How can medical educators support students' well-being?

Even twenty years later, I remember well the pervasive despair that engulfed me for much of my first two years of medical school. Even with a personal support system that included my family and several former college roommates and friends who lived in the same city, I struggled to find my bearings, academically and emotionally. Now that I spend much of my time teaching first-year medical students, I have wondered if the learning environment that I and other faculty provide contributes negatively or positively to their well-being.

A 2016 systematic review in JAMA examined the self-reported prevalence of depression, depressive symptoms, and suicidal ideation in medical students from 43 countries who were surveyed from 1982 to 2015. Longitudinal studies showed that students' mental health worsened significantly after starting medical school, with a median absolute increase in symptoms of 13.5%. On average, 27 percent of students reported depression or depressive symptoms, but only 16 percent of those students sought formal treatment. In contrast to my own experience, which was feeling much happier once I began third-year clerkships, there was no significant difference in depression prevalence between the preclinical and clinical years. Most alarmingly, 11 percent of students in these studies reported having suicidal thoughts during medical school.

A second systematic review examined associations between learning environment interventions and medical student well-being. The evidence base was limited: only 3 of 28 included studies were randomized trials, and most studies were conducted at a single site. Interventions that appeared to be effective in improving students' well-being included pass/fail grading systems, increased time with patients during the preclinical years, mental health programs, wellness programs including mind-body stress reduction skills, and formal advising/mentoring programs. In an accompanying editorial, Dr. Stuart Slavin observed that the educational culture of some medical schools is often an obstacle to implementing these kinds of reforms:

When signals of problems involving student mental health arise, the reaction in medical education has commonly been failure to recognize that the main problem is often with the environment, not the student. The response has often been limited, such as advising students to eat well, exercise, do yoga, meditate, and participate in narrative medicine activities. These approaches ... may distract educators from recognizing that the learning environment is at the core of the problem, and more must be done to improve it.

To be sure, maximizing student well-being is not the only or even the most important goal of medical education. But just as it is possible to create positive practice environments that protect clinicians from burnout, educators can prepare students to practice medicine competently in learning environments that are least likely to harm their mental health.

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This post first appeared on Common Sense Family Doctor on December 19, 2016.

Keep your options open - become a family physician

One of the persistent fallacies that I hear from medical students at my institution who are trying to decide between residency programs in internal and family medicine is that by choosing internal medicine, they can "keep their options open" to either become a generalist or to specialize, while choosing family medicine will close off all options except practicing traditional office-based primary care. In fact, nothing could be farther from the truth. If you choose an internal medicine residency, I counsel these students, the odds are overwhelmingly high that you will end up as a subspecialist (-ologist) at a tertiary care medical center. In contrast, the options available to a family medicine residency graduate are nearly limitless. Among my family physician colleagues are hospitalists, infectious disease and HIV experts, urgent care and team physicians; those who perform C-sections, colonoscopies, and appendectomies in the U.S. and throughout the world; teachers, researchers, guideline gurus, health system leaders, and public health officials; those who are comfortable practicing in rural areas, urban areas, and in every community size in between.

I often characterize my own career in family medicine as atypical, but that implies (falsely) that there is a "typical" path. I usually spend Monday mornings blogging or editing papers written by others, then precept family medicine residents in the afternoon. Tomorrow, I will actually be seeing my own patients in clinic all day, but the next five Mondays after that illustrate many of the options available to an academic family physician:

Monday, April 23
AM: Give the "What Is Family Medicine?" lecture to the new clerkship students. It's late in the 3rd year, but perhaps one or more can still be persuaded to "keep their options open" and fall in love with my specialty.
PM: Attend a multidisciplinary panel meeting for the American Academy of Otolaryngology-Head and Neck Surgery clinical practice guideline on epistaxis (nosebleeds).

Monday, April 30
Travel to Leawood, Kansas for a two-day American Family Physician editors meeting. Never in my wildest dreams as a medical student could I have imagined that I would become Deputy Editor of the second-largest medical journal (by print circulation) in the world, and the most monthly website views of any medical journal.

Monday, May 7
Attend the Society of Teachers of Family Medicine Annual Spring Conference in DC, where I am a co-presenter on two seminars and a scholarly poster.

Monday, May 14
Travel to Lancaster, PA, where the following morning I will present Grand Rounds at my alma mater (Lancaster General Hospital Family Medicine Residency).

Monday, May 21
Attend Georgetown's 2018 Teaching, Learning and Innovation Summer Institute as a member of this year's Technology-Enhanced Learning Colloquium for faculty across all university campuses.

Guest Post: Growing family medicine means changing med school admissions

- Larry Bauer, MSW, MEd

One of the things that I’ve always enjoyed about working with and supporting family physicians was the sense that I was helping not only the underdog, but one of the only groups within the house of medicine that could demonstrate its value in terms of improving the health of the population while reducing the cost of care; doing more with less.

I’ve also encountered elitism in medicine as an educator, as a faculty member, as a family member whose relations have encountered elitism and its effects, and as a patient myself. I want the underdog to lead the charge to reform the U.S. health care system. We would all be better off if family medicine and primary care led.

In Dr. Lin's description of remedies to the problem of too few family physicians, I think he left out the critical element. Our nation’s medical schools are becoming a playground for children from families of special means. Research clearly shows that a very disproportionate number of students admitted to our medical schools are from families with high and exceptionally high income expectations.

Children from families with limited means are disproportionately not making it over the hump. We know from 30 years of research that if more children from first generation to college families were admitted into our medical schools, and if those who have been out for a few years (not only a "gap year") were admitted to our medical schools, and if those from rural backgrounds were admitted to our medical schools, we would have more graduates choose family medicine and primary care, and probably general surgery and psychiatry as well.

This literally is the elephant in the room. I find that very few in family medicine and none outside of family medicine are willing to consider this issue.

I was on the forefront when I was on the faculty in the Department of Family and Community Medicine at Penn State University, as we collectively fought to increase family medicine faculty's teaching of students from first year to fourth year. We invest extraordinary faculty time and energy into teaching in most medical schools in the U.S. Family Medicine faculty are stretched thin because they want to increase students’ exposure to family physicians throughout all years of medical school.

But unless we address the core issue - the monolithic socioeconomic backgrounds of the students our medical schools are admitting - all of this additional expenditure of faculty time (which by the way is a very scarce and valuable resource) is not likely to change the picture. It’s time to focus on this issue. This can not be done by Family Medicine alone. It’s going to take a coalition of people within the medical school and in the larger community.

And a comment on AAMC’s response: the issue is not changing the interview process to address the “personal” side of the candidate. The issue is who is being interviewed in the first place. The second issue is who does the selecting. If basic science and non-clinical faculty continue to make up a large proportion of admissions committees, nothing will change.

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Larry Bauer is CEO of the Family Medicine Education Consortium.

A family physician's favorite podcasts - updated for 2018

Late last year, I announced that I was planning to start my own podcast, to be called Common Sense Family Doctor after this blog. I did some reading about podcasting, downloaded Audacity to my laptop, and purchased the rights to some cool-sounding podcast theme music. Then life intervened. Patient care, teaching, editing, and other professional responsibilities completely consumed the time I thought that I would devote to the podcast, which remains on the drawing board. So what is the way forward? With the support of Georgetown's Center for New Designs in Learning & Scholarship, I now plan to explore podcasting to replace selected lecture content in my Patients, Populations and Policy course for first-year medical students. I hope that this "blended learning" project will give me the impetus I need to move forward with podcasting to a general audience sometime this summer. In the meantime, I've updated my previous list of favorite podcasts for your listening pleasure.

Health policy

HealthCetera
The Impact
POLITICO's Pulse Check
RoS: Review of Systems
State of Reform
What the Health?

Current events and popular culture

Every Little Thing
The Forward
How I Built This
TED Radio Hour
This American Life
30 for 30 Podcasts

History

Backstory
The Civil War: A History Podcast
Presidential
Revisionist History
Uncivil

Science and medicine

Air/Space
American Family Physician podcast
Hidden Brain
Houston We Have a Podcast
Methods
Sidedoor