Surviving and Thriving in Medical Training and Beyond : A third-year elective for medical students to learn self-care skills and to enhance interpersonal aspects of the practice of medicine.

Proposal to the Academy of Medical Educators
Caroline Day, M.D. and Rick McKinney, MD

HYPOTHESIS: Our thesis is that the risk of student/professional burnout can be reduced by providing students with tools of self-care in an experiential elective offered in the third year, principally during the intersessions, and developed to coordinate with other reflective and personal growth efforts already a part of the curriculum.

Background Information
Medical students come to UCSF to begin the study of medicine with not only extraordinary academic strengths, but also a proven strong commitment to the interpersonal aspects of patient care. They enter a demanding, rewarding, and stressful environment, which will largely define their lives for the next several years. The effects of this stress are legion, beginning in the classroom first year, intensifying especially during the third year with clinical rotations, again during internship, and lasting to differing degrees throughout careers.

An informal survey of faculty involved in activities of reflection and personal/ professional development at UCSF revealed unanimous agreement that there is a need to expand on these subject matters, particularly for third year students (see list of supporters at end of document). There is a desperate need to develop effective methods to help our students and our colleagues find ways to deal more successfully with these stresses, remain more human and more satisfied, and maintain more of the sense of compassion that led many of them to the career initially.

OVERALL CONCEPT
This new third year elective, "Surviving and Thriving," would further the development and maintenance of central concepts and skills of self-care through didactic and experiential teaching and the creation of peer support groups. The class will meet as a group for three hours in an evening during each of three intersessions over a ten-month period. The first hour of meeting time will be dedicated to presentation of information related to one of the five core content areas described in "Tasks and Timeline" that focus on the interpersonal aspects of the practice of medicine and the tools of self-care. The remaining two hours will be comprised of small and large group discussions and experiential work. The small groups will meet less formally for dinner and discussion once or twice between each intersession to enhance development of group identity and cohesiveness and to provide additional experiential learning and support. Each student will be able to attend most but not all of these sessions. Online assignments and communication will supplement these efforts. This elective is appropriate for all medical students regardless of the eventual choice of specialty and is useful for the practice of both clinical and academic medicine.

GOALS AND OBJECTIVES
We propose to develop a ten-month interdisciplinary third-year elective with the following learning objectives:
Knowledge
Skills
Attitudes

PLAN FOR EVALUATION

Evaluation of student performance:
Written assessment of student performance and participation will be obtained from faculty, mentors, and students. Attendance, verbal and written participation, and the student's personal effort and risk will be taken into account. These will be compiled into a standard student evaluation format.

Evaluation of the format and content of the course:
Written feedback will be obtained from faculty, mentors, student advisors, and students regarding the format and content of the course. This information will be integrated into the planning of the course format and content in subsequent years.

Evaluation of course effectiveness:
For the pilot program, a questionnaire will be implemented to assess students at the beginning and at the end of the 10-month period of the course. A preliminary survey from the Dean's office of all students in the third year class will allow establishing which students would be interested in this subject matter (communication skills, emotional intelligence, physical health, balance, and awareness of social being). From this survey, students would self-stratify into those willing to take the course (an extra time commitment during the third year) versus those students who may see these skills or subject matters as important but are not be willing to take on the extra commitment. This will allow for a comparable control group. A control group of third-year students "interested, but not committing to the elective" would be invited to complete the same questionnaire with the offer of a small payment. The two groups will be assessed to identify changes in students from the time they enrolled in the course to the time of its completion in comparison to peers who have not participated. Course effectiveness will be evaluated based on assessment of students' knowledge, skills, and attitudes before and after taking the course, particularly focusing on self-perceived skills in emotional intelligence, communication awareness, physical health awareness, balance, and recognition of their social and human needs. The same questionnaire will be requested again for both control and test (curriculum participating) students near the end of the fourth year of medical school.

An indirect measure of student performance outside of the elective and possibly as a result of this course can be measured using E'Value. The standard questions of E'Value already prompt attending physicians to assess students' communication skills and functioning as a part of a team. We can assess if students in the test group versus those in control group show any change in these skills longitudinally over third and fourth year as measured by "blinded" attendings.

This proposal does not include long-term plans for assessment of UCSF students' well being, but focuses on this pilot's attempt to meet student needs in the five content areas (as verified in the April 2003 focus group). Our goal is to use the pilot year to do extensive literature review on the subject of self-care and physician burnout, to make connection with other schools involved in similar efforts , and to refine our measurement tools, all for the purpose of developing the scholarship of this effort toward publishable material. We are interested in applying prior existing or modified, validated tools to measure students' knowledge, skills, and attitudes as they proceed through training and into practice, especially around prevalence and prevention of burnout and in measures of professional and personal satisfaction. This pilot year will seed this UCSF effort (that will subsequently be funded using outside resources) to lead innovation in teaching that strives to assure maintained excellence and personal satisfaction in its graduating physicians.

PLAN FOR CONTINUATION OF PROJECT AT END OF FUNDING CYCLE
If the course meets initial expectations, Ellen Hughes, M.D. (advisory group member and Director of Education for the Osher Center for Integrative Medicine) has generously offered to house this curriculum at the Osher Center and to provide at least partial funding for several years after this pilot as such curriculum meets the need of her OCIM R25 grant looking at teaching self-care. After analysis of the data from the pilot elective, we also intent to seek earnestly other outside sources for ongoing funding to continue this course. Potential sources would include the NBME, The Fetzer Foundation, the Templeton Foundation, and the George Soros Foundation Grant for Medicine as a Profession.

For further information, please contact:
Caroline Day, M.D. at caroline.day@ucsfmedctr.org
Rick McKinney, MD at rmickmdld@yahoo.com