12 minute read
Using mind-body medicine for self-awareness and self-care in medical school
An innovative educational program at Georgetown University School of Medicine teaches mind–body medicine skills to blend science and humanism to foster student and faculty self-awareness and self-care.
For many medical students, medical school proves to be an extremely stressful time. A challenging and time-intensive curriculum, increasing student debt, exposure to death and suffering, student abuse, and sleep deprivation are several of the stressors contributing to a difficult medical school environment. Existing literature consistently demonstrates that medical students exhibit significantly higher psychological distress relative to both the general population and to their peers.
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Such psychological distress has a variety of harmful consequences, including the development of substance abuse, other mental illnesses, a decrease in academic performance, and a reduction in provider quality of patient care. Recent research demonstrates that medical student distress decreases empathy, a characteristic that correlates with clinical competence and whose development has been identified by the Association of American Medical Colleges as a key goal for graduation. 3 Medical students also demonstrate greater levels of depression and anxiety than reported in the general population or age-matched peers. 1 This fact takes on even greater significance when considering that psychosocial characteristics, including levels of depression, anxiety, and self-esteem, may in fact be better predictors of clinical competence than medical admissions test scores.
Growing evidence demonstrates that a variety of self-care curricula have been effective at reducing medical student distress, depression and anxiety and improving a variety of other factors, including self-awareness, emotional competence, and empathy. Shapiro et al 5 found that a mindfulness-based stress reduction (MBSR) program aimed at medical and pre-medical students reduced levels of anxiety, depression and distress and increased levels of empathy. Rosenzweig et al 6 further demonstrated that an MBSR intervention improved coping skills and decreased mood disturbance scores among medical students. These findings led our group to consider developing and implementing a program at Georgetown University School of Medicine (GUSOM), which would expose medical students to mind–body medicine techniques such as meditation, imagery and movement. Our goal was to provide a curricular intervention that would foster student self-awareness which could lead to self-care, and thereby help students to manage stress and improve their wellbeing.
Development of the mind–body programme
We were fortunate to obtain a small curriculum innovation grant from the School of Medicine, which enabled us to apply for a five-year education grant from the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health. With the award of the NCCAM-funded education grant in 2001, resources were now in place to support the efforts of a group of faculty members to develop the mind–body medicine program and integrate knowledge, skills and attitudes of this area into the medical curriculum. Initially, three faculty members from the department of physiology took a week-long professional training program in mind–body medicine skills, offered by the Center for Mind–Body Medicine in Washington, DC. Over the following year, one of us (NH) was recruited to direct the program and to develop an in-house training program. The training of four–six faculty members a year then began in earnest and now averages 10–12 a year. Most of the faculty involved were invited to participate because of their high profile role at the school (course and clerkship directors or division chiefs), as well as their willingness to commit time and effort to the goals of the program. At the same time, learning outcomes for the program were defined in terms of desired student competencies that were consistent with the school’s mission. Those objectives and competencies appear below.
Competencies and objectives of the mind-body medicine programme
Competencies
This course is designed to facilitate the student’s mastery of the following defined competencies at Georgetown University School of Medicine:
A–5: An understanding and knowledge of oneself, including the scope and limits of one’s knowledge, skills, and values.
B–7: The ability to learn independently with a critical awareness of the scope and limits of one’s knowledge, skills, and values.
C–5: An awareness of the importance of maintaining one’s own well-being and of balancing the demands of professional and personal life.
Learning objectives
At the completion of this elective course students will
(a) Describe a variety of healing modalities including meditation, guided imagery, autogenic training, journal writing and movement and reflect on the ways these skills can be helpful personally and professionally.
(b) Articulate the importance of self-awareness and self-care for personal health and well-being and the importance of maintaining a balance between the intellectual, emotional, physical social and spiritual aspects of their lives.
(c) Comprehend the value of an on going commitment to personal growth as fundamental to the practice of medicine.
Description of the course
The course in mind–body medicine at Georgetown University School of Medicine is currently being offered to first, second and third year medical students. A separate opportunity is offered to interested faculty members. Classes meet for two consecutive hours, once a week for 11 weeks, with two faculty members who co-facilitate each session. The course is designed with nearly 60% of the activities devoted to experiential learning, and with the remaining time devoted to the sharing of student insights and reflections and to the discussion of skills that were experienced.
Over the 11 sessions, students are taught various mind–body medicine skills including self-awareness, meditation, guided imagery, bio-feedback, autogenic training, art, journal writing, and movement (see Table 2). Students learn the techniques, practise them and discuss their experiences with members of the group. Thus, students have the opportunity not only for individual attention and instruction, but also for sharing what they are learning about mind–body medicine and about themselves.
Mind–body medicine techniques
Breathing (slow, diaphragmatic)
Meditation (mindfulness/awareness)
Guided imagery (several types)
Bio-feedback (thermal)
Autogenic training (self-hypnosis)
Art (emphasis on non-cognitive drawing)
Music (used in meditation and imagery sessions)
Movement (shaking/dancing, walking meditation)
Writing (journals, dialogues)
About a week before the course begins, an initial orientation is held, where students learn expectations and intended outcomes for the course. In addition, pre-course self-assessment forms are completed at that time, which include a number of survey instruments. Students receive a packet of information including guidelines for group behavior, course assignments, a list of recommended readings and various articles that focus on the most current evidence for health benefits of mind–body medicine and theoretical underpinnings for integrating mind–body medicine skills into medical practice.
Of importance to the healing quality of the course is the physical environment in which it is held. To that end, the students meet in a serene, dimly-lit room in which 12 chairs are arranged in a circle with a table in the centre of the circle. A candle, a vase filled with fresh flowers, a dish containing chocolate, and a set of tingha bells (with which to begin and end each meditation) are placed on the table – not the typical medical school setting!
Students in the mind–body medicine course begin each session with an opening meditation
Each session follows a structured format. An opening ritual such as lighting a candle begins each session. The purpose of the candle is to provide a focal point to help bring the participants’ attention into the present moment and to remind them why they are there. This is followed by the ringing of the tingsha bells to begin a 10-minute opening meditation, which allows students to shift their focus from their hectic lives to become present in the moment.
After the brief opening meditation, the ‘check-in’ period begins. Students are invited, one at a time, to share aspects of their daily experiences, discuss any issues they have and explore insights and revelations that they have discovered about themselves. Facilitators participate along with students, sharing their week’s experiences, reactions, and perceptions with the group. The active engagement of the faculty facilitators is essential to create a safe setting and also because these individuals (some of whom are course or clerkship directors) serve as important role models for the students. Of critical importance is the atmosphere of generous listening, confidentiality, nonjudgment, safety, and respect that is facilitated by the group process.
Following the hour-long ‘check-in’, a mind–body medicine skill is introduced by the faculty co-leaders. Each week, a new skill is presented. At this time, the techniques are explained, if relevant, the scientific basis is discussed, and then the skill is demonstrated and experienced. The skills include various meditations (sitting, eating, walking and forgiveness), guided imageries, autogenic training, bio-feedback, art sessions, journal writing, and movement. Students practise and process their understanding of this new skill and are invited (but not compelled) to reflect and share their insights with the group. Sessions typically end with a five-minute closing meditation.
Expectations of students are that they will practise the skill that they learned during each session for a minimum of 10 minutes a day throughout the upcoming week. In addition, they are asked to write at least one journal entry of any length each day, practise a form of meditation (sitting, eating, walking) for a minimum of 10 minutes a day, and participate in at least one physical activity (walking, jogging, exercising, playing a physical sport) three to five days a week.
At the conclusion of the course, students are asked to complete post-assessment forms. These are analysed along with the pre-assessment forms that were completed during orientation before the course began. In addition, they are asked to answer six open-ended questions that inquire as to whether the course affected their view of medicine, medical school, and their relationship with their classmates.
Summary of outcomes
To date, more than 700 individuals have participated in the mind–body medicine skills program, including more than 500 medical students, 130 graduate students (primarily students enrolled in the CAM MS and PhD degree track in physiology), close to 90 nursing students, and more than 50 members of the faculty. The program is first introduced to first year medical students in the spring semester. We chose the first year for mind–body skills groups because it is a time when attitudes toward medicine are just beginning
to be formed, but could be powerfully shaped. The students were required to write a short paragraph and explain their motivation for taking the course. Approximately 60 students, representing a third of the class, enrolls. Many were not sure what they were getting into, but had heard from upper classmates that the experience was very worthwhile. Working with first year students also offered us the opportunity to engage students at the beginning of their career so they could use the techniques they learned and the insights they gained throughout their training experience. We hoped that the friendships they made, and the feeling of the community they created in the intimacy of the small groups, would be supportive and sustaining throughout medical school.
A number of survey instruments are used in the student groups to document some of the changes that occur. These include the 10-item Perceived Stress Scale (PSS) 7 the 15-item Mindful Awareness Attention Scale (MAAS) developed by Brown and Ryan, 8 and a newly created 21-item survey instrument, the Mind–body Skills Attitudinal Scale (MBSS). 9 We consistently find reductions in students’ perceived stress and an increase in mindfulness awareness. Moreover, there are a number of attitudinal shifts that occur related to increased sense of coping with the stresses of medical school and greater empathy of participating students towards their classmates.
The students also respond to six open-ended questions that address how the course helped the student, if at all, and how has it changed the students’ attitudes towards medicine, medical school and their classmates, if at all. Data regarding the qualitative content analysis was published a number of years ago. 10 Five central themes emerged from the student responses which were related to: 1 connections, 2 self-discovery, 3 learning, 4 stress relief, and 5 medical education. From all our analysis it appears that students self-awareness and self-reflection increases, and we believe their degree of empathy is fostered as well.
Our analysis of the impact on faculty is less well defined. However, the course surveys are replete with poignant statements about how the experience has transformed individuals to reflect on their lives, their priorities, and the necessity to introduce more balance in how they conduct their day-to-day affairs. There is also the acknowledgement that taking time for oneself is essential for optimal wellbeing.
Our experience to date suggests that incorporating a course in mind–body medicine skills in medical school may represent a unique and important way to help advance several desirable educational goals, such as increased student empathy and mindfulness, in addition to reducing students’ perceived stress in medical school.
Acknowledgement
The development of the mind–body medicine programme and the research described was supported by an educational curriculum grant (R25 AT 00419 from the National Center for Complementary and Alternative Medicine), and by a curriculum innovation (CIRCLE) grant from Georgetown University School of Medicine.
Written by:
Scott Karpowicz
Third year medical student, Mind–body Medicine Group participant
Participating in the mind–body medicine programme has had a noticeable impact on my wellbeing throughout medical school, and I am convinced it will have a lasting effect on my career as a physician.The programme goes far beyond mere stress management – it has improved my self-awareness and listening skills, given me a stronger sense of compassion and empathy, and helped build a supportive community within the medical school. I look forward to taking the skills and experiences gained from this programme into the realm of daily patient care.
Nancy Harazduk
Director, Mind–body Medicine Program, Georgetown University School of Medicine
For the past eight years my passion has been to create a culture that embodies compassion, respect, self-reflection, and authentic collegial relationships among medical students and faculty. I envision a culture that encourages collaboration rather than competition, support rather than judgment, and connection rather than isolation. We have begun this journey with our mind–body medicine programme. And what a remarkable journey it is, as students, faculty and administrators work together toward a more balanced, effective and humanistic model of medical education.
Aviad Haramati
Professor of Physiology and Medicine, Georgetown University School of Medicine
My career as a renal physiologist – with a 20-year research focus on fluid and electrolyte homeostasis – took a distinct, non-conventional turn nine years ago, when we embarked on an educational initiative at Georgetown University to incorporate CAM and integrative medicine, especially mind–body medicine skills, into the medical curriculum.Along the way, I learned quite a bit about education and health. I also learned about authenticity, relationships and non-judgment, and now expend significant effort to rethink the way we train physicians. It continues to be quite the adventure!
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