Mindfulness in the Medical Learning Environment: An Opportunity for the Struggling Learner?

Abstract

Mindfulness is defined as nonjudgmentally and purposefully paying attention in the present moment. Mindfulness may be a valuable tool in the remediation armamentarium, useful in bringing attention to an individual’s struggles. However, such application has largely been unexplored. In this essay, we provide a conceptual framework for future empirical study of mindfulness interventions for struggling medical learners. We review literature on mindfulness interventions in medical education at-large, apply them to the struggling medical learner, discuss limitations to mindful practice, and provide recommendations that will help faculty assigned to struggling learners be mindful themselves to optimally function in these roles.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-024-02115-8.

Introduction

“Where do you see yourself in five or ten years?”

This is a question that has been posed to both of us at various times throughout our careers. What usually follows is plan creation to get us to our next stage: acceptance into medical school, matching to residency or fellowship, academic promotion, or national leadership. However, with all this forward-thinking, it admittedly seems like very little attention is paid to the “here” and the “now;” to the successes, triumphs, challenges, and failures that we have experienced along the way in getting us to where we are today.

Throughout our careers, we have had the opportunity to be forward-thinking, often losing sight of the present as we strive for the future. However, we posit that this same luxury cannot be afforded to those who have experienced significant struggles and setbacks along their pathway—you cannot focus on the future when the present needs your attention. One common challenge when working with a struggling medical trainee is when the student, resident, or fellow lacks insight into her or his struggles [1]. Additionally, in a reimbursement system that incentivizes clinical productivity, the attention of the mentor or coach to a struggling trainee may be difficult to hold.

Mindfulness is often defined as “the awareness that arises from paying attention, on purpose, in the present moment, and non-judgmentally” [2]. One can be mindful during a formal mindfulness meditation practice such as focusing intentionally on the natural breath while bringing attention to various parts of the body. Alternatively, mindfulness can be practiced in an informal manner throughout our daily lives as we bring our conscious attention to even the most mundane of activities such as cleaning, doing the dishes, or even walking [3]. Individuals may have a certain innate level of mindfulness exhibited in their daily lives, often termed trait [4] or dispositional [5] mindfulness. Alternatively, brief mindfulness interventions also have the ability to induce a sort of state [6] mindfulness, where one takes time out of a busy day to increase their attention in a particular way.

Mindfulness is already taking a prominent role in medical education [7, 8]. However, we believe that mindfulness may be a valuable tool in the remediation armamentarium, useful in bringing attention to an individual’s struggles at hand, creating awareness that will assist in more accurately identifying the affected learner’s deficiencies, and hopefully allowing for a more rapid rectification of said issues. In this essay, we will explore the use of mindfulness interventions in medical education, organized into sections on undergraduate medical education (UME), graduate medical education (GME), and the mindful coach. In each section, we will reference conceptual, theoretical, and empirical literature supporting existing mindfulness interventions. Our goal is to make a case for how mindfulness could help the struggling learner, provide practical tips where applicable (primarily in the GME and coaching sections), and describe a conceptual framework for a future pilot study.

Mindfulness and the Medical Student

Struggling medical students may face difficulties on many fronts: academic, social, personal, and financial. Given the highly selective nature of UME admissions, medical students may not be accustomed to struggling. Consequently, academic failure may result in students minimizing, externalizing, and blaming faculty or the institution for their struggles. Students may have poor insight into their struggles, resist change, and rarely identify themselves. On the contrary, other students may tend to beat up on themselves for their struggles. All of this makes it particularly challenging for mentors and coaches to provide effective remediation for medical students, and we believe MBIs may be an opportunity to assist the struggling medical student.

The goals of mindful practice are to become more aware of one’s own mental processes, listen more attentively, become flexible, and recognize bias and judgments. Mindful practice involves a sense of “unfinishedness,” curiosity, and humility. Mindful self-awareness may help the student become conscious of his or her strengths, limitations, and sources of professional satisfaction.

Mindfulness-based interventions (MBIs) have increasingly gained popularity in healthcare settings [9]. Mindfulness programs can be found in over 250 US health systems, are currently being studied as curricular elements for students at multiple medical colleges around the United States [7], and are recommended by the General Medical Council in the United Kingdom [10].

The importance of mindfulness in medical and health profession students has been studied, with several systematic reviews showing benefits of MBIs in medical undergraduates [11, 12]. While some results were mixed [11], the included studies support a reduction in burnout [11], depression [11, 12], as well as stress and anxiety [12]. MBIs also led to improved student empathy and self-efficacy [12]. The benefits of MBIs with medical students may also extend well beyond the intervention itself. A study of medical students involved in a curriculum based on four, once-weekly, 60-min classroom sessions found changes in self-reported behaviors and attitudes up to 6 months later [13]. In another study, medical students randomized to the mindfulness-based stress reduction (MBSR) course showed small to moderate improvement in mental health at 20-month follow-up [14].

The newest frontier has been online programs. A small study evaluating a hybrid of peer facilitation and online mindfulness intervention showed evidence of feasibility [15] and a follow-up study showed that two-thirds of participants completed all modules of the program, though daily practice was low [16]. While not specific to medical students, another study of an online MBI led to changes in self-compassion that persisted for up to 6 weeks [17].

Challenges to the implementation of MBIs do exist. Medical students face extreme time pressures given demanding curricula, rendering participation in weekly group longitudinal programs challenging. Interest and response to mindfulness training were equal or higher in clinical than in pre-clinical students [18] which may indicate timing and delivery of MBIs should be level-of-training specific. Since many reported interventions are elective, we suspect the higher quality studies with positive outcomes may have selection bias, as students who dropped out of one study had significantly higher psychological symptoms [19]. Mandatory MBIs in UME have been evaluated, and still tend to be well-received [20]. However, 17% of those surveyed felt MBIs should remain purely elective, with qualitative comments supporting this sentiment. Thus, we still propose an elective approach to such interventions, recognizing that power dynamics might lead some students to agree to MBIs even if they don’t really desire to do so.

One practical mindfulness-based tip that students can adopt is that of embracing a beginner’s mind, or an intentional openness and lack of preconceptions. This has been proposed to help mitigate biases in clinical practice and try to limit the unconscious autopilot state that may occur with increased training [21]. This may also help learners continue to foster a growth mindset, allowing them to better embrace constructive feedback to improve from a struggling state, rather than focusing more on evaluation implications in the high-stress competitive nature of the residency application cycle. While we are including this tip within the UME section of this essay, more advanced learners and clinician-educators may also benefit from embodying this concept so they may view junior learners with a similar frame of reference, meeting them where they are at in their educational journey.

Take Home Point #1: Embracing an open awareness and minimizing preconceptions may help foster a growth mindset, positioning a medical student to better tackle present struggles

Mindfulness and the Resident or Fellow

Residency and fellowship programs frequently have committees tasked with early identification of struggling learners. These committees are often charged with “diagnosing” a learner’s deficiency or deficiencies based on data provided to them in the form of clinical rotation evaluations. While there are often evaluative data that can inform objective competency-based definitions of struggles, we aim to keep our definition of the struggling learner (and thus, who may benefit from MBIs) intentionally broad, as external or secondary issues may often be contributing. It is advocated that mentors or coaches evaluate for such secondary issues, including mental health conditions [22] and sleep disturbances [23]. However, in our experience, inquiry into these areas rarely produces tangible results. Anecdotally, we have identified these issues at a far lower prevalence than what is reported in the literature for depression [24], sleep deprivation [25], and at-risk substance use [26] in graduate medical trainees.

There are multiple potential explanations for this discrepancy. While the responsibility to inquire about these issues traditionally falls on the faculty, bringing attention and awareness to them may fall on the struggling trainee. Obviously, these issues are difficult to discuss, especially with faculty physicians who may be in a position of authority over the struggling learner. Alternatively, and what we speculate may be more likely, is that the trainee may not be aware of the role that these secondary issues are playing in her or his poor performance. In fact, denial may be thought of as the flip side of the awareness coin [27]. With focus and attention as key components of mindfulness, a more mindful trainee may have a greater chance for remedial success. Multiple qualitative [28–30] and mixed-methods [31, 32] studies of MBIs in GME have reported residents noting increased self-awareness as main themes. Residents described being more aware of their own emotions as well as in identifying their own needs. Group mindfulness classes where resident struggles were shared also helped residents identify that they were not alone in their challenges. We believe such self- and community-awareness could improve identification, normalization, and acceptance of clinical struggles.

Take Home Point #2: Mindfulness may be a strategy to assist a struggling resident or fellow to recognize (and be able to address) outside factors that may be impacting clinical training performance

An additional concept linked to insight, awareness, and mindfulness is intrinsic motivation. Intrinsically motivated individuals are frequently more open to experiences and actively engaged. This is extremely relevant to the remediating resident or fellow with poor self-insight. Traditional remediation programs often come in the form of top-down checklists fraught with time-sensitive tasks and negative feedback. These remediation plan characteristics may have the unintended consequence of ultimately decreasing intrinsic motivation of the struggling medical learner. On the other hand, actively engaging the struggling resident in remediation plan creation may allow for greater intrinsic motivation for remedial success.

With 80-h work weeks, ill and dying patients, and constant critique from supervising physicians, GME training is an unbelievably stressful environment. While some residents and fellows may have little insight into their problems, others may have painfully acute senses of their performance problems, finding themselves in ruminative thought cycles. The literature argues mindfulness may have a place in reducing rumination that may come from such day-to-day stress [33, 34], and newer qualitative studies specific to the GME population support this [29]. While this benefit is not necessarily limited to the struggling learner, in our experience, residents and fellows who find themselves on remediation often become hyper-focused on the decision of being placed on remediation, potentially affecting further progress.

While we have found no research on mindfulness specific to the struggling learner, the data we have reviewed suggest that mindfulness would likely have a positive impact in this population. In a national survey of residency training programs in one specialty, it was noted that personal, professional, or situational mental stress could explain greater than 70% of cases of unsatisfactory resident performance [35]. MBIs have been shown to improve stress and burnout in resident populations [31, 36, 37], with potentially greater benefit based on resident perception of residency stress [38], or degree of emotional exhaustion [39]. Brief MBIs have been shown to improve objective measures of stress in procedural simulations [40], and notably decreased procedural errors. Even MBIs that do not show improvement in objective measures of stress may still have benefits in trainee clinical performance [41]. Thus, we believe MBIs directed toward stress management may in turn lead to a more successful trainee.

Take Home Point #3: Employ mindfulness-based interventions to help the struggling medical student move beyond rumination toward a sense of “unfinishedness.”

Like any intervention, we must also identify any potential negative impact MBIs may have in hopes of better selecting the appropriate types of interventions. A study on the effectiveness of school-based mindfulness training delivered by teachers resulted in worse scores on risk of depression and well-being immediately post-intervention and 1-year follow-up [42]. However, this population was both significantly younger than traditional GME trainees, and included those at risk for mental health problems. Nevertheless, MBIs could make things worse as learners become more aware of their own distress, especially for those with anxiety, and need to be used carefully.

While it is likely that broad mindfulness interventions are helpful for those in UME and for attending physicians, the same may not be true for residents experiencing difficulties without intentionally selecting a specific activity that pairs with the individual area for improvement. Different mental training practices have been shown to work on different developmental domains, with attention training improving attentional performance, loving-kindness work increasing compassion, and socio-cognitive practices impacting perspective-taking [43]. Additionally, while mindful practice requires few to no financial resources, we must recognize that the cost to the learner may be high related to the very precious resource of time. Learners who struggle may not feel they have much discretionary time and engaging in longer meditation practices of 30 to 45 min per day could add to their distress. Thankfully, a mixed-methods study found similar wellness outcomes between medical learners who took an introductory mindfulness class only and those who were randomized to receive an additional eight week meditation course [44]. Nevertheless, with these limitations in mind, we feel that mindfulness practices have a favorable cost and risk to benefit ratio.

The question of what specific meditative interventions to use is supplanted by the more important question of how much is enough. As little as 10 h of mindfulness training may lead to positive outcomes [45]. In physician populations, longer mindfulness interventions such as the 8-week MBSR course [46] appear to be most studied as a potential treatment for burnout [47]. However, not all MBIs are time-intensive. The body scan, which is the first formal mindfulness meditation and a crucial part of the MBSR program, has participants focus on their breath before moving their awareness to different parts of their body from head to toe or vice versa. Studies evaluating this technique’s efficacy looked at practices as short as 5 min with an average scan time of just over 15 min [46]. This introductory activity is adaptable for those not formally enrolled in MBSR, as the exercise (narrated by Kabat-Zinn himself) is easily found through free online video hosting platforms. For those interested in a more embodied experience, yoga is a moving meditative practice that is steeped in mindfulness. However, there are also critics of yoga [48], as it has often been incorrectly proposed as a treatment for burnout, rather than focusing on fixing systemic issues in healthcare that lead to emotional exhaustion, depersonalization, and a reduced sense of accomplishment. In reality, both may be true. While the existing literature suggests that residents may experience system-level issues such as sleep deprivation [25] or mistreatment [49] that may contribute to their burnout, we posit that not all competency-based deficiencies are steeped in burnout. Rather, competency achievement is a very individual process, with each resident or fellow reaching behavioral milestones at the level ready for unsupervised practice sooner or later than others. A more mindful resident or fellow may be better equipped to recognize where they are on their own trajectory toward unsupervised practice. Thus, we hold fast in our recommendation to keep MBIs, including yoga, in the remediation armamentarium.

Finally, the identification of more mindful trainees at the beginning of remediation programs may allow mindfulness training interventions to be focused on others more likely to benefit. The Mindful Attention Awareness Scale [50] may be a useful tool in accomplishing this.

The Mindful Coach

Successful remediation of the struggling medical learner does not solely depend on the qualities and experiences of the remediating individual—context matters. There appears to be a significant lack of standardization of remediation coaching and mentorship [51]. Moreover, trainees and coaches may struggle to find mutually agreeable times to meet [52]. This is in part due to the multiple competing commitments that practicing physicians, those most assigned as remediation coaches, are balancing. As such, when educators are faced with the struggling medical learner, they may have limited training, resources, and time to provide their undivided attention to their assigned struggling learner.

In practical terms, mindfulness can help the coach prepare for coaching sessions by placing competing commitments of clinical care, research, or administration on hold and center her or himself before meeting with a learner. During the session, mindfulness may help the coach bring attention back to the trainee when the mind starts to wander. Remaining non-judgmental is also key so that the coach can empathize with and provide constructive feedback to a trainee. The coach can also teach both formal and informal mindfulness practices to trainees. Given that mindfulness in coaching can be enhanced with appropriate preparation [53], we recommend mindfulness training be offered in all coaching curricula. Finally, while the authors of this essay practice in the United States which notably has a unique healthcare system, mindfulness practices do appear to have a direct benefit on clinicians practicing outside America [54].

Take Home Point #4: The mentor of a struggling learner may similarly utilize mindfulness strategies to focus attention away from competing commitments and toward their protégé

Resources exist to cultivate the mindful coach. Academic medical centers frequently offer the full MBSR course at a cost, with various scholarships available. If an 8-week in-person mindfulness course is not affordable or convenient, there are a multitude of guided meditation and yoga smartphone applications, many of which have extended free membership trials to frontline healthcare providers. Such applications have shown promise for healthcare workers [55], including trainees [56, 57]. Additionally, we have included multiple mindfulness meditation scripts (ESM Appendix) such as one that a mentor or coach may use with a struggling learner. These suggestions should be part of a consistent practice to reap the most benefits, and we encourage further study of these within the realm of remediation to know which choices in the menu of options have the best efficacy.

Take Home Point #5: Consistency of practice is more important that total time involved with mindfulness and finding a personal “hook” or social network may help retain interest and maintain accountability respectively

As greater attention is paid to issues of diversity in healthcare and medical education [58], it may become increasingly likely that a remediation coach is paired with a struggling learner of a vastly different cultural background. “Without a critical awareness of differences that are socially meaningful [...], mentoring relationships will fail to achieve their full potential” [59]^(p1−2). There are multiple possible solutions to tackle this challenge. “Mentoring Across Differences” workshops have been incorporated into larger faculty development programs and presented at national and international educational conferences. These workshops foster self-awareness and mindful practices to challenge diverse audiences of 10–150 mentors and protégés by bringing awareness to assumptions through openly discussing differences [59]. These workshops were met with overall positive narrative evaluations and have been published in a manner that allows them to serve as an easily adoptable teaching resource. On a more individual level, mentors may introspectively work through Chopra and Saint’s [60] five steps for a mindful mentorship practice: start with yourself, put yourself in their shoes, practice slowing down, be grateful, and embrace selflessness. These five mindfulness steps may be thought of as variations on the theme of building resilience to tackle life’s challenges, particularly the challenge of coaching the struggling medical learner.

Conclusions

In our exploration of the intersecting literature on mindfulness, medical education, and the struggling medical learner, we believe mindfulness may have a positive impact on the struggling trainee and holds great potential as a tool in the remediation armamentarium. We believe this article provides the groundwork for a pilot or larger study on mindfulness and the struggling medical learner to fill this important gap in the literature. While barriers exist to adopting mindfulness within medical education such as a high-pressure work environment with extreme time demands and daily life or death situations, utilizing the take home points from this article will help readers understand the potential impact mindfulness holds for the struggling learner. It is our hope that implementing such practices will not only help these learners but also the educators who are tasked with helping them succeed.

Supplementary Information

Below is the link to the electronic supplementary material.

Declarations

Conflict of Interest

The authors declare no conflicts of interest. The views expressed are those of the authors and should not be construed to represent the positions of the University of Colorado, UCHealth, Pennsylvania State University College of Medicine, the Penn State Medical Group, or the Milton S. Hershey Medical Center.