Medical Students, Stress and Coping Skills: Taking a Look

Welcome everyone to our session today the health system of science open Foreman series is intended to provide faculty with foundational knowledge regarding the core domains of health system science given that students are a really vital part of our system as Learners and co-creators of knowledge a deeper understanding of their well-being is certainly a benefit to an HSS focused audience assistant thinkers we must consider the wellness of all the members of our system and our team so we can better support one another and in turn keep our system healthy our presenters for today are Dr David music senior Dean for faculty Affairs at the Virginia Tech Korean School of Medicine Dr Tracy Chris associate Dean for clinical science years three and four and associate professor of Psychiatry and Behavioral Medicine at Virginia Tech Korean School of Medicine and Mariah Rudd director office of continuing professional development at Virginia Tech Carilion school of medicine and Carilion Clinic I'm going to go ahead and turn it over to our presenters well thank you very much uh we're grateful for this opportunity to present our work to date and uh we would like to start out by publicly thanking Beth Pine and giving her credit for being part of this study in the very beginning and also Dr Brock muchison Dr Murchison is the dean of assessment here at vtcsom and serves as our honest broker and does uh our data analysis so thank you to those folks so the content of today will be definitions what we know about medical students studies our focus our study Focus qualitative themes scales data and then resources for students learning objectives we have four we're going to Define burnout stress and coping in the context of medical student education identify medical students ability to cope compared to others and then identify various types of coping skills and explain our the VTC Som coping study results to date a few definitions and you probably know these but we we like to just review these we think of stress as an unpleasant feeling resulting from external demands and we certainly know that folks in medicine be it medical students faculty whomever do a really good job of also putting internal pressure on themselves as well internal demands and so all of that together creates stress coping is a cognitive and emotional attempt to deal with internal or external demands of an encountered situation and I would like to add people cope differently what's right for one is not necessarily right for another so we all have ways that we deal with our our stressors and medical students also deal with their stressors in different ways each one individually burnout we've heard that familiar Triad emotional exhaustion depersonalization decreased personal accomplishment resilience the ability to rebound from a stressful experience we hear that and we're going to hear that throughout a career resilience the resilience of a person the resilience of an organization such as Carilion Clinic that's a high reliability organization so you'll hear that term uh throughout not only in medical school but in our careers I will point out decreased personal accomplishment there are definitely studies that show if you have a good sense of personal accomplishment that your empathy scores go up when you're stressed depressed empty scores drops so that's an important issue too in terms of empathy as we think about ourselves and how we react to patients throughout our career stressors of a medical student well for some of us it's been a while since we were in medical school but we we're around medical students we teach them we help them we listen and we know that they have a tremendous amount of stress they work more hours than other students they're busy uh they're they're doing a lot they have a high workload they take call they stay in the hospital overnight they have things on weekends they uh have a high workload and they have a broadness to their studies they may be in clubs they may be in interest groups they know pathology histology pharmacology Humanities they know and study a lot of different things and then in year three they have to walk through each clerkship and they're expected to know a vast amount of information so there's a broadness to what they do they also have exam frequency and then the stress that comes with those exams the stress to pass and in some in some exams pass to even move forward in their education so exam frequency and stress high expectations some internal some external they have high expectations of themselves they've been at the top of their class in high school probably in college and now here they are in medical school competing against others little time for hobbies we hear this from our medical students we hear this in feedback they're trying to make sure that they exercise every day and that they take care of their relationships and take care of their studies and see their families and travel and do things and so they oftentimes can't figure out exactly how do I balance all that and how do I have work life balance and now there's more of a term of work life Harmony how do I do all that and then competition we work hard at this school not to cause that between students but sometimes students do feel that even with classmates or with others and so so that's a stressor as well also they're confronted with topics like death and grief and unless they've been an EMT or a nurse prior to medical school it may be that they've never been around someone who has passed away or a dead person or something like that and so so that's an issue for them they're confronted with those topics and we'll oftentimes hear from them and their feedback that on their Internal Medicine rotation or surgical rotation they saw or participated in the care of a person who passed away and we also have a a former chaplain at Korean Clinic his name is Richard Brown and Richard actually works for the school and meets with our students on one of their courtships to help them deal with topics like death and grief and get used to what they're going to see and learn to cope with the stressful things that they're going to see well what do we know from the literature well we know that up to 90 percent of medical students experience stress that's a little surprising I'm surprised that data doesn't show 100 of the data shows 90 percent we know that there's a relationship between stress and depression U.S and Canadian medical students have a high have higher levels of distress than the general population we also know that females feel greater stress than males do and that's been shown in several studies also that about a half of students have burnout and and that's an interesting statistic we know that amongst faculty or or Physicians actually across the country it's about 40 percent so about half of students have burnout and about 10 have experienced suicidal ideation so we look at this and we say wow that's that's concerning information there that's that's been shown in the literature a few other tidbits we know that their ability to cope can impact their academic success and their emotional health and that they have stress in years one and two they also have stress when they transition to that clinical setting their their feeling sometimes the Imposter syndrome here they are they're trying to be a part of a team they they feel like they're in a hierarchical structure um even if we don't create that they they sometimes can feel that students across the country feel that and here I am I'm the medical student I'm the the low personal the totem pole and again we strive not to have that that know you and our learning environment but they can feel that that that's been known for years um medical students with higher stress tend to have lower academic scores which in turn increases their stress and further impacts their academic performance so it's like well what came first you know with the chicken or the egg and so which comes first there's stress and infects their performance or they don't have a strong performance and then they feel more stressed the majority of pre-clinical and clinical students use active coping strategies for stress active coping strategies are associated with higher life satisfaction well what does that mean that means that they use coping strategies like seeking support from other people um and and and having solution focused strategies in order to work with their stressors however there are emotional coping mechanisms that students use that are associated with more distress and depression and those are things like isolating using substances um drinking doing things that they're trying to treat the emotional aspect of of what they're dealing with a few a few other things we know also the double AMC has done a study um and this was from 2014 and they they found out something interesting that when you look at students whether you're looking at their their gender their sexual orientation you're looking at underrepresented minorities you're looking at what whatever fact you're looking at including first generation college students the group of people who are most affected across or who are affected across the most number of Wellness metrics is that group that's um first generation college students and when you have that type of thing going on those students feel stressed and they also have an effect on their quality of life they may have Financial stressors they may have isolation a lack of support so so that was just an interesting finding by the double AMC back in 2014. I mentioned Canadian medical students earlier a study done on Canadian medical students showed that medical students are not more resilient nor are medical students better equipped with coping skills than peers in the population thank you Dr Chris appreciate that very much and as we continue with our presentation just to provide a tiny little bit more uh context uh we note the items on this slide uh as background for our study so there have been lots of studies as Dr Chris mentioned uh that have addressed the prevalence of burnout and depression among U.S medical students one of the references we've given you is for a recent study from academic medicine in 2019 which again confirmed that this particular group of of students is at a high experience is a high prevalence of burnout and depression in fact they're nearly six times more likely to discontinue their education when compared to students from other professional programs in their same age cohort and then more recently some of you probably know that we've done two wide scale surveys at our academic Health Center here looking at burnout we use the maslak burnout inventory which is the gold standard for measurement of being at risk for Burnout and as you can see there in the 2016 study we included medical students and found that 48 percent of them were at risk for Burnout and then when we repeated the study in 2019 unfortunately we found that 60 percent of our students were at risk for Burnout we have not done the study since 2019 but this is well established in the literature it's also been suggested that um there is a a relationship between burnout and distress and patient care in fact it has been stated in numerous studies that that the the stress and burnout experience by clinicians could have a negative impact on patient care I don't know that this the literature is uh extremely conclusive on this but it has been widely looked at in a number of different studies and it's summarized nicely in this 2018 statement from Jama their Charter on physician well-being where they talk about physician well-being and related issues such as depression and dissatisfaction overall with their career being associated with sub-optimal patient care as well as things like lower patient satisfaction decreased access to care and increasing health care costs so all of this again is providing good context and background for our study which we will turn to now Dr Chris I'll turn it back over to you and thanks Dr music uh he just he's right we continue to work on this in fact we say we're going to be in the nursing home by the time we write this paper we hope that our medical students take care of us over the local nursing home um so wanting to go over some resources that are available um and these are both for academic um and for for uh academic and for for wellness um so we have the office of academic counseling and Enrichment Services and um we have a peer educator program there and what that means is that we have some students who are upperclassmen upper class women however you want to say that who some students who are available to tutor uh students particularly in the the basic science part of their education so we have students helping other students uh faculty student mentoring program and what that means is we have a Cadre of Faculty who have come forward and said hey I had challenges in medical school I had some issues in medical school I dealt with and they're willing to help students who are having some some specific challenges while they're in medical school so that that's a good program for our students we have step prep resources the school here provides practice exams and a year subscription to your world questions for sep exams and we also have an alumnus from our first year class class of 2014 who has taken a lead in helping our students in their step preparation we also have uh accommodations through the VT services for students with disabilities and Kerry canopt here on our campus and she works with students who have issues maybe they have a hearing issue or some sort of accommodation is needed and so she works uh with them and and with the main campus to help work out these particular issues uh VTC Som as as well as the main campus VT uh recognize really the unique stresses of students particularly students who are health profession students and have increased the resources and access to resources you've probably heard of the cook Counseling Center which is on the main campus and they have uh therapists and psychiatrists available to help out with students and then also there's a fairly new um uh fairly new access called timely care and it's appropriately named there is access to the timely Care Resource for students 24 7 365. they can call and seek counseling and so this is really valuable for students to have this available to to be used whenever they they need it literally whenever they need it also there's an email that comes out usually on Fridays called Wellness weekly and if you haven't seen this in your inbox or deleted it or whatever didn't open it I encourage you to open it up it's a very long email it has all kinds of resources it has recipes that are healthy recipes it has events such as game nights or hikes or whatever is going on that would afford uh folks students the opportunity to participate and not be isolated and so Wellness weekly is just a great resource for uh for people to look at and and have options of things to do uh that affect their Wellness also there's a link called other Wellness Resources at the school here we also have Stu something called our student Commons which we have it's also an lcme requirement and they can uh gather there there's a piano there's some games and and it's a large space on the second floor that's for them and used by them also we have a wellness room here at the school where students can go into a a room and and meditate and sit sit and meditate and have some free time to themselves to think and meditate uh also Center for inclusion which is uh located in uh in Riverside three I'm sorry Riverside one and there's an area there for students and then we have a gym here at the school um that students can sign up for and use there's lots of exercise equipment as well as a television in there if they want to exercise while they watch whatever there's a gem on the second floor um another thing is that they have a membership to carillion Wellness also called formerly the rack the Roanoke athletic center but they have a membership to Korean wellness and we know that they they use that quite a bit and participate in various Sports there um also there's Wellness programming and partnering with hokey wellness and fbri some examples of hokey Wellness are the folks from the main campus will come down and they'll offer um they'll offer treats or massages or things uh for uh for the people on this campus so those are are good programs as well foreign in summary we wanted to point out some some high points of what what can we uh learn from this study well student stress levels vary considerably by year but are generally elevated really no surprise their medical school is stressful but sometimes they feel overwhelmed students are self-critical we know the Imposter syndrome is real feeling like they're they're not capable or not deserving or not able to do they really shouldn't be there why am I here students could improve on seeking help from others um they're socialized to be tough uh but they they can seek help and they could improve in doing so and we're we're here to do that and there are lots of resources available um the data are fairly consistent across the two classes for which we have full data and the VTC Som has many resources available in support of our students and so they're there to be used and and I know through student affairs particularly they're encouraged to use them I I do want to ask I know that Dr Knight is tied up in clinic and not available for comments I I just heard from him if if Emily Holt Forest is available and in the audience I I can't see if she's here but if she is available and wants to make any comment uh and she's intimately involved with a lot of this I'd like to see if she's available hi everybody yep I'm here uh I think you covered it really well Tracy the only thing I would mention related to the peer educator program is students have the option to um there's three different entry points for it there's group sessions there's walk-in hours and there's one-on-one um pairings that we can do with the upper level students so and it's a very active program there's 30 peer Educators currently um employed by BTC but otherwise you covered everything really well but if folks have questions about all of the resources you just listed I'm more than happy to help answer them well and I would also like to point out that Dr Holt Forest is the author of the aforementioned weekly Wellness weekly that comes out the most Thursdays or Fridays and it is extraordinarily well done and uh so if you're not getting that and would like to do that uh I'm sure she would uh like to hear from you but it is a really good resource it talks about well-being and wellness across a number of different Realms so encourage you to take a look at that more than happy to add to the list of folks who use it there's 1200 on there already so you'll be in very good company awesome here's our references and um I think that at this point we want to say plenty of time for just reactions and or questions from folks in attendance today so uh Sarah yeah thanks everyone and thank you to our presenters for providing us with this fantastic information um so we do have some questions and comments in the chat I'm going to read through those uh and then if other folks have questions or want to uh comment or add to questions that we read out please feel free to unmute yourself and do so um Dr Ben Coley mentioned or had a question um could this reflect use of SSRI ssnri and other therapeutic drugs in reference to your slide talking about alcohol or other drugs that may be used um yeah I can I can take that one um thanks uh thanks Dr bankoli for your question um it's interesting the term drugs is used also now for instead of medications I I know in my own practice I try to use medications instead of drugs when I'm talking with patients um I I think because of the context in which it was asked where it said drugs I'm sorry alcohol or other drugs I I I'm gonna think that they understood that that was an illicit substance or a substance that's not considered a healthy substance I'm saying illicit because marijuana's not illegal in Virginia but I I I think they probably understood the context that it was meant to mean something that that's uh elicit or not healthy or not prescribed by someone Dr Pauley has a question uh in your Reflections do you believe students who completed the surveys are more or less likely to have felt stress than those who did not complete um that's a great question heart hard hard to say really I mean um yeah I'm not sure how I'm not sure how we could tell just to be honest um we looked at our Baseline we did not present the Baseline data today and Tracy I'm trying to remember if there was a market difference between our Baseline data and what we found in these two classes um we did I think the Baseline survey we had better participation as I recall but that might be one way to get a get a little bit of insight into is look at the Baseline group but I'm not sure yeah it's hard to say um and and thanks for that question it's hard to say um I I think if we had higher numbers we would have just a little better layout but it's it's really hard to say whether you know you know if you think of an analogy to that the learning environment or or the people that are given the answers or or the people who are filling out evals that's all the students so we feel like we give a broad look but this we didn't have all the students respond so I think it's just tough to say and then we have a number of comments and I'll read through those for everyone um being critical of self could be a functional characteristic of high Achievers um it would be interesting to see stress among faculty um in the mindfulness elective M1 and M2 students we learn about self-compassion including practices that support reduced self-judgment and then there was a follow-up to that comment um I second what Lori it was Laurie Seidel that made the initial comment there um I said what Laurie said the longitudinal electives offer students the opportunity to build community and support Networks and then there was one other question um have there been situations where a student has taken a leave of absence um the answer to that last question is um students are allowed to take a leave of absence and over the course of the school since 2000 uh and 10 when the first class came in the answer of that is yes and I'm so glad I'm so glad for Dr sidel's comment I'm glad Lori if you're still here I'm glad you're here and um the the contribution that the longitudinal elective makes uh and the emphasis on mindfulness I think could make a a big difference in this area so appreciate everything that you're doing with our students and for our students yeah I appreciate all the comments uh that have that have come in if there are additional questions or comments uh feel free to either put those in the chat or if you would prefer to unmute yourself um and provide those please feel free to do so uh price um really very very interesting to see what our students are doing uh Melanie sort of um alluded to the fact that most high-functioning people um distressible jobs are self-critical and I I I foreign agree and and I don't want us to dwell on this longer than we need to but I wondered if there was a difference between um imposter syndrome and analyzing yourself critically and working out that you are not for example you know the best person to leave this project for example or you're not you know top of the class I mean that doesn't mean that you're not worthy but you know I sort of wonder if there's a way for us to differentiate between both situations yeah I think that's I'm sorry go ahead no no that was exactly my point that I'm not sure the way the question was asked it differentiates well so I'm not sure those answers reflect true imposter syndrome and not instead an ability to self-analyze and learn from mistakes well yeah and thanks thanks Dr prusikowski you know I I think a way to think of it is everyone that has imposter syndrome would be self-critical right but not everyone who's self-critical has impostor syndrome um so I I agree it's inherent in the nature of people who are high Achievers I saw that part in Melanie's comment um High Achievers um and and those are folks in other schools not just medical schools but they're they're going to um have that in that internal pressure and place that on themselves um and you know part of that is what can we do to to help that and I and I think one of the things that we can continue to do and and maybe do even better is when we're with them for instance is is set expectations for them and and set goals with them expectations for their days and students talk a lot about that in their feedback and I'm speaking more to years three and four here because that's what I'm more familiar with um but you know to help them feel good about what they're they're doing um and set expectations and that way they know what they're supposed to do each day and they'll know that they have accomplished that so that's something that we hear a lot from them is we want to know what you want us to do what are the expectations and then they feel like they can reach that so I think that would help people to know that they have achieved what their supposed to do uh even on a on a daily basis on a courtship basis yeah I mean I I think you raise a really good point uh Dr Bank calling drkowski about this particular item now I would point out if you look at the instrument itself uh it is asking you to answer that question in the context of how you deal with or how you cope with stress in your life so in theory when you're when you're when you're filling out the survey you're answering that and the other questions in terms of is this a way that I use to cope with stress in my life and I think the idea would be that being self-critical is not an effective way to deal with with stress in your life um so but but it's a very good point and and a fine point between you know appropriate uh appropriate uh um ability to to be self-critical and self-reflective and and grow uh sort of intrinsically versus you know doing that a little too much and becoming you know falling more into the area of imposter syndrome and I don't know where exactly that line is but it's a very good point Dr Dain has a question uh the PSS was meant to be scored quantitatively has the mean of that scale changed within class over the years of the study for like in force for example or from year to year with an entry class so M1 through M4 for either of the two years for which you have data across those four years and and I you know an earlier version of when we were looking at the data had the auto means in it and we decided to go with the percentages so I don't have the item means in front of me so that's a very good question that we can go back and look in the data but I don't know the answer to that right now Frank yeah and I I don't either and I'm gonna add just a comment to that when you look through the literature about stress in medical students um I know one of the papers I looked at talked about the importance of having qualitative data as well as your quantitative data and so I one thing and we can go back and look at that thanks for that comment one thing I like about what we're doing in this study is we are asking we do have the the free comments um the expression for comments and so hopefully that will that will help us as well and and we're really looking forward to hearing about what those comments are as we see the change in step one being pass fail and step two being the scored item when we and I'm getting a little off topic here Frank but in talking about the qualitative piece and the quantitative piece when we started we didn't know that step one was going to go to pass fail so we have a set of data now pre that change and now a set of data posts that change and so we're we're looking forward to seeing what we get and how those numbers are going to compare um and and certainly having quantitative and qualitative data I think will help us to to layer that out [Music] same thing with covet you know we have data from students who were unimpacted unaffected by covet and then we'll have some data for students who obviously were impacted by it so it'd be interesting to see if there are any differences there too I see Cindy's question um the answer is that the day this data has not been directly shared with them um so we don't have a reaction from them I have a question for you um have any of these uh questions uh either an individual response or as a collective response across these different um questions that you all ask on the survey are we using any of that data to be able to do some intervention with students that are answering those those questions in certain ways in terms of you know like an early intervention that we might be able to implement to better support students with stress and with their overall well-being foreign well it's anonymized so we we wouldn't know who I mean our our honest broker would obviously be able to figure that out but we don't you know we've not we don't know who it is um so so that you know we don't know exactly who it is I I want to comment back on what how I answered Cindy's question the the data sets haven't been shown to the students and the qualitative themes we have had posters here in the research days and we did have a poster at the Double AMC in 2018 um regard I think it was 2018 uh regarding our uh some initial findings so we've we've shared it in that way but we've not shared all of the uh all of the details and I think to your question Sarah um and Dr Chris and Dr music have been involved in this project longer than I have but I think one of the intentions you know once we do look at you know finish collecting data is to try to Target um interventions on a more of a global level like related to the stressors that they identify and when they identify them not necessarily on like the individual level but also the potential to look at our data um with different demographic um filters on it you know looking at you know grades or uh uh background things of that nature and trying to also um you know maybe Target those groups if there are big stressors or coping mechanisms that we could identify to share with them um so I don't think that there's interventions in the individual level but maybe on the more you know Medical School level that might be tailored based on the findings um but as we saw there are lots of great resources out there already it's just getting I think the students connected with them yeah that was that was going to be my comment I think that many of the themes that we found or many of the things that we've learned are familiar and so for example we already have a number of different support systems in place for students around certain key areas such as exam time or transition to clerkship or when they're applying for their uh especially you know their residency match trying to figure out which career path uh specific career path they want to take you know there's there's lots of programming already in place and so when we saw these themes we thought well you know we've we're seeing some familiar things here but thankfully we do have some things in place already that are designed to support those students around some of those big issues yeah I'm going to throw in a comment here a little off topic but to um uh back to that the question from Sarah we survey the students quite a lot in fact we worry about survey itis so in years one and two and three and four and you know with our learning I can speak more um thoroughly to years three and four when we survey our students in the learning environment that also that data is anonymized and we don't break break that code to find out who said what be it positive or negative however the one reason that we would ever break that would be if we had a concern of safety of a student or safety uh to others otherwise it's all anonymized but but we we do hear a lot from our students who have a lot of contact that would be the only circumstance by which we would ever break break that data it looks like we do have one more question uh before our hour is up and thank you for um adding uh to the question that I that I had asked um those clarifying bits of information um are you planning to look to see if the support strategies implemented have resulted in students taking less leave of absence in relationship to stress and that was Dr Van Coley asking that question it's a great idea I mean my impression I don't I'm not as familiar with this as maybe Dr Holt or um Dr Chris but my impression is that we we have had so few students uh take a leave of absence that we might not see a big impact but I could be wrong about that uh Emily any comments I have lots of thoughts I think that um we have not I have not tracked a number of student leaves relative to the implementation of various resources but a month the mind that if a student is in a position where they are not performing optimally and they find that for their personal Wellness they need time away from medical school um and then return that they need support in that way um that said if a student is struggling with the circumstance and they think that with appropriate measures put in place they can perform at their best in this space and continue forward then again they should be supported so it's a very nuanced thing depending on a given student circumstance and so I think we have to be nimble and our ability to help them I want to thank everyone for their questions and for attending today and uh to the teach Academy team for uh setting everything up for us and and and putting this all all together for us and just appreciate so much that people are interested in this uh in the in the wellness of of our students and we're interested in the wellness of Faculty as well I saw that comment in the in the in the chat um and certainly the wellness of all it takes a village and takes a team and uh we're just so appreciative of of everyone attending today and and uh thinking about this issue moving forward thank you both so much for all of your contributions uh well all of you um I know Mariah was involved uh Aubry was involved as well so uh thank you all so much we will make sure and have our resources posted online if you would like to engage in looking at those further and we'll also have a recording of this session up on our our webpage very soon thanks everyone for being here today appreciate you and thanks again to our presenters couldn't do it without you thank you thank you.