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Context Because medical education is known to be their own wellbeing had been diminished by the burden
demanding and stressful, Case Western Reserve of information to be learned in medical school; (3)
University developed a programme which included a talking to peers was a useful coping mechanism, and (4)
wellness elective which focused on stress reduction and the elective gave permission to engage in wellness
personal wellness. activities without additional guilt.
Objectives The purpose of this study was to explore Conclusions Based on the students' responses, a well-
students' perceptions of medical school stress and to ness elective could be a useful addition to the rst- or
assess their perspective on the wellness elective. second-year medical curriculum.
Subjects The essays of 60 medical students enrolled in Keywords Education, medical, undergraduate;
the wellness elective were used. education, medical; stress, *etiology; health promotion;
Methods The essays were analysed using qualitative adaptation, psychological, psychology; curriculum;
methodology. Results were validated by questionnaires America.
mailed to the students 2 years later. Medical Education 2001;35:652659
Results It was found that the students felt that: (1)
wellness issues should be important for physicians; (2)
Table 1 Summary of major themes discovered with their over-concern about the emotional wellbeing
of others.
1. Wellness issues in medical education
A. Realization of importance of physician's wellness
I nd it paradoxical that we are taught to take
B. Lack of concern about own health as compared with concern care of others, to understand how they are feel-
for others ing, but how we are feeling is just not as im-
2. Medical school stresses portant.
A. Overwhelming burden of information
B. Difculty relaxing, and guilty feelings about relaxation time Medical school stresses
C. Sleep deprivation A recurrent stress which was mentioned in the students'
3. Stress management strategies essays was the overwhelming amount of information
A. Emotional ventilation students are expected to learn during their rst and
B. Support system second years of medical training. Many felt over-
C. Taking time out
whelmed by content demands.
D. Others
4. Evaluation of the wellness elective The medical school curriculum keeps the stu-
A. Realization of the importance of personal wellbeing and dents extremely occupied both in class and in
obtaining permission for self-care digesting the never ending ow of information
B. Opportunity to nd collegiality with students who share we are expected to learn. It took me more than
similar perspective on self-care
C. Being provided with new coping strategies
four months to realize that this ow is con-
tinuous and my expectation that I would have
some time off when a test was over was totally
stress management strategies and course aspects most erroneous. On the very next day after an exam,
appreciated, and 12 subcategories were identied from there would be a load of new material to be
the students' essays (see Table 1.) learned. I began to feel mentally exhausted, but
my initial inclination was that success would
Essay excerpts only come if every spare moment was spent in
the learning process.
The following are major themes identied by the
authors and excerpts from the students' essays sup- As a rst-year medical student, I have felt bom-
porting the themes. barded by the many demands and expectations
placed upon me. I experienced a great deal of
Wellness issues in medical training stress, especially in the rst two months as I
The students' essays demonstrated an awareness of the attempted to adjust to the daily grind.
importance of physicians' maintaining wellness, and The rst- and second-year medical students in the
indicated that students felt that wellness training is an Wellness Elective appeared to have difculty relaxing
essential part of the medical school curriculum. and engaging in activities normally associated with
The Wellness Elective is an excellent way to personal wellbeing. Not only did the students nd little
teach the humanistic side of medicine. As future time for relaxation, but they also expressed feelings of
doctors, we must remember that medicine is both guilt when opportunities for relaxation did occur.
a science and an art. Too often we are overly I also nd that I am not taking the time to do the
concerned about our difcult core science cour- things that I enjoy. I have been feeling as though I
ses and do not realize that, in order to be effective was not who I was before I entered medical
physicians, we must be healthy and well-adjusted school. I am not as free, and denitely not as
ourselves. happy. Whenever I have stolen some moments
For me, being a doctor is also about being a for myself I have felt some of the `old' me coming
healer, and if you are not well yourself it is hard back. It is hard to take time off without feeling
to make other people well. Thus I must take the guilty.
time needed to be well for my own sake as much Relaxation is a very important, but yet, a very
as for my patients' sakes. difcult task while in medical school. The main
Some students also acknowledged a relative lack of problem for me is to decide on a time devoted
concern about their own emotional wellbeing compared solely to relaxation without feeling guilty about
not studying. The reason for this is that in one weekend during late January to get away
medical school one can always study more. from school. Although I had to miss a day of
classes, I came back refreshed and was more
Sleep deprivation was a common student complaint.
productive.
The rst and foremost requirement for me is
Additional coping skills mentioned in the students'
sleep. Most of the time I don't get as much as I
essays included relaxation techniques, meditation,
want, and I am always tired.
exercise, religious faith, attending concerts and/or
participating in a choral group.
Stress management strategies
A variety of coping skills was described in the students'
Evaluation of the Wellness Elective
essays, but one of the most frequently mentioned
CWRU's elective wellness course helped the partici-
techniques was talking to others. Talking with peers
pants realize the importance of personal wellbeing.
allows the student to establish a commonality of
It also served as an authority mechanism, giving
experience related to stress (what some refer to as `in
students permission to engage in self-care without the
the same boat') and provides an outlet for venting
additional burden of guilt they usually associated with
emotions.
activities they consider to be self-indulgent.
I think one important way to reduce stress and
This elective has taught me that I need to be
foster wellness is to have a venue for discussing
active in trying to prevent stress from taking over
problems or venting. I have found that often I
my life. I have to learn that I cannot possibly
think I am the only one feeling inadequate and
learn everything and that I need and deserve a
isolated, but when I seek out someone to talk to, I
break here and there. Also when I am taking
nd that they feel that way too.
these breaks, I need to enjoy them and not dwell
Daily stress relievers include talking to people. on the fact that I am not doing work.
The most common way for me to try to relieve
The elective was extremely helpful to me. I feel
stress is to talk to someone. Talking to other
that I never really neglected my personal needs
medical students helps me remember that I am
and the elective encouraged me to continue my
not the only one who is frustrated with workload
habits that I do to keep stress down and happi-
or the lack of free time.
ness up in my life. I was able to nurture the
Another coping skill included maintaining close relationship with my wife, by taking time off with
family ties and support systems. her.
I have a support system of family, friends, and a This elective is indeed the one elective in medical
ance so I feel comfortable in my personal life. school that cares for the medical students. I used
They help me put medical school behind me for much of the information gained in making my
the hours that I am with them. own lifestyle healthier. This is one of the few
electives where it is okay to be yourself and to
I have a life outside of medical school. My wife is
take time to put self-care back into medical
more important than any glycoprotein I currently
school education.
know about.
The Wellness Elective was an awareness elective
A third coping skill was the ability to take breaks from
in many ways for me. It helped emphasize issues
medicine.
that are important to me and reminded me to pay
On a daily basis, I spend some time by myself in attention to things that will encourage wellness.
quiet. I nd a comfortable place at home and just
What I learned from the elective is that to help
do nothing for a little while. It may not be a long
my patients, children or anyone, I need to help
time, but doing this helps me to focus on me and
myself rst.
my emotions.
The course also provided students with an oppor-
At the beginning of medical school, I was afraid
tunity to establish collegiality among their peers.
to miss any classes, reviews or anything related
Realizing that their classmates also suffered from stress
to school. However, I have realized that if I am
helped validate individual concerns as normal and
stressed out it is important to take some time
manageable.
away from school. For example, I ew home
This session showed me the importance of For the other two students who listed negative
knowing that others are going through the same comments, the realization of what lay in the future was,
difculties and uncertainties that you are. It perhaps, the most stressful of all.
reminded me that it is important to reach out and
I wanted to know that everything changed, all the
talk to fellow students.
horror stories of clerkships and residencies were
I wish I had taken this elective earlier, I appre- not really true and that doctors were still people
ciated having the stresses I feel validated and with lives outside medicine. I found that the doctor
shared by others. or resident was still battling some of the same
problems I had found.
To begin with, the elective is a great idea. The
rst and second years really need a group like this Although it was comforting to realize I was not
where we can vent our frustrations as well as alone and that others struggled as I did, it was not
learn from people who have experienced the comforting at all to think that things might still be
same stresses. unsettled, frantic, and not enjoyable in years to
come.
Student participants also mentioned the practical
aspects of the course which increased the students'
sense of condence and self-control. Student survey
I am mad at myself for not taking this elective Questionnaires were mailed to the 54 students whose
earlier. The elective really opened a lot of doors essays were reviewed. A total of 22 students
to different ways to cope and deal with life. responded (13 to the rst mailing and nine additional
students to the second mailing) giving a response rate
The most important thing that I have learned is
of 406%. Of 22 respondents, seven were males and
that by having better coping strategies, I will have
15 were females; 20 were rst-year and two were
a better attitude toward my work, and I will be a
second-year students when they took the course.
happier and healthier person in general.
Table 2 shows the degree of the students' agreement
The speakers gave me new or more concrete ways with each theme identied by the authors. Theme 5
of thinking about the coping skills that I had, at had not actually been selected as a theme, as negative
some level, discovered by trial and error last year. comments were found in only three essays. It was
included in the questionnaire to assess whether other
Throughout the course of the elective, I think I
students may have had negative opinions but had not
gained a greater feeling of control.
included them in their essays. Theme 2, medical
I intend to employ the valuable techniques I have school stress, was divided in the questionnaire into
learned in this class and will certainly seek advice two parts. The rst part, theme 2A, related to the
and help from others if I feel the need. It is general stress in medical school and theme 2B items
comforting to know that support is readily asked the students about the specic types of stress
available to the student who may need it. they encountered. Of the respondents, 100% agreed
with themes 1, 2A and 3. There was one no-response
Three students' essays contained negative comments.
to themes 2B and 4, respectively, and one student
One of them felt the course needlessly over-emphasized
disagreed with 2B as a theme. Only one participant
stress associated with medical school, thus de-empha-
agreed that the course over-emphasized the stress
sizing the ethic of hard work normally associated with
associated with medicine.
professional training.
In addition to the themes, three questions were
It can be discouraging to come to a class and only included in the survey. All participants answered `yes'
talk about stress, especially if I am not feeling to the rst question, `Do these themes seem reason-
overwhelmed. If I keep hearing or talking about able to you?' All but two participants (918%)
it, I may start feeling that way by the time the answered `yes' to the second question, `Do you think
hour is over. I think it is important to encourage these themes are descriptive of the course?' One
speakers to focus on the benets of the long student, who was unsure whether the themes were
hours and hard work required by a career in descriptive of the course wrote: `Most seem appro-
medicine. Many speakers seemed to identify the priate, but I already knew the importance of balance
stresses of being a medical student, but did not and I wanted a better idea of how to achieve it'. The
encourage us to realize that it's all worth it. nal question solicited other issues not identied by
Strongly Strongly No
Theme agree Agree Disagree disagree response
1 Students who took the Wellness Elective identied the importance 10 (455) 12 (545)
of physicians' wellness in medical training
2A Students encountered much stress during medical school 12 (545) 10 (465)
2B The most common stresses of medical students are an overwhelming 11 (500) 9 (410) 1 (45) 1 (45)
burden of information, difculty relaxing, or feeling guilty about
taking time to relax, and sleep deprivation
3 The most common stress management strategies used by students are 10 (455) 12 (545)
emotional ventilation, support systems, and taking time out from
studies to do other things
4 Students most appreciated that the Wellness Elective helped them 4 (182) 17 (773) 1 (45)
realize the importance of personal wellbeing, gave permission for
self-care, gave an opportunity to nd collegiality, and provided a
variety of coping strategies
5 Students felt that the Wellness Elective over-emphasized stress itself 1 (45) 18 (820) 1 (45) 2 (90)
and devalued the worth of hard work. Realistic expectations offered
in this course seemed discouraging
the authors. One student commented that some other academic demands, while in the clinical years the major
overwhelming issues included how one's performance themes shift to caring for patients and dealing with
as a student compared with that of others, what medical personnel.8 Clearly, the students who took the
students really needed to know to be an MD, and Wellness Elective agreed with ndings from previous
concerns about the future. studies that the curriculum of medical school itself is a
major source of stress.3 They said they felt over-
whelmed by the massive amount of material to be
Discussion
mastered. These feelings resulted in guilt about relax-
Results from this study indicate that wellness issues ation and self-care, which in turn produced additional
were well accepted by the students who took the course. self-generated stress. As medical knowledge continues
All of the students surveyed acknowledged the to expand, this source of stress will increase.
importance of a physician's having a sound mind and Among the variety of coping techniques reported,
body. Nonetheless, they seemed to have difculty talking with other students and fostering collegiality
making their own wellbeing a priority and were strug- were mentioned most often. A small study of practising
gling with the stresses of medical school. Students also physicians similarly found that discussion was used as a
agreed with the themes that the authors found in the way of coping with stress.9 Supporting this coping
essays. mechanism in medical school may help students learn a
This study is timely because of the growing aware- skill that will serve them well in their future practice.
ness of the importance of wellness. The public is Some students indicated that the support of family
becoming more health-conscious and people are assu- members and signicant others helped alleviate stress.
ming grater responsibility for their own wellbeing. In Other studies have varied on this point. Some suggest
response to these trends, the medical community that social support reduces stress among medical stu-
should become more wellness-oriented. The changing dents,10,11 and the presence of strong social ties is the
medical climate demands that physicians learn to factor most positively related to better health and life
practice, as well as preach, wellness-promoting life- satisfaction.12 However, this strategy does not always
styles. seem to prevent psychological distress, as social ties
Perceived stresses and concerns of medical students may present competing demands on an individual's
during the basic science years are generally related to time.13 Another study shows that social support outside
the medical school context is correlated with lower work inherent in medicine are important in order to
academic performance, especially for women. The understand the feelings of some of the students and to
authors suggest that outside social supports may place improve future course development. Future courses
more demands on students' limited time.14 Strong need to help students appreciate that, although stress is
social ties seem to be a double-edged sword, providing inherent in the clinical practice of medicine, they can
emotional support, but also demanding the time and successfully cope with it by attending to their wellness
energy of the students. in ways that are appropriate to their personalities and
More female than male students participated in this lifestyles. They must learn to acknowledge the presence
elective; 66% were women compared with a proportion of stress in their lives, and develop a plan for coping
of 44% women students in the rst- and second-year with it, in order to enjoy the benets of being a physi-
classes. Conclusions cannot be drawn from the study cian.
results as to why women students were over-repre- One of the limitations of this study is that the
sented in this course. Whether female students course examined was an elective. Since students self-
experience more stress or are more interested in selected to take the Wellness Elective, generalizations
wellness is an issue which merits further exploration. to other students cannot be made. However, the goal
The higher number of rst-year students selecting this of qualitative research is not to make comparisons, but
elective may indicate that by the second year, students to gain a better understanding of the group being
are feeling more comfortable about dealing with the studied.
stresses of medical school, as suggested in other Coombs et al.17 suggest that the needs for realistic
studies.2 expectations, emotional expression and a balanced
Rospenda, Halpert & Richman suggest that the use perspective and lifestyle must be met in order to
of time-management strategies may be particularly prevent emotional impairment during medical school.
helpful in reducing the stress levels of medical stu- This elective offered a good source for these three
dents.14 The present study detected little about the use curricular objectives. However, as suggested by one
of time management as a coping skill. This omission student, future Wellness Electives should include more
suggests that time management should be taught in the `how to' sessions.
Wellness Elective in the future. Since women tend to The study might have had more validity if both a pre-
put more emphasis on the importance of social and post-elective essay had been used and compared
connections,15 time management for female students with each other. A pre-elective essay could have helped
may need to emphasize ways of balancing social to answer questions concerning, for example, the
demands with academic needs. Time management source and degree of stress and the expected outcomes
continues to be an important skill for residents and of the elective.
faculty members,16 so learning this coping mechanism In conclusion, this Wellness Elective appeared to be
in medical school would be benecial. well accepted by the medical students who chose to
Overall, the comments regarding this course were take it. Students expressed interest in learning new
extremely positive. The most impressive nding was ways to cope with the burden of the stress they were
that the Wellness Elective legitimized the need for experiencing, and found comfort in knowing other
students to care for themselves. This course gave the students were experiencing similar difculties. Also,
students validation for the notion that they were enti- they appreciated the `permission' they received in the
tled to have time for personal wellbeing without feeling elective to take time away from studies to relax. Medical
guilty. The positive comments in the essays were sup- schools should provide a more structured curriculum
ported by the responses to the mailed questionnaire and for students' personal wellbeing. A wellness elective
may indicate that the elective was meeting an important may be especially well-suited to rst- and second-year
student need. There were very few negative comments medical students. Future research could explore
about the course in the essays, so we did not categorize barriers to incorporating wellness education into
these negative comments as a major theme. However, medical training.
we wanted to be certain that the three essays which
included negative comments were not more represen-
Acknowledgements
tative of students' views. Thus, we included a theme 5
in the questionnaire for students' comments. As seen in Portions of this paper were presented at the 32nd
Table 2, only one student agreed with the statement Society of Teachers of Family Medicine Annual Spring
that the course over-emphasized the stress in medicine. Conference, April 29, 1999, Seattle, Washington,
Nevertheless, the comments about the stress and hard USA.