Stanford Medical School Offers New Course on Finding Meaning and Balance in Medicine

A new course at Stanford’s Medical School, “Meaning in Medicine: Staying Connected to What Matters Most,” seeks to “immunize” students from future physician burnout by inspiring them to explore and connect with their personal motivations for entering medicine. 

Examples of weekly topics include: What Wellness Means to You, Spirituality and Faith in Medical Care, and Grief and Suffering. And mini lectures cover topics such as how to manage conversations with patients facing serious illness, distinguishing values from goals and preferences, and finding mentors. Each of the weekly sessions also leave space for open dialogue where students can entertain questions of faith, empathy, and what it means to care for a patient while also caring for themselves and their own wellbeing.

The course, developed by Henry Bair, a resident physician and Stanford Med alum, and Tyler Johnson, an oncologist at Stanford Health Care, was inspired by a podcast the two host together. The podcast, A Doctor’s Art, explores themes that seek to reconnect the practice of medicine to its mission, which all too often gets lost in the day-to-day burdens of administration, electronic health records, staffing, and corporatization. 

The response to the course has been overwhelming. Nearly a quarter of Stanford’s pre-clinical students have expressed an interest in taking the course before and just after it opened. And, at the conclusion of the course, every student who participated said that they would recommend the course to others. 

“In medicine, where science converges with art, suffering meets solace, and the human spirit confronts the limits of the body, it is increasingly easy to lose sight of our purpose and of ourselves. But our students have shown an eagerness to cherish their personal, intellectual, emotional, and spiritual motives for entering the profession; this eagerness, in turn, instills the courage and wisdom to seek balance and meaning. All medical trainees ought to be afforded the opportunity to do so, for this, ultimately, is just about the most effective way to individually prepare future clinicians against burnout,” Bair and Johnson wrote in an article for MedPage Today.

State Medical Boards Drop Broad Mental Health and Substance Abuse Questions from Licensure Applications

In a win for physician mental health, 21 states have opted to remove broad mental health or substance abuse questions from medical licensure applications, according to data gathered by the Dr. Lorna Breen Heroes Foundation.

Among these 21 states, the licensing application language is consistent with one of three options: it asks one question that addresses all mental and physical health conditions (consistent with the Federation of State Medical Board’s (FSMB) recommended language), does not ask about applicant health at all, or implements an attestation model with supportive language around mental health and “safe haven” non-reporting options for physicians who are receiving care.

The Dr. Lorna Breen Heroes Foundation, whose namesake died by suicide after experiencing severe burnout while working in emergency medicine during the early period of the covid pandemic in NYC, advocates for better mental health practices for physicians and policies that reduce physician burnout. Two components of the Foundation’s mission include working with state medical boards to remove mental health and substance abuse questions from credentialing applications, and increasing transparency around states’ policies.

The mission is personal for the foundation. Shortly before Dr. Breen’s death, she had shared her reluctance to seek help with family members. She feared that she would no longer be able to practice medicine if she did so. And, Dr. Breen’s hesitance is reflective of the physician population. According to Medscape’s 2023 Physician Burnout & Depression Report, 40 percent of physicians said that they would not seek help for burnout or depression out of fear of repercussions from their employer or state medical board.

The Foundation is not alone in advocating for changes that support clinician wellbeing. Other organizations within the medical community have also voiced support for reform. In 2020, over 40 professional medical organizations, including the AMA, the American Academy of Family Physicians and the American Psychiatric Association, signed a joint statement in support of changing disclosure practices about mental health. And, the AMA and FSMB recommendations support questions that focus only on current impairments rather than historical struggles.

According to the FSMB, "Application questions must focus only on current impairment and not on illness, diagnosis, or previous treatment in order to be compliant with the Americans with Disabilities Act." Similarly, the AMA recommends that any questions required of physicians be restricted to “conditions that currently impair the clinician’s ability to perform their job." And the Joint Commission, an organization that accredits hospitals, removed the requirement for hospitals to question applicants on their mental health history. “We strongly encourage organizations to not ask about past history of mental health conditions or treatment," they wrote in a statement. "It is critical that we ensure health care workers can feel free to access mental health resources."

Stay up-to-date on state policy using the Dr. Lorna Breen Heroes Foundation tracker, here.

New Physicians that Train in Surgery or Identify as a Sexual Minority are More Likely to Struggle with Mental Health During Intern Year

The trials of residency, particularly in the first year after completing medical school, are well documented. First year residents or interns work long and demanding hours in a high stress environment, and do so on little and irregular sleep. And two new studies out of the University of Michigan, which used data from the Michigan Neuroscience Institute’s Intern Health Study, show that two groups are at higher risk for developing negative mental health outcomes during this time: surgical trainees and those who identify as a sexual minority (lesbian, gay, bisexual, or other non-heterosexual).

The first study led by Tasha Hughes, MD, MPH, and an assistant professor in the University of Michigan Department of Surgery, explored changes in surgical residents’ mental health during the intern year, and also looked at how surgical residents’ experiences compare to those of other (non-surgical) residents. 

Hughes and her team found that, initially, surgical interns enter the program with lower rates of existing depression symptoms than a similar age cohort within the general population. However, after the intern year, almost one-third (32 percent) of interns screened positive for depression, based on their scores from at least one mood survey. 

Among the surgical interns, some demographic groups were more likely to develop depression—females, sexual minorities, singles (those with no partner), those working the most hours on average, and those with a history of negative childhood experiences. However, even after adjusting for these demographic factors, surgical interns were more likely than other interns to develop new-onset depression, except for when work hours were taken into account. Additionally, among those who screened positive for depression, 64 percent continued to report signs of depression on a later survey. 

Perhaps, equally worrisome, was that many of the surgical interns did not seek assistance. Just 26 percent of those whose scores were consistent with depression sought mental health care during their intern year. Hughes explains the importance of the findings for promoting a healthier learning environment. “Surgical training, especially in the United States, can be a period of intense stress, which we find is linked to new onset of depression,” said Hughes. “These findings suggest a need for surgical program directors, leaders, and health systems to continue to find ways to mitigate the effects of surgical training, normalize help-seeking, make mental health support easily available, and pay special attention to those with characteristics that might put them at increased risk.”

The second study, led by Tejal Patel, a student in her senior year at the University of Michigan, looked specifically at interns who started training in 2016 through 2018 and who identified as lesbian, gay, bisexual, or other non-heterosexual. 

At the commencement of the intern year, the sexual minority group’s depression scores were higher than those of the heterosexual group. However, rather than remaining consistent over time, the study found that the gap increased throughout the year with larger differences in mental health occurring in the second half of the year. “These results indicate that interns who are part of sexual minority groups may experience unique workplace stressors leading to a widening disparity in mental health,” said Patel. 

Narrative Medicine Helps Physicians Gain Empathy, Make Connections, and Accept Difficult Experiences

Creative writing may not be the first course that comes to mind when you think about a pre-med or medical school curriculum. But, writing—along with other arts and humanities courses—can play a vital role in preparing medical students for life as a physician. 

Rita Charon, along with a multidisciplinary group of scholars, founded the discipline of narrative medicine in 2003, in response to the increasingly bureaucratic direction of medical care. Narrative medicine’s goal is to recenter physicians on the humanity of their patients by providing tools to allow physicians to contextualize patients outside of the hospital setting and uncover ways to connect by considering a patient’s pain, stories, life, and loved ones. Charon describes narrative medicine as a “...commitment to understanding patients’ lives, caring for the caregivers, and giving voice to the suffering.” 

The benefits of incorporating narrative medicine, or the study of arts and humanities into the medical curriculum are clear. In 2010, Columbia Medical Students were required to take a half-semester arts and humanities course in narrative medicine, and these students were then interviewed in focus groups about the experience. The findings, published in the Journal of Academic Medicine in 2014, were summarized: “Students’ comments articulated the known features of narrative medicine—attention, representation, and affiliation—and endorsed all three as being valuable to professional identity development. They spoke of the salience of their work in narrative medicine to medicine and medical education and its dividends of critical thinking, reflection, and pleasure.” 

In addition to promoting empathy and connection, Pulitzer Prize-winning journalist Michael Vitez, Director of Narrative Medicine at Temple University’s School of Medicine, spoke to the value that writing can provide in helping students work through complex and painful experiences. He described a medical student who wrote a poem after a difficult day in her psychiatric rotation. “It helped her process her emotions and turn a really bad day into something valuable,” he said. 

Narrative medicine can also bolster physicians who are struggling with symptoms of burnout. “No one was talking about clinician burnout at that time. But, as narrative medicine programs began to spread across the country, some physicians trained in its principles began to see how it can protect clinicians from feeling a sense of depersonalization and other symptoms of burnout,” Dr. Charon told Neurology Today. In the same article, Sneha Mantri, MD, MS, and Assistant Professor of Neurology at Duke University School of Medicine, described how her struggle caring for critically ill patients during residency led her to seek an MS in Narrative Medicine. In her view, the degree gave her the tools to return to medical practice and deal with the “burnout-inducing frustration of treating chronically ill patients with difficult-to-manage symptoms” and replace it with empathy for the patient’s perspective and the reminder “that knowing medical facts is just one part of caring for a patient.”

If you are a premedical or medical student with an interest in the arts and humanities, pursue it! It will likely play an invaluable role in preparing you to analyze, contextualize, and show up for patients with empathy and understanding. And as you prepare your applications for medical school, residency, or fellowship, be sure to highlight the skills that you have gained through previous humanities coursework and experiences, and the perspectives you have gained. 

Examples of narrative medical texts here: 

“How to Tell a Mother Her Child Is Dead,” Naomi Rosenberg, MD, New York Times

“What We Talk About When We Talk About the Code,” Lilli Schussler, JAMA Cardiology

Related blogs:

Covid Crisis Brings Attention to the Need for Humanities in Medical School Curriculum

Physicians Less Likely to Feel Happy Outside of Work

The covid-19 pandemic has caused significant stress to medical caregivers. And it extends beyond their professional lives. Medscape’s 2022 Physician Lifestyle and Happiness report provides insight into physicians’ habits, downtime, work-life balance, and relationships, and includes responses from more than 10,000 U.S. physicians representing almost 30 specialties. 

When asked about their life prior to the pandemic, eight in ten physicians reported that they were very (40 percent) or somewhat (41 percent) happy outside of work. Now, fewer than six in ten say that they are happy outside of work. Just 24 percent say they are very happy and 35 percent are somewhat happy. And, notably, just one-third of respondents feel that they have enough time (always or usually) to spend on their own health and wellness, with men more likely to have time (38 percent) than women (27 percent). Just under half of physicians, 44 percent, “sometimes” have the time to focus on their own wellbeing.

To maintain their happiness and mental health, most physicians say that they spend time with family/friends (68 percent), engage in activities/enjoyable hobbies (66 percent), and exercise (63 percent). Just under half say they focus on getting enough sleep (49 percent) and eating healthy (44 percent). The majority of physicians do say that they exercise regularly—34 percent exercise two to three times a week and 33 percent exercise four or more times a week.  When asked about weight, about one-third say that they are working to maintain their current weight (30 percent), while just over half are looking to lose weight (51 percent). 

Over half of physicians, 55 percent, say that they would take a salary reduction to have a better work-life balance, an increase of eight percentage points from 47 percent a year ago. Female physicians are more likely to express a willingness to take a pay cut for improved work-life balance, with 60 percent saying they would give up salary for balance compared to 53 percent of men. In terms of time away from work, most physicians take between one and four weeks of vacation; 30 percent take one to two weeks and 40 percent take three to four weeks. These numbers are similar to last year’s report. 

Most physicians are married or in a committed relationship (89 percent of men, 75 percent of women). And the majority, 82 percent, describe their marriage as very good or good, which is similar to last year. While the percentages are high across specialties, 91 percent of otolaryngologists and immunologists describe their unions as good or very good, while critical care (76 percent) and plastic surgery (75 percent) fall on the lower side. Forty-three percent of physicians are married to another physician or healthcare worker, though the majority (56 percent) are married to a partner outside of medicine. Among physicians who are parents, 35 percent feel conflicted between work and family demands. Almost half of female physicians, 48 percent, are conflicted or very conflicted, whereas 29 percent of their male counterparts report feeling the same. About 30 percent of both men and women physicians report feeling somewhat conflicted.

Physician wellbeing is critical for preventing burnout, particularly in the aftermath of the pandemic, as burnout levels remain high and directly impact the quality of care provided to patients. The AMA has taken on the topic of physician burnout to spur advocacy, research, and provide tactical resources to improve wellbeing, which prospective and current medical students may wish to review. Medical students should strive to integrate wellbeing practices into their lifestyles as early as possible—healthy dietary and movement habits, outlets for stress, and strong relationships that may help them to withstand the stress of medical school and patient care.