Medical student wellness in Canada: time for a national curriculum framework.

There is substantial evidence showing that medical student wellness is a worsening problem in Canada. It is apparent that medical students' wellness deteriorates throughout their training. Medical schools and their governing bodies are responding by integrating wellness into competency frameworks and accreditation standards through a combination of system- and individual-level approaches. System-level strategies that consider how policies, medical culture, and the "hidden curriculum" impact student wellness, are essential for reducing burnout prevalence and achieving optimal wellness outcomes. Individual-level initiatives such as wellness programming are widespread and more commonly used. These are often didactic, placing the onus on the student without addressing the learning environment. Despite significant progress, there is little programming consistency across schools or training levels. There is no wellness curriculum framework for Canadian undergraduate medical education that aligns with residency competencies. Creating such a framework would help align individual- and system-level initiatives and smooth the transition from medical school to residency. The framework would organize goals within relevant wellness domains, allow for local adaptability, consider basic learner needs, and be learner-informed. Physicians whose wellness has been supported throughout their training will positively contribute to the quality of patient care, work environments, and in sustaining a healthy Canadian population.

Introduction

Physician and learner wellness is an alarming problem within the Canadian medical community. There is substantial evidence showing that this workforce has deteriorating wellness.[1]-[4] Canadian medical students reported burnout and suicidal ideation rates of 37% and 6%, respectively in 2016.[5] Furthermore, in 2019, there was an increased prevalence of mood disorders, anxiety disorders, suicidal ideation, and psychological distress in Canadian medical students relative to age-matched controls from the general population.[4] Action is needed to improve physicians' wellness and the work environment to enhance patient care, reduce costs, and sustain a healthy population.[6] These efforts must begin with medical trainees to ensure that they can thrive at all stages of their careers.[7]–[9]

The landscape of wellness in Canadian medical education

To prevent further deterioration, Canadian national organizations, accreditation bodies, and provincial and territorial medical associations have collectively integrated wellness into standards, guiding recommendations, competencies, and policies.[10]-[13] These standards have prompted medical faculties across Canada to incorporate wellness into their undergraduate programming.[7],[14]-[16] For example, McGill University’s longitudinal wellness curriculum utilizes lectures, small group sessions, and workshops to enhance learner resilience and mental health.[16] Notwithstanding these programming efforts, the authors have experienced inconsistent approaches to wellness promotion across Canada, varying from periodic student-led initiatives to full-fledged curricula.[16]

With no consistent scale or singular definition of “wellness” for medical students, it is unclear which interventions have had the most significant impact.[17] As a result, little guidance is available for those looking to establish an evidence-based medical school wellness curriculum. To the best of our knowledge, there is no standardized wellness curriculum framework for Canadian undergraduate medical education that aligns with existing residency wellness competencies.

What makes a medical student unwell?

The factors that promote wellness or lead to burnout can be categorized into individual- and system-level factors. Progress toward reducing burnout prevalence and achieving optimal wellness outcomes will likely come from cohesive strategies targeting both levels.[14],[18],[19]

Individual-level factors

Intrinsic factors, such as personality and learned dispositions, allow students to thrive (or not) throughout medical school by impacting wellness at the individual level. Personality characteristics including introversion, antagonism, and neuroticism are linked to higher burnout rates in clerks.[20] Self-identification with descriptors including “type A,” “workaholic,” and “control-freak” were associated with adverse wellness outcomes.[21]

Promising results from targeted interventions at the individual level have been reported within the domains of physical health (e.g. diet), social relationships (e.g. close relationships), and mental health (e.g. non-medical cultural and recreational interests).[22],[23] Resilience, one’s ability to adapt to conditions of adversity or recover quicky from demanding experiences, is also a protective individual-level characteristic.[23] Positive results have emerged from the Simulated Training for Resilience in Various Environments resiliency training, suggesting arousal management, including controlled breathing and visualization, can promote medical students’ wellness.[24]

System-level factors

Students deal with system-level factors within the working and learning environments, throughout their training.[10],[25] Self-Determination Theory posits that the overarching qualities of a health-promoting learning environment are tied to students’ motivation: the three basic psychological needs of autonomy, competence, and relatedness.[26]

Unfortunately, the frustration of these needs occurs within the Canadian medical education system, wherein students experience rigid scheduling and a limited sense of control that challenges autonomy.[27] High expectations for academic performance combined with a perfectionist culture can hinder perceived competence.[10],[28] Other cultural elements, including mistreatment and a reluctance to admit vulnerability, can impede relatedness.[29],[30] Underlying these challenges is the “hidden curriculum”: the implicit and informal learning in medicine that perpetuates norms such as dehumanization and hidden assessments.[31]

Evidence-based system-level strategies for health-promoting learning environments include flexible scheduling and accommodations policies fostering learner autonomy; pass-fail grading and effective feedback-delivery to increase perceived competence; and transparency surrounding mistreatment and the hidden curriculum to improve relatedness.[18],[32]-[34]

What is next? Towards a pedagogy of wellness in undergraduate medical education

We reviewed the negative effects of medical education on students’ wellness and the patchwork of existing local interventions. The status quo places future physicians and patients at risk of poor outcomes.[35] Though some concerted efforts to improve learner wellness are being made, Canadian stakeholders – students, faculty, and standards-setters – remain fragmented by membership and geography. Furthermore, wellness initiatives compete for human and monetary resources and dedicated curriculum time. Nonetheless, these barriers are being overcome by newly available funding, and the incorporation of wellness into policy and institutional norms.[36]

A wellness curriculum framework for Canadian undergraduate medical education is necessary to organize and guide wellness content targeting individual-level skill development and will be an essential complement to current national standards. It should integrate the wellness domains – as defined by recognized standard-setting organizations such as the World Health Organization[37] – that are the most pertinent to medical students. Such a framework should complement existing curricula and student-driven initiatives locally, while promoting consistent delivery and accountability in alignment with existing national wellness competencies.[11],[12] A skills-based council should develop this framework with diverse representation from the learner, educator, and standards-setting bodies, using a multi-pronged approach to assess contextual needs. After development, the framework should be piloted in a phased, iterative fashion adapted to local curricula to identify barriers to implementation, areas for improvement, and learner wellness outcomes. Success indicators should be assessed and rely on several factors, including outcomes from wellness scales validated in the medical learner population, perceived impact of the framework, and degree of implementation.

Wellness initiatives derived from the framework should comply with the following evidence-based principles. First, they should be informed by the learners who experience them.[38] Second, attempts to support student wellness should begin by considering their basic psychological needs.[30] Third, a successful shift towards a well-physician workforce requires concerted individual- and system-level efforts.[18],[19] Fourth, wellness assessments using validated metrics should guide curriculum evaluation and development over time.

It is time to develop a standardized framework to guide the implementation of skills-based wellness curricula across Canadian medical schools. Such a framework will facilitate the alignment between the individual- and system-level, and help achieve sustainable and improved wellness outcomes for medical students. Physicians whose wellness needs are supported throughout their training will positively contribute to the quality of patient care, work environments, and a healthy Canadian population.