The responses from Questionnaire 1 allow for several, numerically supported claims to be made in favor of factors students associate strongly with their wellness, and factors that are conducive to wellness. These supported claims gain necessary, personal context when taken alongside interview responses. The potential for such cross-analysis was the original motivation for performing this mixed methodology study. Key themes present and mutually supported by both the questionnaire and interview responses can be organized into a series of related discussions.
How is wellness enabled and conceived?
The survey format is suited to gather data on the contributing factors for wellness, how wellness (however conceived by the participant) is enabled. As for these enabling factors, on Questionnaire 1, at all three timepoints Family, Academic Performance, and Friends are consistently the highest ranked in their importance to overall wellness. Alone Time and Hobbies are consistently lowly ranked, and Financial Stability remained last in ranking at all three timepoints. These findings are thoroughly reflected in the interview responses, which allowed further exploration into the individual conceptions of wellness that are enabled by these factors. Throughout the interviews, when students are asked to elaborate their idea of wellness, mention of Family and Friends numerous times (70 mentions of family and 91 mentions of friends) and the role of Academic Performance is mentioned in enough detail to warrant separate discussion. Not a single interviewed participant mentioned Financial Stability as a factor contributing to their wellness, and only one person mentioned finances as one of the barriers to wellness. Although this finding may not be generalizable across school, geographic area, and/or year in schooling, the lower relative weight of this factor during preclinical years is supported by prior findings. Of note, while many previous studies outline the various self-care behaviors employed by students, interview data reveals how these behaviors change depending on current stress level, specifically regarding the choice to socialize.
Through conversation, it could be seen that personal definitions of wellness are broad and deep. Nearly all participants included social, physical, emotional wellbeing into their definition, often explicitly citing the “health triangle,” but they also identified several factors that weigh particularly heavily for them as individuals but are not often discussed, like travel and romance. There was frequent conversation around spiritual well-being, and multiple students commented on their search for inner peace, quietude, and purpose. The importance of family featured prominently both for coping and academic success, suggesting that disruptions (e.g., death or illness of family member) could disproportionately negatively impact wellness and therefore warrants further study. Although one may expect that the relative influence of Family might wane as immersion in the medical community and career path deepens, this was shown not to be the case according to the survey data, which as mentioned continue to be highly favored during repeat midterm and final assessments and the interviews in which participants explained the value of Family (e.g., “I'll call up my mom, my dad, my grandma, my brothers, sister, just talk to them and connect with them…I feel that helps keep me grounded. They give me perspective.”). Finally, the pass/fail system and the awareness of school resources (even if not used) were frequently mentioned as comforting. These factors may partly explain why in our previous study we observed decrease in perceived stress and increase in wellbeing over the course of the year, despite no difference between those who did or did not participate in wellness curriculum.
What is the relationship between wellness and academic performance?
Although unsurprising for this academically-minded study population, Academic Performance is second only to Family as an important factor in overall well-being. One student elaborates, “a large part of my identity and how I view myself is in my abilities, my academics, and my desire to become a doctor.” While important for well-being and central to identity, [academic] work is also cited by almost all as an obstacle to wellness. One participant elaborates, “school is often not the stressor, but rather what exacerbates other stressors,” and another refers to school as “the exacerbated environment.” This begins to explain why by the end of the academic year there is a 17.1% decrease in those who highly rank Academic Performance in their well-being.
Furthermore, results show that students begin to bifurcate into two groups. Students who rank Academic Performance highly in well-being are more likely to choose these extrinsic achievements as important to success in medical school while those who lowly rank Academic Performance are less likely. This bifurcation is reflected in the interview, as some students gauge their success by extrinsic measures ( “a very metric ingrained definition of success”), and others gauge it more holistically (“I have some level of mastery of the material [while] not feeling the class taking over my life”). Several students mentioned that being top was not worth forfeiting wellness (“Even if I was getting the top score on an exam, if I was sacrificing sleep or friendships to do that, I wouldn't feel like that was a success. I would feel like that was not worth the price.”). Those who ranked Academic Performance highly for well-being were also less likely to report on Questionnaire 1 that maintaining wellness in medical school is important, as if wellness is contained within academic performance and does not require additional attention. To our knowledge, this dichotomy has not been shown in previous studies. Given that we found a decrease over time in the percentage who ranked academic performance as key to wellness, it may be that students begin to shift priorities toward internal rewards versus external rewards. Better understanding these associations is an area ripe for more research.
How does the atmosphere of medical education relate?
Seeing as academic work is a major factor of overall student wellness, it follows that student wellness is contextualized within the academic environment. Even early in their medical education, participants have clear opinions towards the atmosphere of medical education, commonly labeled “the system,” and regard it as a hindrance to wellness. Students comment that wellness is treated separately from the rest of formal medical education, saying “In an academic setting, it's [wellness] always an adjunct right?” Student wellness is perceived as not only separate, but also inadequately tended to, as this same student continues, “I feel like it’s something that is talked about but not truly addressed.” Students frequently commented on wellness curricula as insufficient and misguided with four students referring to them as a “band-aid.”
When prompted further about the origins of this institutional attitude towards student wellness, students share numerous insights. They articulate the belief that this attitude is inherited, saying “it’s a systematic mentality coming down on us from physicians,” and that it is perpetuated by an incentive structure whereby “the people who value wellness aren’t rewarded by the system.” One student explains this as the result of “a lot of inefficiencies in our system right now.” Another focuses the issue on how “Wellness is often portrayed in only its negative form, burnout, which also has this connotation that it’s a shortcoming on the part of the people experiencing burnout rather than a shortcoming of the construct.” Altogether, a clear theme of skepticism emerges towards wellness efforts that fail to address the predominant medical culture. This sentiment runs alongside a longstanding and well-known aspect of medical training commonly referred to as the “hidden curriculum,” whereby trainees are placed in a predominant medical culture that teaches behaviors in the clinical workplace that are different or antithetical to what is explicitly taught.[10, 36]
What curricular improvements follow from this discussion?
Just as wellness was found to be diversely conceptualized through our in-depth interviews, a wellness curriculum should not be narrowly biased towards conventional and stereotypic conceptions. Students describe this bias for “people who prefer exercise and mindfulness” and for “activities more leisurely in nature,” and as a narrow “subset of ideas and activities like yoga.” Instead, activities that are cerebral, or otherwise less stereotypically associated with wellness may be more inclusive and well-received. As one student summarized, “One thing that I think is not emphasized enough in wellness is self-efficacy and locus of control.”
Given the close and conflicted relationship between wellness and academics as mutually elucidated through the survey and interview data, it follows that wellness curricula ought to be conceived alongside academic curricula and that academic work (cited universally as the obstacle to wellness activities) be made more manageable. One student expresses “Maybe the answer is not necessarily to have more extra things, but maybe to structure the academic part of school in such a way that it's not as taxing.” This is an echo of a prior meta-analysis study showing marked improvement in well-being with a pass/fail grading system, as well as another Australian study which found favorable response to approved “well-being day” absences. In addition to making curricula more manageable, faculty may also integrate wellness in how they present existing coursework, thereby demonstrating wellness as an integral physician competency and building trust between staff and students, which this same Australian study found lacking.
Furthermore, the emphasis placed on family and independent strategies for maintaining wellness advise a student-directed approach to wellness programming. Interviews reveal adamant opposition to mandatory wellness activities, enough to warrant identification as a core theme, with one student saying “Should’s are a really good way to have people turn their backs.” Both this study and our previous report suggests that student-driven, as opposed to faculty-driven, are more likely to enjoy greater participation and increased student wellness. These findings mirror prior literature, which urges caution in further “institutionalizing” wellness initiatives rather than to have them arise organically from the student body itself. A pronounced trend has been noted in the climate of current medical education where students are choosing to learn content individually and through mixed resources as opposed to traditional scheduled classroom didactics. With these prevailing trends in student attitude, optimal engagement can be expected when wellness initiatives are similarly student-driven, as previously found in one prior study in Singapore. In line with this finding, both in their interview and free-text survey response, many students express support for student-initiated wellness grants at MCASOM-AZ that fund activities proposed by students themselves or for programming that is student-led. To the extent that students find some of the interactions stressful with other students, student-led programming might include strategies for discussing academic worries with each other that are geared toward supportive listening and normalizing common worries. Lastly, and consistent with the main direction of this study to focus on individual conceptions of wellness, many students identified a need for more reflection on the attitudes surrounding their personal wellness and see the value of such reflection. This research interview was noted by many participants as a welcomed occasion for such reflection, suggesting a potential role for peer coaching as a strategy to foster reflection and peer support. On the basis of these and other findings, our school eliminated mandatory lectures and adopted additional peer support programming and student-led wellness curricula, which indeed has had high participation rates. We are currently evaluating the impact of the new programming.
The findings of this study are limited by several features. Firstly, results are limited by small sample sizes for questionnaire responses at all three timepoints, as well as many dropouts at the midterm and final timepoints. This may introduce the bias that students who are feeling particularly unwell are excluded from later responses. Furthermore, study findings reflect only the experience of students in the preclinical years 1 and 2, where there is not yet the additional stressor and rewarding experience of hands-on patient care. Additionally, although having a student interviewer may have allowed for greater trust from participants, it could have introduced an element of bias, whereby students may have felt the pressure to echo sentiments that they may have believed the interviewer or the greater student body may have held.