WholeheartedMD: Medical Students Embracing Vulnerability and Finding Fulfillment

Abstract

Introduction. Medical Students experience high levels of stress throughout their four years. When the COVID-19 pandemic exacerbated this, there was a need for programming and this created an opportunity to provide a whole person, lifestyle medicine approach to enhance medical student wellbeing. Methods. Two student leaders and one faculty member created a 12-week program that addressed the 6 pillars of lifestyle medicine as well as positive psychology. The program was offered to all first year students, and within 12 hours the roster was full with 15 students. The program was held weekly by Zoom for 1-2 hours. Results. Attendance was high each week with full participation from everyone present. In the post program evaluation form, conducted one year after completion of the program, 100% of respondents reported they would recommend this group to another medical student, 71% reported they used tools learned from the group at least weekly. Participants noted that growth mindset, gratitude, mindfulness, priorities, and relationship building were the most used well-being strategies learned in the program. Conclusion. An intervention that is based on the 6 pillars of lifestyle medicine and positive psychology and presented by Zoom is feasible in medical school and well accepted by medical students.

“We entered medicine with a bold desire to relieve suffering and make a difference in the lives of others.”

The disproportionate rates of burnout, depression, anxiety, and suicide in medicine should be addressed by cultivating a culture of honesty and vulnerability about individual experiences.

The Gap

Everyone warned us that medical school would be academically challenging. As medical students, we expected late nights in the library and early mornings in the hospital. Yet, no one warned us that the real challenge would be in maintaining our mental health and sense of identity. The statistics are alarming. A study in 2016 found that 27.2% of medical students had depression or depressive symptoms compared to 7.1% of the general population. Of those students, only 15.7% sought psychiatric treatment and overall, more than 1 in 10 students endorsed struggling with suicidal ideation ¹ . This makes sense when you consider the fact that 82% of medical students endorse at least one form of distress, and 58% endorse more than 3 forms of distress. A recent study found that there is a dose-response relationship between the number of forms of distress a student experiences and recent suicidal ideation or serious thoughts of dropping out. ² Before residency even begins, research suggests that 1 out of every 2 medical students are already experiencing burnout. ³

The COVID-19 pandemic ushered in an era of unprecedented struggle and isolation throughout the world. Students were not immune to this; thus, focusing on school was all the more challenging. March 11, 2020, marked the last day of in-person learning at our medical school. Overnight, we were all heading in different directions. Many of us found ourselves in childhood bedrooms trying to figure out Starling curves and antibiotics amidst the fear of a changing social climate, an escalating pandemic, and the status of our foundational education. Medical school and the rapidly changing world aside, without in-person distractions, we were left with time to examine the state of the world and our place in it. For the first time since entering medical school, we had time to think about our emotional states, the level of stress we were coping with, and what we wanted for our lives. Unfortunately, we were navigating these thoughts alone without the support of our friends, peers, and advisors.

The Program

In an effort to combat the sense of impending doom for student wellness, Harvard Medical School offered first-year students an afternoon of resilience workshops. We each selected 2 to attend, creating small groups that catered to open conversation. Having participated in Dr Beth Frates’ wellbeing class for an hour, we were introduced to the PAVING the Path to Wellness program that empowered people to work toward a healthy body, peaceful mind, and joyful heart. During the class, we took the PAVING the Path to Wellness questionnaire developed by Dr Beth Frates and Harvard Health in 2016. The session addressed topics like failure, boundaries and using gratitude and positivity to increase creativity and productivity. These were seemingly topics of great value and impact, yet we were hearing about them for the first time relatively late in our training

The PAVING the Path to Wellness class sparked a desire for more. Immediately following, we reached out to Dr Frates to inquire how to follow-up on the workshop to gain more skills and to share the information with fellow classmates. Under the guidance and support of Dr Frates, we started a pilot group of 15 medical students. These would become the founding members of what we hoped would become a larger movement. The excitement was palpable as we began to envision the group and how it might start a pivotal and timely conversation about student and physician well-being. We sent out an email introducing the group and accepted members on a rolling basis. Within 12 hours, the roster was full, underscoring the need.

We had no idea if anyone would even show up to our first meeting or what to expect if they did. Virtual events and meetings were just starting to become the norm and building relationships online felt like a foreign concept. To our pleasant surprise, all 15 members attended our inaugural meeting and were ready to engage from the start. Many of us were meeting each other for the first time outside of mandatory classes, so we became proactive about building friendship within our new community. We kicked off our meeting by giving each member time to share why they chose to join the pilot group and what they hoped to take away. Responses ranged from the need to prevent burnout to wanting to learn how to lead a fulfilling life to the desire to build community. This fostered an environment in which everyone played a role in developing the group’s ultimate vision. We decided that our group would be a safe space in which people felt as though they could participate actively or simply listen.

Week after week, students showed up to our meetings. Our weekly check-ins became the cornerstone of our social lives and quickly, our hour-long meetings transitioned to 2 and even 3. Initially, Dr Frates helped lead and guide the conversations, offering her expertise to questions raised such as effective time management, communication strategies, and lifelong wellness. She served as both a teacher and role model. Dr Frates shared information about the 6 pillars of lifestyle medicine (exercise, nutrition, sleep, stress reduction, social connection, and avoidance of risky substances) and how we could use the guidelines to enhance our sense of well-being. Our meetings opened space for shared vulnerability and encouragement. It was a relief to realize that we were not alone in our struggles and that attendings far ahead of us in training were still trying to navigate similar obstacles. We finally had the freedom to discuss topics that were often taboo: uncertainties about the future, struggles we were experiencing, questions about the choice to pursue medicine, and worries about finding our true purpose. Together, we celebrated in joyous moments like passing exams and mourned the passing of loved ones. It was obvious as time went on that we became more and more comfortable sharing openly. We covered topics such as imposter syndrome, insecurity, loneliness, boundary setting, growth mindsets, and cultivating high-quality connections. Each week, we learned from each other and grew with each other.

One year after our first meeting, COVID-19 restrictions were lifted in Boston, and the group was able to safely gather together in person for the first time. We cooked, laughed, and caught up on the past year. Many of us had started our clinical rotations, thought to be the hardest year of medical school. We shared our struggles and triumphs and offered one another advice and listening ears. It was refreshing to be together again and to hear how members were continuing to lean on what they learned in Wholehearted, MD. Many shared how they were even using this to help other students and friends, expanding the reach far beyond the original 15.

The Response

It was beyond amazing to watch as the 15 of us grew and transformed over our 5 months together. We went from barely knowing one another to creating a family. To attempt a more objective collection of data about the success of our group, we sent a survey to 13 members (not including the 2 authors). In an effort to not force or bias survey responses, we did not utilize incentives or track which members had made an effort to complete the survey. In alignment with a foundational pillar of our group, we offered the opportunity to participate in spreading awareness of our impact within our own community of members, recognizing that many would not have the energy or time to answer. Over half of our founding members were able to respond to the survey even while in the midst of our clinical rotations, notably and frequently validated as the “hardest of all four years” in our program. Of the 7 able to dedicate time to survey responses, 71% said they use concepts and skills learned in Wholehearted, MD weekly. More interesting than numerical data are the parts of the program used most frequently as described by our 7 responders. Of the most often discussed themes (growth mindset, gratitude, exercise, time management, priorities, mindfulness, and relationship building), 100% of our respondents endorsed growth mindset, gratitude, and mindfulness as the 3 most frequently used program themes. Overall, 100% of our respondents said they would recommend the group to another medical student out of options ranging from very likely to very unlikely (Figures 1 and 2).

Figure 1.

Survey responses out of 7 responders detailing likelihood of recommending this group to another student out of the options very likely, likely, neutral, unlikely, and very unlikely.

Figure 2.

Survey responses out of 7 responders detailing the most frequently used themes in the Wholehearted, MD program.

While the objective data for the success of the group is minimal and acknowledged as limited, the subjective descriptions of the group’s personal meaning for our members is powerful. When asked to describe Wholehearted, MD in one word, members used descriptors such as: community, growth, holistic, renewal, wholesome, and open-minded. To further expand upon those one-word descriptions, we asked our respondents to describe what Wholehearted, MD means to each of them individually. The group might be best summed up in this member response: “[Wholehearted, MD is] a community of people who are willing to talk honestly about what motivates us in medical school, what our values and boundaries are, and how to think about our lives in medicine as more than just moving from one achievement/milestone to the next.” Other responses include phrases such as: “community and breathing space,” “a sense of connection and regularity during a difficult and stressful time,” “integrating wellness into our life,” and “community and support.” With 7 respondents, this is only a small insight into the group’s potential as a first step in the movement to raise awareness about physician wellness and to prevent it in the earlier stages of our training. However, the qualitative data that we were able to collect does show that in some aspect, a need in our medical school community was met and the community that followed exceeded our initial expectations for the group. This highlights the importance of community in medicine that centers around wellness in order to best prepare students and physicians for dealing with challenges that will undoubtedly come.

The Future

We have described how a lifestyle medicine pioneer and Harvard Medical School faculty member and 15 medical students began to change the culture of medicine from within at the very beginning of our training, demonstrating the need and possibility for change. We hope this is the beginning of a larger conversation about the widespread burnout and need for wellness within the medical community. This work needs to begin early in training, with medical schools directly intervening in our first year of medical school with explicit instruction and engagement in these topics.

We began our movement with a simple concept first trademarked by Dr Beth Frates titled “PAVING the Path to Wellness.” This system is designed to gauge overall wellness using 12 categories to calculate an objective and comprehensive picture of your well-being. There is a foundational well of categories to draw from including physical activity, stress management, attitude, variety of activities, investigations, social connection, sleep, purpose, nutrition, energy, time-outs, and goals. However, each student needs varying amounts of each component to thrive in any given moment. Sometimes, we need more physical activity, while at other times, we may crave more social connection. The primary concept is that there exists a deep foundation from which to derive enjoyment, and we choose which areas to focus on in order to maintain personal equilibrium.

By plotting your total score for each component, you can identify areas of wellness that need improvement and consult the corresponding module for guidance in how to better hone these areas. This is a technique that can be utilized to regularly track your wellness in terms of objective and modifiable activities. The goal is not to accomplish every check-box on the module each day. Rather, it is to identify areas in your life that may need extra focus in order to attain a higher quality of life. At a minimum, this is a practice that many medical students may benefit from as an impartial way to determine whether you are leading a balanced lifestyle in the midst of a difficult training program (Figures 3 and 4).

Figure 3.

The PAVING Wheel with the 12 Steps to Wellness noted in radar plot format.

Figure 4.

The PAVING Wheel with the 12 Steps divided into healthy body, peaceful mind, joyful heart, and action steps.

While spreading awareness of topics and techniques such as “PAVING the Path to Wellness” is an excellent beginning to changing the burnout culture in medicine, our vision is to create a nation-wide program that leads the charge of creating groups led by student leaders and faculty trained to discuss topics relating to burnout and wellness. These can be small peer groups, as ours was initially. Ideally, our hope is that our organization becomes an integral component of the medical school curriculum.

Conclusion

In response to the COVID-19 pandemic, we saw the world change overnight and our entire society change with it. Masks became the new normal, and entire countries closed off travel. From this, one cannot help but wonder that other aspects of our life and culture in medicine are ripe for progress.

There are an infinite number of ways to live a fulfilling life, despite what “success” culture may tell us. That is the beauty in it. At some point, we have to realize that if our definition of success directly inhibits our ability to live happy and healthy lives, we must redefine our definition of success. That can be terrifying when we have held one definition for so long and the environment you are surrounded by encourages a traditional definition. However, we believe that one can hold both the desire to become a competent physician for our communities and the desire to live a balanced and joyful life. In fact, in order to show up as our best selves for the world, we must first show up for ourselves. This will look different for everyone. It may look like a 30-minute walk, taking necessary medications, an extra hour of sleep, setting a boundary, or a conversation with a loved one.

The time for change is now. We entered medicine with a bold desire to relieve suffering and make a difference in the lives of others; however, we only truly do this when we have taken charge of wellness in our own lives. Open, honest dialogue is the first step in changing the status quo. The current culture too often encourages an environment where admitting your struggle is a weakness, yet data shows that the majority of medical students and physicians are struggling in some way. This leaves us with 2 options: either believe that we are all weak or admit that we are all just human. We are far less alone than the world would have us believe. If we can imagine a better future, we can achieve it. Let us pledge to continue the conversation where we are, with colleagues and friends. The practice of medicine is a challenging privilege, one that can only be performed well when its practitioners are leading their lives wholeheartedly.

“Tell me, what is it you plan to do

With your one wild and precious life?”

--Mary Oliver

Take Home Points

1. We must address the disproportionate rates of burnout, depression, anxiety, and suicide in medicine.

2. It is crucial to cultivate a culture in medicine where honesty and vulnerability about individual experiences are the norm.

3. Connecting with medical school students on topics such as holistic wellness and boundary setting must start at the beginning of their training.