Experiences in Lifestyle Medicine: A Medical School Elective

“Lifestyle Medicine is well positioned to address the urgent crises of chronic disease, health inequity, physician burnout and rising costs, all while promoting better health outcomes.”

Introduction

Now that the number of dead in the US from the Sars-CoV2 pandemic has passed one million, this is a good time to reflect on how the adoption of Lifestyle Medicine (LM) into the US medical system might have dramatically helped to alleviate the pain and suffering of the pandemic victims and their families—disproportionately experienced by those with the highest burden of chronic disease. LM, with its demonstrated power to arrest and reverse chronic disease, can decrease the acute suffering caused by the Covid 19 virus while also decreasing the baseline suffering experienced by those with chronic disease before the onset of the pandemic.

Lifestyle Medicine is well positioned to address the urgent crises of chronic disease, health inequity, physician burnout and rising costs, all while promoting better health outcomes. This is in line with the Quadruple Aim of improving patient experience, improving population health, reducing costs, and improving provider experience. ¹

Introducing LM as part of an elective in medical school has the potential to produce a positive effect on the overall culture of medicine, as medical students move into practice and educate the next generation of doctors.

Recent attention to the need for an early introduction to Lifestyle Medicine principles has resulted in a few pioneers developing LM curricula.^2-4 While this is a desirable inclusion, resistance to encroachment upon already precious, limited instruction hours as well as to Lifestyle Medicine itself can be a barrier to rapid LM integration into medical schools. The continued paucity of proper nutrition education in medical schools exemplifies this problem. In 1985, the National Academy of Science (NAS) recommended that medical students receive a minimum of 25 h of nutrition education. In 2004, only 38% of medical schools attained the recommended hours. ⁵ A 2017 study revealed that many medical students and residents feel underprepared to successfully counsel on nutrition. ⁶ This suggests that more than 35 years after the NAS recommendation was issued—whether because it is not followed or because 25 h is not enough—the NAS standard has not successfully prepared future medical providers on nutrition.

At the same time, the growing focus on medical student wellness has brought about innovation in wellness curricula and programs in medical school. ⁷ Many of these innovations work to decrease stress, but do not go far enough to address the emotional and empathic exhaustion, depersonalization, and sense of low personal accomplishment that often result in burnout. ⁸ LM provides active, participatory methods to promote medical student wellness. ⁹ By incorporating opportunities for medical students to work with people healing from chronic, lifestyle related diseases, while implementing modifications in the 6 pillars in their own lives, early exposure to LM could be pivotal to student wellness.

One way to address the need for more LM education, while understanding potential barriers, is to utilize the pre-existing “clinical elective” structure creatively, to provide an alternative that allows for experiential learning and career development opportunities while also addressing medical student health, wellness and burnout.

Development of a Lifestyle Medicine Elective

In spring of 2021, the University of Rochester School of Medicine and Dentistry sponsored the creation of a course that would serve as both an academic and an experiential introduction to Lifestyle Medicine for medical students. The elective—called Experiences in Lifestyle Medicine—was a collaborative effort among two LM practitioners and a highly-interested medical student. The development of the elective followed a four-step structure: Analysis, Design, Development, and Evaluation ¹⁰ with an initial pilot phase. Analysis utilized an assessment of the personal, educational, and professional needs of University of Rochester medical students. Design involved building a multimodal and experiential curriculum using local resources and experts. Development included a pilot elective; structure of the elective was solidified based on input from each medical student taking the elective. After successful piloting, the elective was incorporated into the medical school’s official elective offerings. Ongoing evaluation includes both post-pre survey data (to better understand the elective’s impact on personal wellness, healthy living awareness, LM understanding, and professional interest) and a LM knowledge evaluation before and after the elective. Continued development takes place through re-evaluation, modification and incorporation of feedback.

Elective Overview and Theoretical Basis

Experiences in Lifestyle Medicine, is a two-week clinical elective for third and fourth year medical students that uses a multimodal approach to teach LM, via a partnership between a university and a non-profit organization. The novelty of this elective lies in the dual professional-personal approach (Figure 1). This involves clinical learning, professional mentorship, and in-depth reading along with simultaneous personal Lifestyle Medicine immersion.

Figure 1.

Lifestyle medicine elective framework.

In the elective, students gain professional exposure through clinical learning ranging from hospital consults and outpatient consults to primary care. Students are encouraged to engage with patients while learning effective counseling methods from experienced LM physicians. Core faculty is board-certified in Lifestyle Medicine. Motivational interviewing is modeled by both Jumpstart facilitators and faculty preceptors. The supportive interaction between faculty and student facilitates professional mentorship with built-in opportunities to explore a career in Lifestyle Medicine, and plants the seeds of ongoing mentor-mentee relationships. To increase evidence-based awareness, student-directed in-depth reading is formally incorporated into the elective. With this time, students perform a literature review and create an annotated bibliography on a LM-based intervention in a topic relevant to their medical interests. These discovery-based professional approaches complement the parallel personal LM exposure.

The power of this elective lies in its being structured around participation in a Zoom-based two-week patient program to introduce patients, most of whom have chronic disease, to a whole-food plant-based diet with instruction, skill-building, and support from peers and professionals. ¹¹ The medical students themselves participate—alongside patients, providers and community educators—in Jumpstart, the 15-Day Low-Fat, Whole-Food Plant-Based (WFPB) program offered monthly by Rochester Lifestyle Medicine Institute. Students reap the rewards of the four benefits of participating in the Jumpstart program: experiencing the challenges of making personal changes, learning the personal benefits of moving to a WFPB diet, seeing expert facilitators in action with small groups, and observing first-hand the remarkable improvements in health that many of the participants experience in just two weeks.

Personal Implementation also extends to other pillars of Lifestyle Medicine. Students benefit from self-directed time for LM-based stress management development and learning along with 1:1 guided meditation training. Physical Activity is incorporated through walking-meetings in the surrounding park. While sleep, social connection, and substance use moderation are not the primary emphasis of the elective, students are encouraged to reflect on and engage with these pillars. To solidify personal immersion, students set their own SMART (Specific, Measurable, Achievable, Relevant, and Time-based) goals for each of the pillars. ¹² This opportunity supports the creation of effective SMART goals, and enables them to make changes in each of the pillars of Lifestyle Medicine.

The Personal Implementation component of the elective is critical to changing our health care practices and system because we know that clinicians are more effective at counseling patients in interventions they themselves practice. ¹³ It follows that supporting students in their own personal implementation of LM practices would likely increase effectiveness of patient counseling throughout their future career while potentially decreasing provider burnout in the future through the acquisition and maintenance of resilience boosting tools.

Not only does this approach have the potential for medical students to improve health and develop professionally through LM awareness, but also this elective format with varied engagements aligns with The ACLM Medical Education Task Force’s mission competencies in (1) patient care and procedural skills, (II) Medical Knowledge, (III) practice-based learning and improvement, (IV) interpersonal and communication skills, (V) professionalism, and (VI) systems-based practice as guided by the AAMC’s 13 Core Entrustable Professional Activities for Entering Residency.^14,15

Elective Structure

This two-week elective currently accommodates one student per block, but has the potential to be scaled as needed. It is offered in twelve blocks per year, coinciding with each Jumpstart program. Students start off the week with Jumpstart introductory meetings followed by 1:1 faculty meetings during which elective objectives and individualized SMART goals are discussed. Students engage in outpatient clinical work Tuesday, Wednesday, and Friday of each week during which students observe and participate in LM specific patient counseling.

The elective builds in flex time on Mondays and Thursdays. Flex time involves inpatient consults, in-depth reading, “walk and talk” faculty discussions, WFPB eating immersion and personal practice of LM pillars based on individualized SMART goals. (Figure 2) Assigned readings draw from the Lifestyle Medicine Handbook ¹⁶ along with several select landmark LM articles.^17-26

Figure 2.

Lifestyle medicine elective schedule.

Evaluation: Students fill out a questionnaire and self-evaluation at the end of the elective, reflecting on their changes in the different LM pillars from the beginning to the end of the elective. They provide feedback on their understanding of LM as a specialty, their familiarity with the evidence, their confidence in counseling and supporting patients, and their motivation to incorporate LM into their own lives and into their careers. Students’ clinical counseling skills and LM knowledge are assessed through clinical evaluation of their preceptors, and they receive formal feedback from the course director.

Evaluative Responses: Consolidation of formal feedback is not routinely accessible throughout the year, but direct feedback through maintained contact with students has been overwhelmingly positive. Many students attest to maintenance of personal changes and improved confidence with patient counseling in the LM pillars. To date, six students have completed the elective and it is currently fully booked for the coming year. Partnership with the school’s Lifestyle Medicine Interest Group, founded by authors as a result of this elective creation, has fostered interest and increased visibility of Lifestyle Medicine within the school.

Embodied Learning

The LM elective affords the opportunity for students to engage in a type of learning less-utilized in medical school. Medicine is often taught as an intellectual exercise, but the practice of medicine draws deeply on embodied learning (e.g., learning, practicing and perfecting the physical exam). Recent attention to body pedagogics and embodied learning experiences in the health professions ²⁷ is a useful way to conceptualize the deep learning that exists when physicians dive into LM practices themselves. We are accustomed to language regarding visual, auditory, and kinesthetic learning (VARK model) but rarely discuss embodied learning, which can be defined as “the deliberate use and recognition of multimodal body-mind activities and strategies to facilitate shifts in perspectives, perceptions, paradigms, behavior and actions.” ²⁸

Medical student engagement with WFPB eating and with personal, reflective LM interventions promotes integrated bodily, behavioral, and scientific engagement in learning. There are few other disciplines where a physician who doesn’t share a patient’s diagnoses can participate in and benefit from that same intervention as the patient side-by-side. The embodied learning of health promoting habits can also have the side effect of contributing to greater student/provider health, thereby indirectly supplementing the Quadruple Aim of improved physician experience.

Conclusions

It is imperative that we improve Lifestyle Medicine education in medical schools now. Using the pre-existing clinical education elective structure, University of Rochester faculty and students have worked together to create an elective model to nourish deep learning of lifestyle medicine principles while promoting individual health and career development. This model allows for seamless integration of LM education and practical, embodied learning without curricular overhaul, and is replicable at other institutions with LM physicians because the Jumpstart is a live, Zoom-based program that is available to medical students anywhere. By engaging medical students early and profoundly, this elective has the opportunity to better prepare medical students to succeed in healthcare while also inviting them to be a part of the paradigm shift towards a healthcare system that promotes prevention, equity, and healing.