Poonja

EM physician and award winning physician wellness advocate

@ZafrinaPoonja

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Alex Senger

Dr. Senger is a PGY3 Emergency Medicine resident physician in Kelowna, BC.

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