1. No category

Promoting Healthy Behaviors:
Linking Student Health to
Prevention
Funded by The Robert Wood Johnson Foundation, 20022003.
Research conducted by American Medical Student
Association/Foundation in collaboration with Emory
University “Healthy Doc-Healthy Patient” Project.
Prepared by Lauren Oshman, MD, MPH
American Medical Student Association/Foundation, 2003.
1
Purpose
Examine how the practice of future primary
care physicians is affected by prevention
curricula taught in medical schools and your
schools’ emphasis on medical student wellbeing.
Learn how to foster collaboration of medical
schools and student leadership on local and
national level to facilitate adoption of
exemplary programs to strengthen health
promotion and prevention curricula.
2
Student Well Being Programs
What the research
shows
3
Are We Well in Medical School?

Students’ health falters in medical school.1
–
–


Depression is related to poorer health habits.1
“Maladaptive behaviors” eventually form.2
–

1.
4
2.
3.
4.
Alcohol consumption increases.
Socialization and exercise decrease.
Going to school when sick, self-prescribing and
underuse of medical care.
Residency can further erode wellness.3,4
Ball S, Bax A. Self-care in Medical Education: Effectiveness of Health-habits Interventions for First-year Medical Students. Acad Med 2002; 77(9):
911-917.
Baldwin PJ. Young doctors’ health—II. Health and health behavior. Social Science & Medicine 1997; 45(1): 41-44.
Collier V, McCue J, Markus A, Smith L. Stress in medical residency: status quo after a decade of reform. Annals of Internal Medicine 2002; 136(5):
384-390.
Levey R. Sources of stress for residents and recommendation for programs to assist them. Acad Med 2001; 76(2): 142-150.
What Do We Know About
Wellness?
5

Being a primary care physician and having related
healthy habits oneself predict one’s clinical practice
of prevention. If medicine values disease prevention,
and if physicians’ personal health practices are
consistent predictors of prevention, we ought to
cultivate healthy physicians in medical school.1

In order to give to others, physicians must have their
basic wellness needs met. It is impossible to give
what you don’t have.2
1.
Frank, E, Rothenberg R, Lewis C; Belodoff B. Correlates of physicians’ prevention-related practices. Arch Fam
Med 2000; 9: 359-367.
2.
http://www.dev.kcom.edu/student/stillwell/home.htm
The state of health promotion
programs for students


6
Only 20% of allopathic and osteopathic
medical schools provide wellness programs
for their students.
24% of schools offered health promotion
programs in 1988.
Hooper J, Cox C, Cambre K, Wilburn D, Webster M, Wolf T. Comparison of the support allopathic and osteopathic
medical school health promotion programs for students. The Science of Health Promotion. 1999; 13(3): 171-179.
Student Wellness Programs Declining
150
125
100
75
50
44
55
27
25
Health
promotion
programs
Accredited
medical
schools
0
1997
1993
1988
7
Cox CC, Cambre KM, Wolf TM, Webster MG, Hooper J. Trends in number and administrative characteristics
of medical school health promotion programmes. Med Educ 2001; 35(2): 173-174.
What do preclinical students
think?




8
Wellness is linked to prevention: “...if we sacrifice our own
health from studying too long, staying up too late, stressing out
too much about exams we can’t take care of other people if we
don’t watch our own health first.”
Prevention should be integrated, not separated: “Nobody
goes to those classes because they’re busy with the other
ones…”
Early clinical exposure is important: “In the clinics I’ve
noticed … prevention being important but not in lectures.”
Students want more prevention: “I can count the hours [of
prevention education] on two hands … Miniscule would be the
word.”
AMSA Focus Group, 2002.
What do clinical students think?

Wellness is difficult to achieve: “We're really stressed,
basically.”

Clinical students see mentoring as important to
wellness. “I [would like] having a designated person to whom
students can turn at any time. That would be a hotline . . . A
counselor.”

Clinical experience is most useful in prevention:
“observing physicians who have counseled for many years
counsel a patient on a certain topic …”

Specialty physicians have different opinions. “I'm
going into surgical subspecialty … there is little role for
prevention.”
9
AMSA Focus Group, 2002.
What do Deans think about
Wellness and Prevention?
Our medical school discourages students
from smoking
Strongly agree
Our medical school encourages students
to exercise.
Agree
Neutral
Our medical school encourages students’
healthy eating.
Disagree
Strongly disagree
Our medical school has a good system to
help students cope with stress.
Our medical school encourages
extracurricular activities that promote
medical students’ health.
10
AMSA Survey of Deans, 2003.
0% 10 20 30 40 50 60 70 80 90 100
% % % % % % % % % %
Who should promote healthy
behaviors and prevention?
In order to effectively encourage healthy patient
lifestyles, physicians must adhere to one
themselves.
Primary care physicians need more training in
prevention.
Schools should encourage students/residents to
practice healthy lifestyles.
Faculty should set a good example by practicing a
healthy lifestyle.
0%
11
AMSA Survey of Deans, 2003.
20%
40%
60%
80%
100%
Do physicians have a responsibility to
promote prevention with patients?
100
100
Percentage
80
60
60
40
Deans
Students
31
20
8
1
1
0
Strongly
agree
12
Agree
Neutral
Disagree
Strongly
Disagree
Emory University, Healthy Doc Survey and AMSA Dean Survey data, 2002-2003.
Making the Link Between Student
Wellness and Prevention in Practice
What others have done
13
Emory University
Sample Curricular Interventions
Pre-clinical



14
Medical Decision Making class used Healthy Doc
survey data to learn about statistic (M1s);
Physician panel on substance use (M2s);
1 hour talk in Behavioral Science on alcohol and
tobacco use of physicians, U.S. medical students,
and Emory 2003 medical students (M2s).
The “Healthy Doc-Healthy Patient” Project is a 17 medical school study of and intervention in medical student
health. Two-prong study being conducted at 16 US medical schools (2,000 students, 88% response
rate) tracking the natural history of students’ attitudes and health and counseling behaviors and at
Emory where an intervention to promote healthy student behavior was developed, implemented, and
evaluated.
Emory University
Sample Curricular Interventions
Clinical



15
Ethics/Psychiatry: Complete a Beck Depression
Inventory and an alcohol CAGE screening
questionnaire on themselves;
Ethics/medicine: Completed an advanced directive
and living will for themselves;
Dermatology: Received information about skin cancer
prevention and prevention strategies for themselves
and their patients and a container of sunscreen for
their own use.
Emory University
Sample Curricular Interventions




16
Healthy, quick-cooking class;
Saturday visit to the mountains for hiking and healthy
eating;
Two wine-tasting seminars (student idea, attended
by about 30 students each time) to teach about
using alcohol for purposes other than inebriation;
Weekly yoga classes.
Kirksville COM
Still Well Wellness Program




Program Philosophy: “You are your own first patient.”
“Wellness is considered the cornerstone for each
student to model for future patients.”
Still Well Wellness Program is a voluntary,
comprehensive wellness program that encourages
students to balance medical school with personal
wellness.
Participation: currently 73%.
http://www.kcom.edu/student/stillwell/home.htm
17
Still Well Wellness Program:
Seven Components of Wellness
Emotional
Vocational
Spiritual
Environmental
Intellectual
Social
Physical
18
Still Well Wellness Program:
Benefits
Physical benefits




Preparticipation physical
examination.
Six month fitness assessment.
2 hours free racquetball/week.
Free aerobic classes.
Other benefits



19
Year end recognition banquet.
Quarterly wellness newsletter.
Seminar series – diversity in
medicine, interpersonal
relationship building, stress
management, high
performance nutrition.
Career benefits

Pathways program in career
planning that includes spouse.
Academic benefits




Extra points for participation in
wellness seminar series in
osteopathic manipulation.
M2s do health exams for M1s.
M2s create fitness and wellness
Rx for M1s.
Student committee plans exam
schedule to allow student
attendance at professional
conferences.
Still Well Wellness Program:
Evaluation Results



20
Compared to a similar medical school cohort, both
students in the Still Well Program and the control
cohort had a drop-off in exercise and # leisure
breaks taken up to Xmas break.
After the break, Still Well participants restored their
health habits to the original level, except for sleep
deprivation and the intensity of exercise, while the
control cohort had further declines in health habits.
Still Well participants have lower levels of anxiety.
Kirksville COM
Prevention Curriculum

Complete DOctor course
–

Commitment to student leadership
–

Leadership script documenting student
volunteerism and leadership during and outside
school for reference in residency application.
Grading environment
–
–
21
Preclinical longitudinal course addressing
prevention, wellness, clinical skills.
Percentage grades in first two years.
Pass/Fail grades in clinical rotations.
Loma Linda University
Wellness Program
Alcohol, tobacco & drug
use



“Boundary items” for
Adventists.
Students pledge not to drink
or smoke.
Alcohol treatment and
addiction support available.
Mentorship


Diet and exercise

Counseling

Student Assistance Program
available for counseling.


22
Personal mentor for weekly
meetings, friendship, and
support.
Reaches 40-70 students.
State of the art fitness
complex.
Many extracurricular sports
and activities.
Vegetarian only cafeteria.
Loma Linda University
Curriculum: Ethics and Balance
1st year (20 hours)



23
Wholeness for Physicians
– Stress management,
relationships, controlling
anger, and conflict
resolution.
– Required “Action Option
Plan.”
Orientation to religion and
medicine - discussions on
God and human suffering.
Biomedical ethics.
2nd year

Integration of religion and
medicine
– Integration of prayer and
other treatment
modalities into clinical
context.
Orientation Wellness Workshops
University of Louisville



24
Week-long workshop during M1 orientation,
1981-2001.
Goal: Medical students who practice constructive
self-care will become role models for patients.
Components: Environment, Communication,
Mind/Body, Community, Ethics, Nutrition, Exercise,
Recreation, Stress Reduction, Time Management,
Relaxation, The Arts, Gender Issues, Relationships,
Study Skills, Faith, Coping.
Student Wellness Leadership

UIC Wellness Consortium
–
–

Creighton University Wellness Council
–
–
25
Participants plan wellness and health promotion
activities each month.
Activities include cholesterol & glucose screening,
back safety & ergonomics, walking programs, etc.
Elected medical student representatives.
Participants plan wellness activities, meet with
Dean, and plan lunch presentations.
Data from assessment performed by American Network of Health Promoting Universities, a special
project of the Association of Academic Health Centers, 2002.
Role Modeling and Peer Support
Programs
Case Western Reserve University Wellness
Elective1



Physician presenters role model coping strategies and stress
reduction.
Students perceived the elective to legitimize and give
permission to self care and wellbeing.
Talking with peers and “venting” was effective in stress
reduction.
Mercer


26
1.
Personal Professionalism and Leadership mentorship program.
Promotes student well being, health and wellness.
Lee J, Graham A. Students’ perception of medical school stress and their evaluation of a wellness elective. Med
Education 2001; 35(7): 652-659
Competency Assessment in Self Care
Brown University


Self awareness, self care, and personal growth are
graduation requirements.
Students may demonstrate self awareness by
demonstrating competency in: medical interviewing
class, Psychiatry clerkship, volunteer work, electives,
or one-on-one meetings with student advisor.
http://biomed.brown.edu/Medicine_Programs/MD2000/NineAbil.html
27
Sample Prevention Curricula
What others have done
28
Do recent graduates believe adequate time is
devoted to instruction of prevention?

Health promotion and disease prevention
–

Screening for diseases
–

8.5% inadequate, 90.3% appropriate,
1.2 % excessive.
Infectious disease prevention
–
29
16.9% inadequate, 81.6% appropriate,
1.6% excessive.
24.5% inadequate, 73.8% appropriate, 1.7%
excessive.
AAMC Graduation Questionnaire, 2002.
Exposure to Community and Public
Health
Wayne State University


Course based on ATPM competencies.1
“Clinical Learning Exercises” address public health
learning objectives.
University of Miami


30
12 week Primary Care clerkship incorporates
lectures, small group cases, and CDC Healthy
People screening software.
Student placement in public health settings for one
week.
1. Pomrehn, P., Davis, M., Chen, D., and Barker, W. Prevention for the 21st Century: Setting the context through
Undergrauate Medical Education. Academic Medicine. 2000; 75 (7 Supplement): S5-S14.
Use of Case-Based Learning and
Technology
University of Massachusetts


The McQ’s, a simulated standardized family.1
Case-based modules address health promotion,
lifestyle counseling, risk factor assessment, and
preventive services.
University of Kentucky

31
Computer-based patient management simulation
simulates adult and pediatric preventive care visits
for self-directed student learning exercise.
1. Pugnaire MP, Leong SL, Quirk ME, Mazor K, Gray JM. The standardized family: an innovation in primary
care education at the University of Massachusetts. Acad Med 1999 Jan;74(1 Suppl):S90-7.
What to do now



32
More medical schools should institute
personal health promotion programs to
improve student health.
Medical schools should better integrate
health promotion programs with clinical
prevention curricula.
Personal wellness may be a successful
“hook” to interest medical students in
prevention.
What Can Students Do?

Orientation Activities - Medical student survival week, tour
of school wellness resources, panel discussion on surviving
basic science classes.

Seminars and Panel Discussion - Massage circle, prayer
group, finger painting, pasta sculptures, drumming circle, Tai
Chi, exercise/outdoor activities club, weekly yoga class.

Student Wellness Activities – Panel on relationships in
med. school, effective study habits, time management
strategies, effects of sleep deprivation, spirituality and wellness
discussion.

33

Peer Support Networks - Big sib/little sib program.
Student-Dean Collaboration - Lunch with the Dean.
Students Can Get Further
Experience through AMSA







34
http://www.amsa.org/well/
Humanistic Medicine Action Committee
Action Committee on Medical Education
Humanistic Medicine Retreats
LIGHT Rotation for Fourth Year Students
Opportunities & curriculum through AMSA’s
Complementary and Alternative Medicine project
(http://www.amsa.org/humed/CAM/)
Director of Student Programming
([email protected])
What Can Deans Do?
“Let us emancipate the student, and give him time and
opportunity for the cultivation of his mind, so that in
his pupilage he shall not be a puppet in the hands of
others, but rather a self-relying and reflecting being.”
–Sir William Osler




35
Foster student initiated activities and support student leaders.
Identify faculty leaders in prevention and wellness and provide
support through faculty development.1
Provide institutional resources.2
Promote reporting and publishing of successful programs.
1. Sachdeva AK. Faculty development and support needed to integrate the learning of prevention in the
curricula of medical schools. Acad Med 2000; 75(7): S35-S42.
2. AMSA Dean’s Survey, 2003.