“Flourish in the Clerkship Year”: a Curriculum to Promote Wellbeing in Medical Students

Abstract

The stresses of medical training can lead to burnout and other adverse outcomes. The Flourish curriculum was designed to mitigate negative effects of stress among clerkship students through debriefing and skills-building activities that foster practical wisdom: mindfulness, appreciative practice, story-telling/listening, and reflection. Students rated the curriculum highly, felt it addressed common concerns about clerkships, and were able to apply techniques from the curriculum to their clinical work. This framework can help students process their experiences and benefit from peer support, mentorship, and reflection. Fostering medical students’ wisdom capacities for reflection and compassion may be protective against burnout during their training.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-022-01522-z.

Background

Medical educators aim for students to develop compassion, integrity, empathy, professionalism, and commitment to service. However, stress during medical school can lead to burnout and other negative consequences, including poor mental health, loss of empathy, reduced patient satisfaction, and medical errors [1]. These negative effects of stress may be mitigated through strategies that promote resilience and help trainees cope with stress [2]. We aimed to create an intervention for medical students that would not only reduce burnout risk but foster skills for growing and maintaining professional virtues and compassionate care.

To design our intervention, we utilized a conceptual model of professional development that focuses on compassion, applying knowledge to the correct situation, and tolerating uncertainty called “practical wisdom” [3]. Although wisdom is an understudied concept in medical education, the psychology literature has developed models for understanding its components and development [4]. Ardelt’s 3D Wisdom model conceptualizes wisdom with three domains of cognitive, reflective, and affective capacities [5]. The cognitive domain includes understanding deeper meaning, awareness of limitations of knowledge, and tolerance for ambiguity. The reflective domain includes self-awareness and the capacity to see things from multiple perspectives. The affective domain includes compassion and desire to foster the wellbeing of others. Means to facilitate wisdom development in medical education previously proposed by William Branch include role modeling of these domains by faculty with reflection on clinical experiences, mindfulness of one’s feelings and reactions, story-telling as a means to increase reflection, and group support [6].

We chose evidence-based techniques of mindfulness, appreciative practice, reflection, and story-telling to foster wisdom. Mindfulness is characterized by self-regulated attention with nonjudgmental awareness and forms the basis for mindfulness-based stress reduction [7–11]. Appreciative practices are grounded in strength-based appreciative inquiry principles and that foster wellbeing; they include reframing, positive communication, gratitude, finding meaning in work, and fostering positive emotions [12–16]. Reflective practice, which includes reflective writing and group discussion, can improve or preserve empathy, enhance clinical skills, and foster wellness [17–20]. Narrative medicine offers techniques for honoring patient stories and improving students’ humanistic abilities [21–24].

We designed a curriculum for students during their clerkships, a particularly stressful time during medical training [25]. By introducing students to multiple techniques, we aimed to offer a menu of options for coping, stress reduction, and emotional growth. In designing the sessions, we sought input from content experts in appreciative practice, mindfulness, and narrative medicine. Our content experts were faculty members from the departments of internal medicine and neurology, including leadership roles in the Mindfulness Center and the Center for Appreciative Practice at the University of Virginia. Our aim was to pilot the new curriculum and evaluate students’ attitudes and experiences.

Activity

The curriculum, entitled “Flourish in the Clerkship Year”, was designed with the first session scheduled to coincide with the transition week between students’ pre-clinical phase and the clinical rotations, followed by 12 monthly sessions over the course of the clerkship year, from February 2017 through January 2018. Sessions were held in the evenings with dinner provided. It was unknown whether the skills component (such as learning mindfulness techniques) would be more helpful than small group contact with longitudinal faculty mentorship alone. Therefore, we randomized students into two groups: an intervention group with a skills component and monthly debriefing, and a control group with monthly debriefing only.

For the intervention group, each session included debriefing about clerkship experiences and instruction in a technique of story-telling, mindfulness, appreciative practice, or reflective writing. For the control group, each session was devoted entirely to debriefing about clerkship experiences with no formal curricular activities. Each group had two consistent faculty mentors to facilitate their sessions.

We subsequently created an accessible version of the course website so that materials could be shared with other educators. Table 1 gives an overview of each session with topic, techniques, discussion, and readings/handouts. Detailed plans for each session with instructions for facilitators, outlines, guidance on use of the audio files and readings, discussion prompts, and exercises are available on the course website: https://sites.google.com/virginia.edu/flourish.

Table 1.

Sequence of sessions for intervention group with techniques, discussion points, and readings

Session	Topic	Techniques	Discussion	Readings/handouts
1	Tell Me A Story 1	Stepping Stones	The use of story in medicine	“Tell Me a Story” prompts
2	Mindfulness 1	Centering exercise Stress response meditation Abdominal breaths (stress reduction meditation) STOP technique Gel in and breathe	Introduction to mindfulness and its connection to stress
3	Appreciative Practice 1	Interpersonal Circumplex Assume positive intent Positive Gossip Framing/Reframing Inquiry vs judgement	Framing and reframing; choosing a positive perspective	Tips for flourishing in the clerkship year (shared from prior clerkship students)
4	Reflective Writing 1	Reflective writing exercise	Introduction to narrative medicine and reflective writing	Reading Guide for Reflective Practice (Charon)1 “The Things They Carried”2
5	Tell Me A Story 2	Parallel charting	Revisit “Tell Me a Story” prompts; introduce “Point of View” writing	“What the Doctor Said”3 Commentary (Gianakos)4
6	Mindfulness 2	Kindness meditation	Review techniques from first mindfulness session; cultivating positive emotions
7	Appreciative Practice 2	Three good things Gratitude journal	Importance of gratitude and means to cultivate it
8	Reflective Writing 2	Reflective writing exercise	Reflective writing as a way to see from different viewpoints	“The Ship Pounding”5 “Two Poets, One Illness”6
9	Tell Me A Story 3	Parallel charting	Story from biomedical versus patient narrative perspectives
10	Mindfulness 3	Compassion meditation	Cultivating compassion towards others and self	Empathy and compassion7 GRACE model8 Compassion training9
11	Appreciative Practice 3	Reframing Assume positive intent Positive gossip Inquiry vs judgment	Using appreciative techniques to improve encounter that did not go well
12	Reflective Writing 3	Revisit Stepping Stones	Reflection on development through the course	“The Way It Is”10

¹Charon, R., Hermann, N., & Devlin, M. J. (2016). Close reading and creative writing in clinical education: teaching attention, representation, and affiliation. Acad Med, 91(3), 345–350

²O’Brien, Tim. The things they carried. New York, NY: Houghton Mifflin, 1990

³"What the Doctor Said" by Raymond Carver, from All of us: collected poems. Harvill Press. Copyright 1996 by Raymond Carver

⁴Gianakos, D. (2008). Medicine and the arts. What the Doctor Said by Raymond Carver. Commentary. Acad Med, 83(4), 420–421

⁵Donald Hall, “The Ship Pounding” from without. Houghton Mifflin. Copyright 1998 by Donald Hall

⁶Levine, C. (2010). Two poets, one illness: J Gen Intern Med. 2010 Mar;25(3):274–5. https://doi.org/10.1007/s11606-009-1220-5. Epub 2010 Jan 12

⁷Singer, T., & Klimecki, O. M. (2014). Empathy and compassion. Curr Biol, 24(18), R875-R878. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25247366

⁸Halifax, J. (2014). G.R.A.C.E. for nurses: cultivating compassion in nurse/patient interactions. Journal of Nursing Education and Practice, 4, 121–128

⁹Weng, H. Y., Fox, A. S., Shackman, A. J., Stodola, D. E., Caldwell, J. Z., Olson, M. C.,... Davidson, R. J. (2013). Compassion training alters altruism and neural responses to suffering. Psychol Sci, 24(7), 1171–1180

¹⁰William Stafford, “The Way It Is” from The way it is: new and selected poems. Graywolf Press. Copyright 1998 by William Stafford

Qualitative measures of students’ perceptions and experiences were collected using pre- and post-clerkship surveys and mentor notes from curricular sessions (Supplementary File 1). Two coders determined the themes independently and then established consensus on the final themes. The study was approved by our Institutional Review Board (IRB) and Group on Research in Medical Education.

Results

Out of 139 eligible pre-clerkship students, 29 expressed interest and were randomized, 15 to the intervention and 14 to the control group. A total of 27 students attended the first course session and completed formal consent. Two were excluded from the control group due to not attending the first session and three students dropped out during the study, leaving a total of 13 students in the intervention group and 11 in control. Students in both groups had similar age (mean 26.7 years, SD 1.6 for intervention; mean 27.1, SD 2.8 for control) and relationship status (half single, half married or partnered). The intervention group had a female predominance (73% female), while the control group was even (50% female). Most students attended 4–6 sessions for the intervention group (92%). For the control group, there was a range of participation with students attending 1–3 sessions (20%), 4–6 sessions (30%), 7–9 sessions (30%), and 10–12 sessions (20%).

Students were asked to rate the value of each aspect of the Flourish curriculum on a 5-point scale from very low to very high value. More students in the intervention than the control group rated these aspects as high or very high value: having a place to process clerkship experience (92% vs 70%), helping manage stress and difficult emotions (77% vs 60%). For other aspects, the same number of students in both intervention and control groups gave high/very high ratings: monthly group sessions (69% vs 70%), having a peer group to talk with (92% vs 90%), and faculty mentors (77% vs 80%). Figure 1 shows students’ rating of the curriculum.

Fig. 1.

Students’ ratings of aspects of the Flourish curriculum with percentage of control group vs intervention group that rated each aspect of high or very high value

For qualitative analysis of the discussion content and pre- and post-clerkship surveys, themes were generated by two coders and a final list produced by consensus, with all themes from the consensus reported. Both intervention and control groups included debriefing and discussion of student’s experiences. After each session, facilitators summarized the discussion. In both groups, discussion themes included professional development, role models, student role in clerkships, reframing negative experiences, interpersonal communication skills, physical and emotional burdens of clerkships, time management, self-care, and work-life balance. In the control group, additional themes were discrimination in healthcare, personal bias, and boundaries with patients. These discussion topics were student-generated within the debriefing of their clerkship experiences. In the intervention group, discussions contained additional topics in response to planned prompts of their curriculum: patient as a person, mindfulness, empathy, compassion, reflective writing in patient care, cultivating kindness, and appreciative practice.

In their pre-clerkship surveys, students expressed needs for sharing experiences, peer support, mentorship, and reflection which matched students’ post-clerkship impressions of the value of Flourish. Both groups noted similar highlights of the Flourish curriculum, emphasizing shared experience, peer support, mentorship, and reflection. In post-clerkship surveys, students in the intervention group were asked how they had applied techniques learned in the curriculum to their clinical work. For analysis of responses to this question, quotes were classified according to which technique of the curriculum was being discussed. Examples are shown in Table 2. Participants expressed a desire both for shorter sessions and more time for debriefing about their clinical experiences. This feedback has been taken into account in subsequent iterations of the curriculum.

Table 2.

Examples of application of Flourish techniques to intervention group students’ clinical work

Curricular technique	Example of application
Mindfulness	“I tried to employ mindfulness on a daily basis in situation where I felt negatively towards a person or situation to better understand why I was feeling a particular way and how to prevent those feelings from influencing the situation”
	“I have used mindfulness teaching and writing to allow myself the opportunity to process my clinical experiences”
	“I do try and practice mindfulness once a week to reset”
Appreciative practice	“Whenever I’m feeling down I try to list 3–5 things that I’m grateful for that day and then I do that for the next few days”
	“Gratitude – constantly remind myself how lucky I am to be here”
	“Actively trying to feel gratitude when I am angry, upset, exhausted”
	“Reframing difficult interactions with patients or housestaff made me stress less about how that reflected on me personally”
	"I try to practice reframing experiences and remembering that they happen for a reason"
	“Assuming positive intent was a nice little mantra to carry with me when I found myself complaining or listening to others complain”
Story telling/listening	“Taking time to listen and learn more about the patient (beyond their disease process)”
	“Becoming an advocate for my patient”
Reflection	“Copied ‘what the doctor said’ into my little black book that I carry with me and I reread it on occasion to remind myself the weight of our words”
	“I’ve tried to write more about positive things happening in my life”

Discussion

“Practical wisdom” is doing the right thing, at the right time, in the right way, for the right reason and can be developed through practice [26]. Framing the development of expertise around practical wisdom cultivates clinicians with habits of mind that promote informed flexibility, ongoing learning, and humility [27]. The ability of developing practical wisdom to reduce burnout is supported by evidence that students with strong abilities in emotive and cognitive empathy have lower depersonalization [28]. The transition from preclinical to clinical phases of training is a vulnerable time for students [29]. The Flourish curriculum was designed to mitigate stress among clerkship students by fostering practical wisdom. Our team’s experience provided a framework for skills-building activities to increase wisdom, using techniques of mindfulness, appreciative practice, story-telling/listening, and reflection.

Students’ highly valued multiple aspects of Flourish to address clerkship stress. In both groups, students valued the opportunity for sharing experiences, peer support, mentorship, and reflection. In the intervention group, students applied techniques from the curriculum to their clinical work to reduce stress. The monthly sessions provide both longitudinal support from a consistent group of faculty and peers and allow spaced repetition with progressive complexity. The intervention group was led by faculty with expertise in mindfulness and appreciative practice techniques, which may not be available at all institutions. By providing the materials on an accessible course website, including recordings of the exercises, we aim to help other educators overcome this potential barrier.

The main limitation of the pilot study was a small sample size, which makes it difficult to evaluate for differences in effectiveness of the curriculum between groups. Participation in the pilot was voluntary, in addition to students’ other activities, so a small size was not unexpected. Subsequently, the Flourish curriculum has been integrated with the students’ required clinical skills course, thus allowing all students to benefit from the opportunity without a time commitment outside of class responsibilities.

For cohorts after the pilot phase, the Flourish curriculum didactic and skills-building content has not been limited to the clerkship period only but distributed across their 4-year time course. The techniques of mindfulness, appreciative practice, story-telling/listening, and reflection are introduced during the pre-clinical phase. During the clerkship phase, students build on skills and work more on application and reflection. Longitudinal mentorship and peer support are provided through students’ small groups which include six students and a faculty mentor who remain together through the students’ 4-year training. In addition to inspiring changes at our own institution, we aim to disseminate the Flourish curriculum to support other educators who seek to focus on cultivating wellbeing, resilience, and wisdom in their medical students.

Supplementary Information

Below is the link to the electronic supplementary material.

Funding

This curriculum was supported by a grant from the Academy of Distinguished Educators at the University of Virginia School of Medicine.

Availability of Data and Material

The datasets generated during and/or analyzed during the current study are not publicly available to preserve participants’ privacy. Curriculum materials are available on the course website (https://sites.google.com/virginia.edu/flourish).

Code Availability

Not applicable.

Declarations

Ethics Approval

The study was approved by our Institutional Review Board (IRB) and by the Group on Research in Medical Education Committee which provides additional review of any study involving medical students at our institution.

Conflict of Interest

The authors declare no competing interests.