Bringing Resilience to the Classroom

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For years, Stuart Slavin, MD, MEd, had worked hard to create a supportive environment for medical students at Saint Louis University School of Medicine. And early feedback seemed to suggest students were happy. 

Then, in 2008, Slavin and colleagues surveyed students using specific mental health indicators. They found that depression and anxiety among Saint Louis students mirrored the troubling nationwide trends that suggest medical students are experiencing depression at significantly higher rates than similarly aged people in the general population. In response, Slavin, associate dean for curriculum at Saint Louis, looked into how the curriculum and its demands were having a negative effect on students’ mental health. The inquiry led to major curriculum changes and a dramatic improvement in student mental health. Among first-year students, depression rates dropped from 27 percent in 2009 to 4 percent in 2015 and anxiety declined from 56 percent to 14 percent during that same time period. 

“The stresses in medical school are significant, but they don’t end there,” said Slavin, also a professor of pediatrics. “Stress is inherent in residency programs, and in medical practice, so I think trying to equip students with skills to better manage stress makes great sense. I view these resiliency skills as not just specific to medical school; these are life skills.”

Adding resiliency, wellness to the curricula

Saint Louis University has been a pioneer in bringing resiliency skills to the medical school and in using student wellness as a key driver in curriculum redevelopment. And more medical schools are beginning to develop, test, and implement ways to insert resiliency into curricula and give students tools to manage stress, prevent burnout, and protect their mental health. This innovative curricular approach is a departure from more traditional efforts, which often focused on enhancing access to mental health and wellness services. 

“One of the dangers of wellness interventions is students think they have to choose between wellness and academics. But investing in your wellness doesn’t take away from academic productivity—it’s likely to enhance it. I think that’s a really important way to frame this issue.” 

Stuart Slavin, MD, MEd 
Saint Louis University School of Medicine

“A lot of this stems from our belief that medical students these days are experiencing greater degrees of distress, anxiety, and burnout than ever before,” said Allan Tunkel, MD, PhD, associate dean for medical education at Warren Alpert Medical School of Brown University. “It’s critically important that we give students the tools to deal with these issues as early as possible.” 

While the literature is slim on historical trends in medical student mental wellness, research has found that medical students are more likely to exhibit depression symptoms and experience burnout than the general population. At Alpert, the resiliency curriculum is still being finalized, but Tunkel said it will now be part of orientation for incoming classes. During their first year, students will also have several hour-long resiliency sessions. At the behest of students, Alpert recently rolled out a one-day, mandatory resiliency and professional development retreat for second-year medical students. Tunkel said the school hopes to follow up the retreat with additional resiliency sessions scheduled at peak times of stress, such as when students are studying for USMLE Step 1 exams. 

At Saint Louis University, the high rates of depression and anxiety in students also led to changes in the existing curriculum. For example, human anatomy used to be the first course, but the content was so challenging—both emotionally and cognitively—that it led to disproportionate stress, Slavin said. On average, about 30 of 175 students would fail the course’s first exam and another 30 would score within five points of failing. So in 2011, human anatomy became the second major course after cell and molecular biology, the content of which many students had learned before. The longer acclimation period to the rigors of medical school eventually led to fewer failing grades in human anatomy, Slavin reported.  

In addition to reworking the traditional curriculum to reduce student anxiety, Saint Louis University also gives medical students specific instructions on how to cope with the demands of school. For instance, all first-year students participate in a required resiliency and mindfulness curriculum that, among other skills, teaches them how to recognize and offset counterproductive thoughts and to view personal setbacks as learning opportunities. 

“One of the dangers of wellness interventions is students think they have to choose between wellness and academics,” he said. “But investing in your wellness doesn’t take away from academic productivity—it’s likely to enhance it. I think that’s a really important way to frame this issue.”

Addressing burnout in residency

Resiliency is making its way into residency programs as well. At The Ohio State University Wexner Medical Center, general surgery resident Michelle Nguyen, MD, MPH, served as lead investigator on a pilot project to address professional burnout in residents, faculty, and staff. The project is unique, Nguyen said, because it seeks to examine the effect of improved provider resiliency on patient satisfaction and safety.

“I do think resiliency should be a top priority for [medical schools] because if you don’t have well students and well residents, then patients suffer,” Nguyen said.

In winter 2015, Nguyen began recruiting medical center residents and faculty, particularly reaching out to those on the front lines of medicine, such as emergency and internal medicine physicians. At baseline, a majority of participants reported some level of burnout. Over the next handful of months, participants took part in online resiliency education modules offered through Ohio State’s Center for Integrative Health and Wellness. Then they met once a month to discuss the lessons as a group. The modules covered a variety of resiliency topics and stress reduction techniques, such as deep breathing and meditation.

“We can keep throwing skills at students, but until the culture of medicine changes, I don’t think we’ll see a big change in burnout.” 

Matthew Duncan, MD 
Geisel School of Medicine at Dartmouth

The project, which ended in May, was among the winners of the AAMC 2016 Clinical Care Innovation Awards. Nguyen is still analyzing the outcomes, but she said if results are positive, she hopes to disseminate the resiliency modules more widely to all residents at the medical center.

At the Geisel School of Medicine at Dartmouth, academic skills are paired with resiliency skills during an extended, three-month orientation for first-year students. For example, lessons on how to evaluate quiz results are paired with information about how to view struggle and failure as an opportunity for growth rather than as a sign of ineptitude, explained Matthew Duncan, MD, associate dean for student affairs and assistant professor of psychiatry at Geisel. The academic-resiliency skills pairing will officially roll out during the 2016–2017 academic year, Duncan said.

Resiliency lessons are included in other preclinical courses at Geisel as well, and Duncan said he and colleagues hope to develop a more official resiliency curriculum soon. However, he also noted that focusing on the individual will only go so far.

“We can do all of this teaching about individual resilience, but the medical curriculum and the practice and culture of medicine will have to be addressed as well. We can keep throwing skills at students, but until the culture of medicine changes, I don’t think we’ll see a big change in burnout.”