Mindfulness Meditation for Medical Students: a Student-Led Initiative to Expose Medical Students to Mindfulness Practices

Abstract

Purpose

To explore the feasibility and impact of a brief mindfulness training for medical students and to learn about the perceptions, expectations, and problems associated with mindfulness practices in the context of medicine and medical education.

Method

Forty-one medical students were randomized into either an introductory mindfulness class only or an introductory mindfulness class plus an 8-week mindfulness meditation course. Quantitative and qualitative data were collected from both groups after the introductory class and again after the full course. Qualitative data was subject to close iterative reading as part of a grounded-theory-guided content analysis, generating a list of codes which were then assigned to statements and arranged into overarching themes.

Results

Mindfulness and awareness were negatively correlated with stress and depression. Students who took the full mindfulness course emerged with a greater familiarity with and willingness to utilize mindfulness modalities. There was no significant difference on wellness outcomes between the introductory-course-only group and the full-mindfulness-course group. Thematic analysis revealed student aspirations for a mindfulness alternative in medicine and medical education but also a recognition of the challenges inherent in applying such an alternative.

Conclusion

A mindfulness course for medical students is feasible and has potential as a wellness and educational initiative. Shorter duration mindfulness interventions may increase accessibility without significantly reducing benefit. Interpretation of overarching themes derived from the grounded theory analysis illuminates the subject of mindfulness for medical students from the perspective of students themselves.

Background

Significant evidence suggests that medical students are at disproportionately high risk for depression and anxiety [1]. Mindfulness practices have the potential to improve medical student mental health as well as provide an experiential foundation for the biopsychosocial model of medicine [2]. Mindfulness interventions are also clinical alternatives that medical students should be familiar with. Perhaps, the most influential definition of mindfulness comes from Kabat-Zinn (1994), who defined it as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” [3]. Mindfulness is the capacity for present-moment-oriented attention and awareness. This capacity can be exercised and strengthened with certain practices [4]. These practices involve simply attending to present experience as it unfolds—including sensations, affects, and cognitions—and continuously returning to present experience when pulled away by reaction to or interaction with an internal or external event. It is theorized that such practices have complex physiologic and psychological effects, including decreased rumination and cognitive reactivity and a parasympathetic autonomic “relaxation” response throughout the body [5–7]. These effects are thought to relieve mood disturbances such as depression and anxiety.

Among medical students, mindfulness has shown great promise. In a seminal randomized control trial, Shapiro et al. demonstrated reduced anxiety, distress, and depression among medical students practicing mindfulness, with an increase in empathy [8]. Over the past two decades, quality evidence has continued to emerge suggesting that mindfulness modalities may improve medical student wellness. As such, mindfulness has been increasingly implemented to varying degrees in many medical schools, with reports of reduced medical student stress, depression, and anxiety, increased empathy, self-regulation, and self-compassion, and improved comfort with interpersonal clinical skills [9–11]. In addition, students gained improved self-care behaviors and adaptive coping mechanisms. These outcomes have significant implications in improving student wellness, increasing clinical efficacy, and reducing burnout rates among physicians and future physicians [12, 13].

A mindfulness course for medical students may also help better integrate behavioral and social science components into medical school curriculum. Such integration requires increased student awareness of the philosophical and practical implications of the biopsychosocial model [2]. Medical students have reported that to better integrate behavioral and social science (BSS) into their clinical training, medical schools must demonstrate cultural congruence between aspects of BSS and biomedicine. One study concludes that “modelling and practical training in the application of [behavioral and social science] principles during the second two years of medical school are needed [14].” Thus, a mindfulness meditation course, which incorporates both practice and theory, may serve an important integrative function as part of a biopsychosocial medical curriculum.

However, the preliminary evidence for the efficacy of mindfulness, coupled with its safety, cost-effectiveness, and wide availability, may not be matched by an interest in research and utilization of mindfulness modalities. While some authors have noted high satisfaction and engagement of medical students with a mindfulness course, others saw a high attrition rate [15, 16]. Several barriers towards the implementation of mindfulness programming in medical school have been noted in the literature. Barriers that have been reported include lack of administrative support, lack of time, insufficient monetary support, and a medical culture that does not see mindfulness and psychosocial intervention as within the purview of most physicians. Medical students may feel that psychosocial interventions such as mindfulness are beyond the domain of the physician and/or that physicians are not capable of significantly impacting psychosocial aspects of health. Others feel that they lack the time, training, or capacity to address psychosocial factors [17, 18]. As a result, mindfulness interventions may be underutilized in medicine. Medical student practical exposure to mindfulness interventions via a mindfulness course for medical students has been associated with a greater likelihood that those students will administer or suggest such interventions in the future [19].

Adaptive new approaches are needed in order to improve the accessibility of medical student exposure to mindfulness meditation. A pilot study by Danilewitz (2016) looked at a peer-led approach to mindfulness for medical students and found significant reductions in stress and improvements in mindfulness, altruism, and self-compassion [16]. This peer-led approach provides significant cost savings and may improve student comfort with the course as it is administered by colleagues rather than authority figures. Others have looked at decreasing the time commitment of a mindfulness intervention. The most common model for a mindfulness course is the mindfulness-based stress reduction (MBSR) program developed by Kabat-Zinn, which consists of once-weekly classes for 8 weeks [20]. Yet, a 5-week abridged course, or even as few as 4–5 online modules and 2–3 in-person sessions, also shows a significant impact on perceived stress [21, 22]. Such an approach would save considerable time and make a mindfulness course for medical students more feasible.

In addition, it is still unclear what aspect or aspects of a mindfulness course mediate its effect on wellness outcomes. It is possible that medical students gain simply from the psychoeducational aspect of mindfulness, in which individuals learn the concepts of mindfulness and intentional attention regulation. One RCT found no statistical significance between a mindfulness intervention with formal meditation practice and a mindfulness psychoeducation condition; both interventions saw significant changes in mindfulness, perceived stress, perseverative thinking, and symptoms of anxiety and depression [23]. Similarly, a meta-analysis found no difference between MBSR and psychoeducation in reducing stress in graduate and undergraduate students [24]. Another randomized controlled trial found an enduring impact of exposure to mindfulness even without consistent formal practice [25].

Therefore, an introductory mindfulness class for medical students, organized by medical students, could be a cost-effective way of exposing medical students to mindfulness meditation as compared to a full mindfulness course. Such truncated exposure, providing mindfulness psychoeducation and very brief practical experience with mindfulness techniques, could have a positive impact on medical student wellness and comfort with clinical mindfulness applications while minimizing the time demand that many students reported to be a major barrier to a mindfulness experience for medical students.

Methods

Students were recruited from the Robert Wood Johnson Medical School student body via email to the student listserv and paper flyers on the medical school campus in Piscataway, New Jersey. Recruitment was targeted at preclinical first and second year medical students on the Piscataway campus, a total of 360 students. Recruited students were randomly assigned via a computer into either (a) an introductory class followed by a full 8-week mindfulness course or (b) the introductory class and a waitlist for the full course. Both groups took the same introductory class together. The full 8-week course was capped at 20 participants for logistical reasons. All students from both groups were invited to complete identical surveys at two time points: Once after the introductory session and again 8 weeks later, after the full course arm was complete.

The introductory class was 2 h long and conducted by a trained mindfulness teacher. It consisted of a short didactic component including information on mindfulness in medicine coupled with guided sitting meditation, walking meditation, and mindful yoga. The 8-week mindfulness meditation course was adapted for medical students from MBSR. The program consisted of seven weekly 1.5 h sessions, in addition to the introductory session. Each session included guided sitting and walking meditation. Students were also asked to practice mindfulness daily at home. The meditation sessions were led by an instructor trained in MBSR. Weekly talks and discussion focused on the impact of physiological and psychological stress on disease processes and wellness behaviors.

Survey data was collected using six instruments: The Five Facet Mindfulness Questionnaire (FFMQ), the Perceived Stress Scale (PSS), the Personal Health Questionnaire (PHQ-8) for depression, the Jefferson Scale of Empathy (JSE), and a Likert-type educational outcomes survey.

In addition, narrative comments were collected from all participants in order to assess student perceptions of mindfulness. We used three open-ended questions:

• What advantages/disadvantages over other therapies such as drug and cognitive behavioral therapy do you think mindfulness might have for treating mental health problems?

• What do you think you got or can get out of this mindfulness course?

• What are some problems that you have had/anticipate having with taking a mindfulness course?

To analyze responses to these open-ended questions, we conducted a dual analytical grounded theory analysis [26]. Two independent readers were given a provisional list of topics identified by the authors, with instructions to read student responses and provide critiques and additions to the initial topic list. They undertook iterative, independent, close readings of student responses and listed topics they saw implicitly or explicitly within student statements. Readers compared their lists, gradually finding a consensus regarding emerging topics. They were then instructed to assemble the topics into more general themes. Readers and authors finalized a list of topics, which became the codes. The readers then assigned these codes to statements contained in the student responses. A “statement” was defined, as per Miller et al. 2014, to be “a comment of any length expressing a complete thought, and typically consisted of several lines of printed transcript, but could be as short as a few words” [27]. Numerical counts and frequency distributions were computed for codes and themes using all student responses from both groups and time points, as a way of searching for themes that remained constant across both groups and data collection time points (Tables 2, 3, and 4).

Table 2.

Frequency of topics and themes in student comments regarding the mindfulness course. What advantages/disadvantages over other therapies such as drug and cognitive behavioral therapy do you think mindfulness might have for treating mental health problems?

Themes	Frequency of codes (# times topic mentioned)	Theme frequency (no. (%) of total topic codes applied)
Safe non-pharmacologic alternative	• No side effects: 30 • Avoid drug dependence/addiction: 10 • Good cost-benefit profile: 7 • No drug interactions: 3 • Alternative to medications: 2	52 (27.4%)
Patient autonomy	• Patient empowerment: 14 • Independence of practice: 9 • Whole person treatment: 8 • Convenient: 5 • Everyday mindfulness tools: 4 • Individualization/variety of practice: 2 • Congruences with patient beliefs: 1	43 (22.6%)
Healthcare system	• Low/no expense: 13 • Highly accessible: 10 • Patient skepticism: 6 • Improved therapeutic relationship: 2 • Problems with insurance coverage: 1 • Stigma: 1	33 (17.4%)
Personal growth and trait change	• Introspection: 8 • Perspective change: 6 • Long-lasting solution: 5 • Coping tools: 4 • Internal drive/self-directed: 2 • Lifestyle change: 2 • Address root cause of mental illness: 1	28 (14.8%)
Mental hygiene and symptom relief	• Stress reduction: 5 • Doubts/problems regarding efficacy: 4 • Clear mind: 3 • Sleep improvement: 2 • Focus on present: 1 • Greater happiness: 1 • Improved quality of life: 3	19 (10%)
Adherence issues	• Requires dedication: 7 • Difficult to learn: 4 • Vulnerability of practice: 2 • Requires time commitment: 2	15 (7.9%)

A total of 310 statements were given codes; the total number of codes applied was 435 (average 1.4 codes per statement). Percent and total number values are of total codes applied for that question, combining responses from before and after the mindfulness interventions. Themes and codes are listed in order of decreasing frequency. For Q3, 16 codes (21.6%) were applied for “no problems relating to the course” and were not included in the table

Table 3.

Frequency of topics and themes in student comments regarding the mindfulness course. What do you think you (got)(can get) out of this mindfulness course?

Themes	Frequency of codes (# times topic mentioned)	Theme frequency no. (%) of total codes applied
Clinical applications	• Understand mindfulness applications: 29 • Advise patients: 13 • Administer mindfulness: 2 • Help myself to help others: 2 • Educate colleagues: 1	47 (29%)
Cognitive skills	• Self-regulation: 11 • Coping skills: 10 • Improved focus: 6 • Thought quality: 3 • Open to novelty: 3 • Mental hygiene: 2 • Efficiency: 1 • Increase resilience: 1	37 (22.8%)
Awareness and fulfillment	• Live in the present: 5 • Positive affect: 5 • Self-awareness: 5 • Understanding/expression/awareness of thoughts: 4 • Increased enjoyment of life: 3 • Improved sense of self: 2 • Perspective change: 2 • Improve sense of satisfaction: 2 • Reflect and prioritize: 2	30 (18.6%)
Symptom improvement	• Decrease stress: 14 • Decrease anxiety: 6 • Improved sleep: 2 • Decrease pain: 1	23 (14.2%)
Mindfulness	• Incorporate/individualize mindfulness for my life: 15 • Develop/renew personal mindfulness practice: 5 • Learn mindfulness from a professional: 1	21 (13%)
Community	• Shared interests: 3 • Community accountability: 1	4 (2.5%)

A total of 310 statements were given codes; the total number of codes applied was 435 (average 1.4 codes per statement). Percent and total number values are of total codes applied for that question, combining responses from before and after the mindfulness interventions. Themes and codes are listed in order of decreasing frequency. For Q3, 16 codes (21.6%) were applied for “no problems relating to the course” and were not included in the table

Table 4.

Frequency of topics and themes in student comments regarding the mindfulness course. What are some problems that you have had/anticipate having with taking a mindfulness course?

Themes	Frequency of codes (# times topic mentioned)	Theme frequency no. (%) of total codes applied
Time	• Finding time to practice/practice consistently: 17 • Finding time to attend class: 6 • Loss of potential study time: 1	24 (32.4%)
Meditation abilities	• Difficulty concentrating: 4 • Anxious/overwhelmed by meditation: 3 • Lack of experience: 2 • Difficulty clearing mind of thoughts: 2 • Meditating “wrong”: 1 • Difficulty applying mindfulness: 1	13 (17.6%)
Skepticism and doubt	• Won’t see benefits/symptom relief: 5 • Skeptical of benefits: 4 • Won’t feel different: 1 • Won’t connect with it: 1	11 (14.9%)
Group experience	• Aided in practice by others: 3 • Concerned about sharing with group: 2 • Distracted by others: 1 • Being inexperienced: 1 • Uncomfortable in group setting: 1	8 (10.8%)
Intrinsic challenges	• Working through thoughts/emotions/experiences: 1 • Difficulties inherent to life: 1	2 (2.7%)

A total of 310 statements were given codes; the total number of codes applied was 435 (average 1.4 codes per statement). Percent and total number values are of total codes applied for that question, combining responses from before and after the mindfulness interventions. Themes and codes are listed in order of decreasing frequency. For Q3, 16 codes (21.6%) were applied for “no problems relating to the course” and were not included in the table

All data was anonymized, collated, and analyzed to look for themes, connections, trends, and correlations between outcome measures. Appropriate IRB approval was obtained for all research activities.

Results

There was significant interest and participation in a mindfulness course for medical students: Of the 360 preclinical students targeted for recruitment, 41 requested to participate in the full 8-week course. This represents 11.4% of the first and second year medical student body. Twenty students were randomly enrolled in the full course and 21 students were assigned to the introductory class only. Of those enrolled in the full course, 75% attended at least 6/8 classes, indicating good feasibility and student engagement. Thirteen first year students and 28 second year students requested to join the course. The average age of total participants was 24.4 years of age, with 32 females and 9 males. The average age in the full course group was 23.9, with 14 females and 6 males. The average age in the introductory-class-only group was 25.1, with 18 females and 3 males.

Of the students who completed the full course, 80% indicated comfort with referring for or administering mindfulness (n = 15). Of those who completed the introductory session alone, only 23% indicated such comfort (n = 13). However, a full 8-week mindfulness course did not seem to have a significant impact on wellness outcomes as compared to a 2-h introductory class alone. The results of wellness surveys measuring stress, depression, and anxiety which were administered to the full course group after they took the introductory class alone did not differ significantly from the identical surveys given to that same group after they completed the full 8-week course. In addition, there were no significant differences between the full course group and the introductory-class-only group in surveys administered to both groups after the 8-week course elapsed.

Correlations were found between several outcomes across both those who attended the introductory session only and those who participated in the full course (Table 1). There was a high positive correlation between stress and depression, Pearson correlation coefficient (PCC) = 0.76, while mindfulness was moderately negatively correlated with depression, PCC = − 0.632. In particular, the awareness component of mindfulness was highly negatively correlated with depression, PCC = − 0.78.

Table 1.

Outcome measure correlations (ffmq, five facet mindfulness questionnaire; PSS, perceived stress scale; dep, depression as measured via PHQ-8)

Pearson correlation coefficients, N = 28 Prob > |r| under H0: Rho = 0
	Describe	Observe	PSS	Aware	Nonjudge	Nonreact	ffmq	dep
Describe	1	0.26103 0.1797	− 0.11563 0.5579	0.35854 0.0610	0.19681 0.3155	0.18428 0.3479	0.61339 0.0005	− 0.29268 0.1307
Observe	0.26103 0.1797	1	− 0.46848 0.0119	0.48617 0.0087	0.16974 0.3878	0.47270 0.0111	0.63274 0.0003	− 0.37300 0.0506
PSS	− 0.11563 0.5579	− 0.46848 0.0119	1	− 0.70566 < 0.0001	− 0.46159 0.0134	− 0.53888 0.0031	− 0.63098 0.0003	0.76009 < 0.0001
Aware	0.35854 0.0610	0.48617 0.0087	− 0.70566 < 0.0001	1	0.63632 0.0003	0.49982 0.0068	0.85556 < 0.0001	− 0.77911 < 0.0001
Nonjudge	0.19681 0.3155	0.16974 0.3878	− 0.46159 0.0134	0.63632 0.0003	1	0.34470 0.0724	0.72180 < 0.0001	− 0.41842 0.0267
Nonreact	0.18428 0.3479	0.47270 0.0111	− 0.53888 0.0031	0.49982 0.0068	0.34470 0.0724	1	0.64862 0.0002	− 0.34219 0.0747
ffmq	0.61339 0.0005	0.63274 0.0003	− 0.63098 0.0003	0.85556 < 0.0001	0.72180 < 0.0001	0.64862 0.0002	1	− 0.63179 0.0003
dep	− 0.29268 0.1307	− 0.37300 0.0506	0.76009 < 0.0001	− 0.77911 < 0.0001	− 0.41842 0.0267	− 0.34219 0.0747	− 0.63179 0.0003

Open-ended questions following completion of the course provided useful qualitative data regarding student perceptions of mindfulness in medicine and their experiences in the mindfulness course. Our findings are reported here for some of the major themes, accompanied by some examples of verbatim student comments. Additional comments can be found in Tables 5, 6, and 7. Numerical and frequency distributions of themes and codes are reported in Tables 2, 3, and 4.

• I).What do medical students perceive to be the advantages and disadvantages of mindfulness as medicine? (Table 5 for additional verbatim student comments)

Table 5.

Sample student comments for each theme. Sample responses to prompt: What do you perceive to be the advantages and disadvantages of mindfulness as medicine?

Theme	Sample comments
Safe non-pharmacologic alternative	• Personally, I avoid taking drugs unless I have to. If there is another technique or natural treatment I almost always prefer it even if it works for me through the placebo effect. • Fewer side effects. • To me, mindfulness seems like it would be very useful in treating mental health problems because it sounds like something you can do anytime anywhere to center yourself without needing to put drugs in your body or needing to wait for an appointment with a professional. • No negative side-effects • Very low risk-benefit ratio. • Why prescribe a drug if it’s possible for patients to control the condition themselves. • Mindfulness is particularly more effective because it does not require xenobiotic drugs; instead, it utilizes internal, noninvasive methods of healing. • Personally, as I patient I would like to try an option like mindfulness first where I would have control before depending on a medication.
Patient autonomy	• It brings the patient to an active/ownership role in their health and life rather than a “checked out” recipe for X symptom to be relieved. • Charging and empowering patients, [putting] them in the driver’s seat of their health. rather than enlisting them to a dependent/victimized mentality that they “need” drugs/therapies/someone else like a doctor to tell them what is best for their body… • More of a sense of agency over oneself/one’s mind. • I think mindfulness empowers people. • Can be practiced without going to the therapist’s office. • It can also give people a greater sense of control over their emotions and lives. • May be easier to continue independently. • Allows patients to be active in their recovery process while providing them with coping techniques that they can use on a daily basis. • Gives patients control • If mindfulness is used in conjunction with other therapies, I expect it would empower patients to have a better “relationship” (compliance, willingness, appreciation, etc) for that therapy. • Mindfulness allows a person to be more organic and understanding with their own feelings, hence giving patients more power and autonomy over their condition.
Healthcare system	• Less expensive. • There is no cost. • Easily accessible • Is easy to ‘prescribe’ • Mindfulness is free and available to everyone, anytime. • Insurance may not cover initial mindfulness training. • Accessible for almost all patients through video or podcasts. • To me, mindfulness seems like it would be very useful in treating mental health problems because it sounds like something you can do anytime anywhere to center yourself without...needing to wait for an appointment with a professional. • Benefit not as clear-cut - depends on practice
Personal growth and trait change	• It is an internal drive to heal • Mindfulness can be applied to a lot of different aspects of a patient’s life. • Mindfulness can also help alter perspectives and lifestyles, which could have far reaching consequence in and of itself. • Allow for the patients to have better introspection • Longitudinal, lasting effects that emphasize “management” over “cure” • Puts the patient into touch with their emotions in a way that allows them to cope with their daily lives
Adherence issues	• Disadvantages might include inefficacy simply because the individual is not able to adopt mindful practices easily. • Difficult to get into the habit without extrinsic motivators • mindfulness practice is taxing. • Requires a certain amount of practice/instruction early on • Compliance is a major disadvantage as patients may feel that they simply do not have time to utilize these techniques. • Hard to implement because you need to learn the techniques. • A disadvantage would be seeing it as a “quick fix” alternative and then getting frustrated with its ineffectiveness when not willing to put the work in. That is to say, if it isn’t done in a dedicated way and is misinterpreted, patients might find it so frustrating as to abandon the concept and rely more heavily on external interventions and self-fulfill their perceived helplessness. • Calming but may at first induce more anxiety because it takes practice to be able to do it.

Table 6.

Sample student comments for each theme. Sample responses to prompt: “What do you think you got/can get out of this mindfulness course?”

Themes	Sample comments
Clinical applications	• A better understanding and appreciation of an intervention that could benefit my patients • I would also like to better understand the extent of the clinical applications for mindfulness so I can speak from empathy when I recommend it to future patients. • I want to be able to have a base of knowledge on which to draw as a physician who would potentially prescribe therapy to patients in the future. • A better understanding of what mindfulness is, how I can apply it in everyday life as a medical student and future physician and how I can use it in patient care. • A greater understanding and tools to administer mindfulness. • I plan to get a better understanding of what mindfulness is and what its potential therapeutic effects are so that I can be a more mindful physician • Better understanding of how it can be useful to patients • Hopefully aid my colleagues and patients in likewise becoming more mindful
Cognitive skills	• I would love to gain better ability to focus while studying. • Encourages creativity and self-monitoring. • Improve focus • I want to be calmer and able to focus more attentively. • I believe that the course has provided me with great coping tools for the future. • I think this course has provided me with another tool to utilize during times of stress that I can use for myself and share with others as well. • Learn how to use mindfulness, have better focus and mental hygiene • Be able to better control my emotions and stress. • I have learned an alternative way to deal with the daily stressors that we face as medical students.
Awareness and fulfillment	• The course was “centering” - helping me to re-understand why I want to be in medicine in the first place and how to better myself so I can help others. • I would like to learn how to live and be happy in the present moment. • A more positive approach to my life • I plan to enhance my own mindfulness to improve my efficiency in the day and overall sense of satisfaction with my life. • The course reminded me of myself and of parts of myself I had neglected or forgotten about from time to time when lost in the rush of checklists and achievements. It many ways it felt like coming home to a sense of myself, a sense of awareness, playfulness, and patience. • Observing emotions without judgement • I want to learn how to be present. • I would like to learn how to live and be happy in the present moment. • Increase reflective practice and capacity
Symptom improvement	• Personally I was able to get back into a mindfulness routine which means clearer thinking, more focus, and better sleep. • I can clear my mind better to fall asleep • I also don’t want to spend most of my time in a state of anxiety or worrying about the future • I hope to relieve some of my anxiety. • Help with my anxiety and possibly ptsd • A different approach to pain management

Table 7.

Sample student comments for each theme. Sample responses to prompt: “What challenges do medical students face in taking a mindfulness course?”

Themes	Sample comments
Time	• I know this is an investment but I cannot understand that it is until I engage in it. • Time commitment and whether I feel like the class is worth my time • I had difficulty finding time to deliberately practice • Setting aside time for daily formal practice with such a busy schedule. • The struggle continues to be finding dedicated time. • Time conflicts with 3rd year rotations. • While for some, finding dedicated time might be problematic, I don’t find this to be an issue as I often make time either before bed or upon waking up.
Meditation abilities	• I am concerned whether my lack of experience or generally distracted state of mind at times will hinder my developing mindfulness (i.e. I’m worried that I’m an inherently ‘unmindful’ person). I’m am worried about being able to experience the benefits of mindfulness, and I sometimes wonder if my experience will be different from the people I know who practice it already. • I’ve done a few mindfulness meditation practices under the guidance of an experienced teacher, but I’m worried that it will be hard for me to do it on my own. I’m hoping the course will provide the necessary skills and resources to practice independently
Group experience	• It’s difficult for me to establish a formal practice the way we did in group. Group also provided a cumulative-energy effect that made meditation easier • I don’t know if I would be able to concentrate when surrounded by people I know • I have difficulty expressing and sharing emotions and opinions. I’m a little concerned about having to share our experiences and progress with the group • I am a little worried that I am such a novice in my own practice, and that it can be challenging at times to commit my time to my own practice, but I hope the class will motivate me to do this! • I found it difficult to stay motivated to practice on my own constantly throughout the course • Discomfort with the group setting
Skepticism and doubt	• I do think this type of thing can sometimes delve into crazy, hippy pseudoscience but I will keep an open mind • I am wondering about the extent of its ability to provide specific relief of symptoms (i.e.: back pain) as opposed to just increase personal awareness and perspective • I’m afraid I may not see the alleged benefits

Safe Non-pharmacologic Alternative

Our results made clear than many students are concerned about dependence, addiction, and adverse events associated with the medications used in mental healthcare. “No side effects” was applied 30 times (Table 2), more frequently than any other code. Some were coming from a general perspective that non-pharmaceutical methods should be pursued as first-line:

“Personally, as I patient I would like to try an option like mindfulness first where I would have control before depending on a medication.”

Patient Autonomy

Many students commented on the ways in which the clinical incorporation of mindfulness meditation could empower patients through self-understanding and self-care. A major component of this empowerment was the fact that mindfulness could be practiced independently, in everyday settings, in a way that is tailored to each individual’s life. But this autonomy and empowerment was also related to an increased self-awareness, which gives patients more clarity and understanding in making healthcare decisions. Others saw the avoidance of drugs as the primary way in which mindfulness empowers patients. Interestingly, patient empowerment was also linked to an improved therapeutic relationship and patient compliance.

“It brings the patient to an active/ownership role in their health and life rather than a ‘checked out’ recipe for X symptom to be relieved.”

Healthcare System

Participants commented on the clinical applications of mindfulness in the context of the healthcare system. A recurrent topic was not only the fact that mindfulness techniques can be practiced for free or at a relatively low cost, but also that such techniques are broadly accessible, in particular via free technology mediums.

“Mindfulness is easy to ‘prescribe.’”

Personal Growth and Trait Change

Students described the changes induced by mindfulness as slow long-term development rather than an abrupt or superficial change. Mindfulness produces changes in the way one interacts with challenging thoughts, emotions, and situations, mediated by the application of coping techniques derived from mindfulness.

“[Mindfulness] puts the patient into touch with their emotions in a way that allows them to cope with their daily lives.”

Adherence Issues

However, many students recognized factors intrinsic to the mindfulness practice that made it difficult to implement clinically, primarily the dedication and effort required by mindfulness interventions. Some also pointed out that the practice could even induce anxiety at first, which could dissuade beginner meditators from continuing.

“Compliance is a major disadvantage as patients may feel that they simply do not have time to utilize these techniques.”

• II).What do medical students think they themselves can get out of a mindfulness course? (Table 6 for additional verbatim student comments)

Clinical Applications

When students were asked what they themselves could get out of a mindfulness course, the theme of useful clinical/professional applications was very common. Students hoped to improve their clinical presence and efficacy by becoming more mindful themselves. They also hoped to learn mindfulness techniques that they can then administer or recommend to their patients.

“A better understanding and appreciation of an intervention that could benefit my patients.”

Cognitive Skills

Many students also related to mindfulness as a way to bolster their coping skills, self-regulation, focus, and ability to work efficiently and creatively.

“I want to be calmer and able to focus more attentively.”

Awareness and Fulfillment

Another benefit that students sought to derive from a mindfulness course was a deeper sense of happiness and fulfillment. They saw this as achievable through a personal mindfulness practice, which would foster present-mindedness, a greater self-awareness, and a reorientation of priorities:

“The course reminded me of myself and of parts of myself I had neglected or forgotten about from time to time when lost in the rush of checklists and achievements. It many ways it felt like coming home to a sense of myself, a sense of awareness, playfulness, and patience.”

Symptom Improvement

Others were looking for improvement in personal symptoms, and in particular for a way to decrease anxiety and stress:

“I hope to relieve some of my anxiety.”

• III).What challenges do medical students face in taking a mindfulness course? (Table 7 for additional verbatim student comments)

Time

When asked about potential problems with a mindfulness course, nearly a third of all participants cited a lack of time or a difficulty with time management as a major factor (Table 4). There was a clear struggle for students in trying to decide if the time commitment was worth it. Students commented on having difficulty both attending the mindfulness course sessions and finding time to practice at home.

“Setting aside time for daily formal practice with such a busy schedule.”

Meditation Abilities

Several students also expressed the concern over a disparity in meditation abilities among the medical students in the group, either due to inherent skill or due to prior experience:

“I am concerned whether my lack of experience or generally distracted state of mind at times will hinder my developing mindfulness (i.e. I’m worried that I’m an inherently ‘unmindful’ person). I’m am worried about being able to experience the benefits of mindfulness, and I sometimes wonder if my experience will be different from the people I know who practice it already.”

Group Experience

Interestingly, there were various perspectives on the impact of learning and practicing mindfulness in a group. For some, the group was a boon. But for others, the group setting was a distraction and a potential source of anxiety.

“It’s difficult for me to establish a formal practice the way we did in group. Group also provided a cumulative-energy effect that made meditation easier.”

Discussion

An 8-week mindfulness course for medical students and an introductory session in mindfulness exposed students to a potentially useful self-care and clinical therapeutic modality. A greater degree of exposure—a full course versus a single introductory session—was also associated with more comfort with and a greater willingness to utilize mindfulness modalities. The greater educational value of a full 8-week course may be due to the “mindfulness in medicine” didactic component embedded in the 8-week course as well as the additional experiential familiarity engendered by an 8-week practical exposure. Yet, it was interesting to note that there was no significant difference on wellness outcomes between students who took the full 8-week mindfulness course and those who participated in the introductory course alone. This suggests that, though the full 8-week course may have a positive educational value, a brief introductory class may be a potent and efficient way of providing students with exposure to mindfulness-based wellness activities. This may be due to the fact that, though expertise in mindfulness takes substantial time and effort to cultivate, the instructions for basic mindfulness practices are quite simple and can be absorbed in one class and then applied in independent practice, whether or not one is enrolled in a full mindfulness course.

The qualitative and quantitative data that emerged provides some insight into the dynamics of medical student self-care and also illuminates medical student perspectives on mindfulness meditation techniques in medicine.

Certain overarching connections seemed to link the various major themes of our analysis. As a therapeutic modality, the benefits of mindfulness seem to derive from its top-down approach mediated by executive functions. This top-down approach emphasizes long-term changes in self-management and self-awareness which have a system-wide impact on behavior and experience. The statistical correlation we found between awareness and stress reduction underpins this idea of awareness as a mediating factor in delivering the benefits of mindfulness. Rather than targeting a particular receptor group or applying a standardized clinical intervention, mindfulness modalities—which are focused on whole-person experience, self-awareness, and self-regulation—are inherently more holistic, individualized, and internally guided.

Yet, the difficulties with mindfulness as a treatment modality also seem to stem from this internally propelled, individualized approach. Individual application requires individual effort; the efficacy of mindfulness modalities hinges on patient effort and dedication as well as willingness to explore the self and potentially experience vulnerability.

Two threads emerged in regard to what students thought they themselves could get out of a mindfulness course: (1) practical results and (2) self-growth. Students were seeking practical cognitive skills to help them focus, improve thought clarity, reduce anxiety, improve sleep, and successfully navigate the stress of medical school. In addition, they were also looking for greater happiness, reflectivity, reorientation towards personal values, and an overall improved sense of satisfaction in life.

The problems students related to mindfulness can be connected by common threads of time, ability, and effort. These represent anxieties that medical students are already well familiar with from their experiences with medical education. Students felt that time constraints were the biggest obstacles in the way of fully benefiting from a mindfulness course, both in terms of time to attend classes and time to practice mindfulness techniques at home. Students expressed tension in choosing to do something other than study for exams. In addition, some students were unsure of their capacity to be mindful or meditate, either due to a perception that mindfulness requires too great an effort or a perception that being mindful is an intrinsic ability that some have and others simply do not.

A mindfulness course for medical students has the potential to provide medical students with important self-care strategies that empower them to take an active role in their own health. We have demonstrated how a mindfulness intervention for medical students offers future physicians a level of exposure to mindfulness that gives them the familiarity and knowledge base that they need to discuss mindfulness interventions with their patients and recommended them as appropriate.

Conclusion

The results of this study suggest that a very brief mindfulness intervention for medical students, such as a 2-h introductory mindfulness class, is feasible and may have the same impact on student wellness as a full 8-week mindfulness course. We found interesting correlations between outcomes, particularly a negative correlation between mindfulness and stress. Our data also points to a difference in the educational impact of a full mindfulness course versus an introductory session alone. Those enrolled in the 8-week course were more comfortable recommending mindfulness interventions to their patients and applying mindfulness practices for themselves. Thus, such a course may have a significant impact on physician wellness and clinical recommendation practices. Our dual analytical grounded theory analysis revealed themes and connections that illuminate the sphere of medical student self-care as well as medical student perceptions of mindfulness and the tensions and insights that emerge when applying mindfulness to medicine.

Our study has multiple limitations. Our population was a self-selected group of 41 interested medical students and may have lacked adequate statistical power to detect differences between groups and time points. The process of having individual coders providing their own readings of students’ written statements inevitably introduces an element of subjectivity. We attempted to mitigate bias by seeking the review of independent readers and applying an iterative coding process until a consensus was achieved. However, preconceptions as to which topics and themes were relevant to mindfulness inevitably colored our analysis. We only engaged in a grounded theory analysis but not grounded theory data gathering, as our data collection was not iterative.

In addition, no formal survey was undertaken to assess prior mindfulness experience. Anecdotally, participant comments revealed a range of familiarity with mindfulness across both groups, from the mindfulness naive to those who already had a personal formal meditation practice.

Finally, no attempt was made to compare student comments between groups and time points. The aim of the qualitative component of this study was to illuminate general themes that emerge in medical student comments. Comparing the depth of understanding and the predominance of various topics and themes across groups and time points may have provided additional information, though such an analysis is beyond the scope of this paper.

Despite these limitations, this pilot study and qualitative analysis can help guide medical schools in their efforts to implement mindfulness interventions and apply mindfulness in the clinic by highlighting the hopes and struggles that students face regarding mindfulness in medicine.

It is particularly relevant for medical schools to reflect on the fact that time was perceived as the biggest obstacle towards completion of a mindfulness program for medical students. In addition to simple time constraints, medical students may have great psychological difficulty devoting time to anything beyond the required curriculum. Administrative support and the incorporation of wellness activities such as mindfulness into the medical school curriculum would make it easier and more efficient for students to participate and practice and may relieve anxieties associated with the need to independently allocate time to mindfulness as an extracurricular activity [28].

However, though there is little research regarding the potential adverse effects of a mindfulness course, mindfulness interventions share some common features with psychotherapy and physical exercise and thus potentially common adverse effects as well, including stress and discomfort related to engagement with difficult cognitive and affective states [29]. In addition, mindfulness meditation requires concerted effort on the part of participants and thus may not be effective as a mandatory requirement imposed on uninterested students. More research is needed to further delineate the risk-reward profile of mindfulness interventions in various populations.

Compliance with Ethical Standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflict of Interest

The authors declare that they have no conflicts of interest.