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Association Between Learning Environment Interventions and Medical Student Well-beingA Systematic Review

Educational Objective
To review learning environment interventions associated with improvements in the emotional well-being of medical students.
1 Credit CME
Key Points

Question  What undergraduate medical education learning environment interventions are associated with improved emotional well-being among medical students?

Findings  In a systematic review of the medical literature, only 28 articles described empirically evaluated interventions and only 3 included randomization, so methodologic rigor was limited. However, some data support preclinical pass/fail grading, mental health programs, wellness programs, mentoring programs, curricular restructuring, and multicomponent program reform.

Meaning  There is limited evidence to support learning environment interventions for improvement of emotional well-being among medical students. High-quality research is needed.

Abstract

Importance  Concerns exist about the current quality of undergraduate medical education and its effect on students’ well-being.

Objective  To identify best practices for undergraduate medical education learning environment interventions that are associated with improved emotional well-being of students.

Data Sources  Learning environment interventions were identified by searching the biomedical electronic databases Ovid MEDLINE, EMBASE, the Cochrane Library, and ERIC from database inception dates to October 2016. Studies examined any intervention designed to promote medical students’ emotional well-being in the setting of a US academic medical school, with an outcome defined as students’ reports of well-being as assessed by surveys, semistructured interviews, or other quantitative methods.

Data Extraction and Synthesis  Two investigators independently reviewed abstracts and full-text articles. Data were extracted into tables to summarize results. Study quality was assessed by the Medical Education Research Study Quality Instrument (MERQSI), which has a possible range of 5 to 18; higher scores indicate higher design and methods quality and a score of 14 or higher indicates a high-quality study.

Findings  Twenty-eight articles including at least 8224 participants met eligibility criteria. Study designs included single-group cross-sectional or posttest only (n = 10), single-group pretest/posttest (n = 2), nonrandomized 2-group (n = 13), and randomized clinical trial (n = 3); 89.2% were conducted at a single site, and the mean MERSQI score for all studies was 10.3 (SD, 2.11; range, 5-13). Studies encompassed a variety of interventions, including those focused on pass/fail grading systems (n = 3; mean MERSQI score, 12.0), mental health programs (n = 4; mean MERSQI score, 11.9), mind-body skills programs (n = 7; mean MERSQI score, 11.3), curriculum structure (n = 3; mean MERSQI score, 9.5), multicomponent program reform (n = 5; mean MERSQI score, 9.4), wellness programs (n = 4; mean MERSQI score, 9.0), and advising/mentoring programs (n = 3; mean MERSQI score, 8.2).

Conclusions and Relevance  In this systematic review, limited evidence suggested that some specific learning environment interventions were associated with improved emotional well-being among medical students. However, the overall quality of the evidence was low, highlighting the need for high-quality medical education research.

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Article Information

Corresponding Author: Karina W. Davidson, PhD, MASc, Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W 168th St, PH 9-314, New York, NY 10032 (kd2124@cumc.columbia.edu).

Correction: This article was corrected for an incomplete funding statement on February 19, 2019.

Author Contributions: Drs Davidson and Wasson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wasson, Cusmano, Meli, Louh, Young, Davidson.

Acquisition, analysis, or interpretation of data: Wasson, Cusmano, Meli, Louh, Falzon, Hampsey, Shaffer.

Drafting of the manuscript: Wasson, Cusmano, Meli, Louh, Falzon, Hampsey, Davidson.

Critical revision of the manuscript for important intellectual content: Wasson, Meli, Louh, Young, Shaffer, Davidson.

Obtained funding: Davidson.

Administrative, technical, or material support: Cusmano, Meli, Falzon, Hampsey, Davidson.

Supervision: Wasson.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: Dr Davidson was supported by research grant K24 HL084034 from the National Heart, Lung, and Blood Institute. Dr Wasson was supported by research grant K08 HS024598 from the Agency for Healthcare Research and Quality. Ms Falzon was supported by the National Institutes of Health Science of Behavior Change Common Fund Program through an award administered by the National Institute on Aging (U24AG052175) and contract S15-0142 by Columbia University Medical Center.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

References
1.
Dezee  KJ, Artino  AR, Elnicki  DM, Hemmer  PA, Durning  SJ.  Medical education in the United States of America.  Med Teach. 2012;34(7):521-525.PubMedGoogle ScholarCrossref
2.
Brazeau  CM, Shanafelt  T, Durning  SJ,  et al.  Distress among matriculating medical students relative to the general population.  Acad Med. 2014;89(11):1520-1525.PubMedGoogle ScholarCrossref
3.
Dyrbye  LN, Massie  FS  Jr, Eacker  A,  et al.  Relationship between burnout and professional conduct and attitudes among US medical students.  JAMA. 2010;304(11):1173-1180.PubMedGoogle ScholarCrossref
4.
Schwenk  TL, Davis  L, Wimsatt  LA.  Depression, stigma, and suicidal ideation in medical students.  JAMA. 2010;304(11):1181-1190.PubMedGoogle ScholarCrossref
5.
Dyrbye  LN, Thomas  MR, Massie  FS,  et al.  Burnout and suicidal ideation among US medical students.  Ann Intern Med. 2008;149(5):334-341.PubMedGoogle ScholarCrossref
6.
Association of American Medical Colleges.  Educating Doctors to Provide High Quality Medical Care: A Vision for Medical Education in the United States. Washington, DC: Association of American Medical Colleges; 2004.
7.
Gelfand  J. Grey literature: plausible applications for distance education practices. In: GL’99 Conference Proceedings: Fourth International Conference on Grey Literature: “New Frontiers in Grey Literature.” Amsterdam, the Netherlands: GreyNet; January 2000:1-11. GL Conference Series No. 4.
8.
Stacy  R, Spencer  J.  Assessing the evidence in qualitative medical education research.  Med Educ. 2000;34(7):498-500.PubMedGoogle ScholarCrossref
9.
Côté  L, Turgeon  J.  Appraising qualitative research articles in medicine and medical education.  Med Teach. 2005;27(1):71-75.PubMedGoogle ScholarCrossref
10.
Reed  DA, Cook  DA, Beckman  TJ, Levine  RB, Kern  DE, Wright  SM.  Association between funding and quality of published medical education research.  JAMA. 2007;298(9):1002-1009.PubMedGoogle ScholarCrossref
11.
Cook  DA, Reed  DA.  Appraising the quality of medical education research methods: the Medical Education Research Study Quality Instrument and the Newcastle-Ottawa Scale–Education.  Acad Med. 2015;90(8):1067-1076.PubMedGoogle ScholarCrossref
12.
Lin  H, Lin  E, Auditore  S, Fanning  J.  A narrative review of high-quality literature on the effects of resident duty hours reforms.  Acad Med. 2016;91(1):140-150.PubMedGoogle ScholarCrossref
13.
Bloodgood  RA, Short  JG, Jackson  JM, Martindale  JR.  A change to pass/fail grading in the first two years at one medical school results in improved psychological well-being.  Acad Med. 2009;84(5):655-662.PubMedGoogle ScholarCrossref
14.
DuPuy  HJ. Self-representations of general psychological well-being of American adults. Presented at: American Public Health Association Meeting; Los Angeles, CA; October 15-19, 1978.
15.
Rohe  DE, Barrier  PA, Clark  MM, Cook  DA, Vickers  KS, Decker  PA.  The benefits of pass-fail grading on stress, mood, and group cohesion in medical students.  Mayo Clin Proc. 2006;81(11):1443-1448.PubMedGoogle ScholarCrossref
16.
Cohen  S, Kamarck  T, Mermelstein  R.  A global measure of perceived stress.  J Health Soc Behav. 1983;24(4):385-396.PubMedGoogle ScholarCrossref
17.
Cohen  S. Perceived stress in a probability sample of the United States. In: Oskamp  SSS, ed.  The Social Psychology of Health. Thousand Oaks, CA: Sage Publications; 1988:31-67.
18.
McNair  DM, Lorr  M, Droppleman  LF.  POMS Manual Profile of Mood States. San Diego, CA: EdiTS/Educational and Industrial Testing Service; 1992.
19.
Bollen  KA, Hoyle  RH.  Perceived cohesion: a conceptual and empirical examination.  Soc Forces. 1990;69(2):479-504.Google ScholarCrossref
20.
Reed  DA, Shanafelt  TD, Satele  DW,  et al.  Relationship of pass/fail grading and curriculum structure with well-being among preclinical medical students: a multi-institutional study.  Acad Med. 2011;86(11):1367-1373.PubMedGoogle ScholarCrossref
21.
Maslach  C, Jackson  SE.  The measurement of experienced burnout.  J Organ Behav. 1981;2(2):99-113.Google ScholarCrossref
22.
Stewart  AL, Ware  JE, eds.  Measuring Functioning and Well-being: the Medical Outcome Study Approach. Durham, NC: Duke University Press; 1992.
23.
Tarlov  AR, Ware  JE  Jr, Greenfield  S, Nelson  EC, Perrin  E, Zubkoff  M.  The Medical Outcomes Study: an application of methods for monitoring the results of medical care.  JAMA. 1989;262(7):925-930.PubMedGoogle ScholarCrossref
24.
Thompson  D, Goebert  D, Takeshita  J.  A program for reducing depressive symptoms and suicidal ideation in medical students.  Acad Med. 2010;85(10):1635-1639.PubMedGoogle ScholarCrossref
25.
Radloff  LS.  The CES-D Scale: a self-report depression scale for research in the general population.  Appl Psychol Meas. 1977;1(3):385-401.Google ScholarCrossref
26.
Downs  N, Feng  W, Kirby  B,  et al.  Listening to depression and suicide risk in medical students: the Healer Education Assessment and Referral (HEAR) Program.  Acad Psychiatry. 2014;38(5):547-553.PubMedGoogle ScholarCrossref
27.
Spitzer  RL, Kroenke  K, Williams  JB.  Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study.  JAMA. 1999;282(18):1737-1744.PubMedGoogle ScholarCrossref
28.
Kroenke  K, Spitzer  RL, Williams  JB.  The PHQ-9: validity of a brief depression severity measure.  J Gen Intern Med. 2001;16(9):606-613.PubMedGoogle ScholarCrossref
29.
Seritan  AL, Rai  G, Servis  M, Pomeroy  C.  The office of student wellness: innovating to improve student mental health.  Acad Psychiatry. 2015;39(1):80-84.PubMedGoogle ScholarCrossref
30.
American Association of Medical Colleges. Graduation Questionnaire (GQ). https://www.aamc.org/data/gq/. Accessed October 21, 2016.
31.
Moutier  C, Norcross  W, Jong  P,  et al.  The suicide prevention and depression awareness program at the University of California, San Diego School of Medicine.  Acad Med. 2012;87(3):320-326.PubMedGoogle ScholarCrossref
32.
Erogul  M, Singer  G, McIntyre  T, Stefanov  DG.  Abridged mindfulness intervention to support wellness in first-year medical students.  Teach Learn Med. 2014;26(4):350-356.PubMedGoogle ScholarCrossref
33.
Neff  KD.  The development and validation of a scale to measure self-compassion.  Self Identity. 2003;2(3):223-250.Google ScholarCrossref
34.
Holtzworth-Munroe  A, Munroe  MS, Smith  RE.  Effects of a stress-management training program on first- and second-year medical students.  J Med Educ. 1985;60(5):417-419.PubMedGoogle Scholar
35.
Spielberger  CD, Gorsuch  RL, Lushene  RE, Vagg  PR, Jacobs  GA.  Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1983.
36.
Kraemer  KM, Luberto  CM, O’Bryan  EM, Mysinger  E, Cotton  S.  Mind-body skills training to improve distress tolerance in medical students: a pilot study.  Teach Learn Med. 2016;28(2):219-228.PubMedGoogle ScholarCrossref
37.
Simons  JS, Gaher  RM.  The Distress Tolerance Scale: development and validation of a self-report measure.  Motiv Emot. 2005;29(2):83-102.Google ScholarCrossref
38.
Thompson  ER.  Development and validation of an internationally reliable short-form of the Positive and Negative Affect Schedule (PANAS).  J Cross Cult Psychol. 2007;38(2):227-242.Google ScholarCrossref
39.
Rosenzweig  S, Reibel  DK, Greeson  JM, Brainard  GC, Hojat  M.  Mindfulness-based stress reduction lowers psychological distress in medical students.  Teach Learn Med. 2003;15(2):88-92.PubMedGoogle ScholarCrossref
40.
Finkelstein  C, Brownstein  A, Scott  C, Lan  YL.  Anxiety and stress reduction in medical education: an intervention.  Med Educ. 2007;41(3):258-264.PubMedGoogle ScholarCrossref
41.
Derogatis  LR.  SCL-90-R Administration, Scoring and Procedures Manual, Vol ll. Towson, MD: Clinical Psychometric Research; 1983.
42.
Vitaliano  PP, Russo  J, Carr  JE, Heerwagen  JH.  Medical school pressures and their relationship to anxiety.  J Nerv Ment Dis. 1984;172(12):730-736.PubMedGoogle ScholarCrossref
43.
Whooley  MA, Avins  AL, Miranda  J, Browner  WS.  Case-finding instruments for depression: two questions are as good as many.  J Gen Intern Med. 1997;12(7):439-445.PubMedGoogle ScholarCrossref
44.
Greeson  JM, Toohey  MJ, Pearce  MJ.  An adapted, four-week mind-body skills group for medical students: reducing stress, increasing mindfulness, and enhancing self-care.  Explore (NY). 2015;11(3):186-192.PubMedGoogle ScholarCrossref
45.
Feldman  G, Hayes  A, Kumar  S,  et al.  Mindfulness and emotion regulation: the development and initial validation of the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R).  J Psychopathol Behav Assess. 2006;29(3):177.Google ScholarCrossref
46.
Bond  AR, Mason  HF, Lemaster  CM,  et al.  Embodied health: the effects of a mind-body course for medical students.  Med Educ Online. 2013;18:1-8.PubMedGoogle ScholarCrossref
47.
Dyrbye  LN, Eacker  A, Durning  SJ,  et al.  The impact of stigma and personal experiences on the help-seeking behaviors of medical students with burnout.  Acad Med. 2015;90(7):961-969.PubMedGoogle ScholarCrossref
48.
Plaut  SM, Maxwell  SA, Seng  L, O’Brien  JJ, Fairclough  GF  Jr.  Mental health services for medical students: perceptions of students, student affairs deans, and mental health providers.  Acad Med. 1993;68(5):360-365.PubMedGoogle ScholarCrossref
49.
University of New Mexico Center on Alcoholism, Substance Abuse, and Addictions. The Self-Regulation Questionnaire. http://casaa.unm.edu/inst/SelfRegulation%20Questionnaire%20(SRQ).pdf. Accessed October 26, 2016.
50.
Hojat  M, Mangione  S, Nasca  TJ,  et al.  The Jefferson Scale of Physician Empathy: development and preliminary psychometric data.  Educ Psychol Meas. 2001;61(2):349-365.Google ScholarCrossref
51.
Camp  DL, Hollingsworth  MA, Zaccaro  DJ, Cariaga-Lo  LD, Richards  BF.  Does a problem-based learning curriculum affect depression in medical students?  Acad Med. 1994;69(10)(suppl):S25-S27.PubMedGoogle ScholarCrossref
52.
Zung  WW.  A self-rating depression scale.  Arch Gen Psychiatry. 1965;12:63-70.PubMedGoogle ScholarCrossref
53.
Kornitzer  B, Ronan  E, Rifkin  MR.  Improving the adjustment of educationally disadvantaged students to medical school: the Summer Enrichment Program.  Mt Sinai J Med. 2005;72(5):317-321.PubMedGoogle Scholar
54.
Drolet  BC, Rodgers  S.  A comprehensive medical student wellness program—design and implementation at Vanderbilt School of Medicine.  Acad Med. 2010;85(1):103-110.PubMedGoogle ScholarCrossref
55.
Fleming  A, Cutrer  W, Moutsios  S,  et al.  Building learning communities: evolution of the colleges at Vanderbilt University School of Medicine.  Acad Med. 2013;88(9):1246-1251.PubMedGoogle ScholarCrossref
56.
Real  FJ, Zackoff  MW, Davidson  MA, Yakes  EA.  Medical student distress and the impact of a school-sponsored wellness initiative.  Med Sci Educ. 2015;25(4):397-406.Google ScholarCrossref
57.
Spitzer  RL, Williams  JB, Kroenke  K,  et al.  Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study.  JAMA. 1994;272(22):1749-1756.PubMedGoogle ScholarCrossref
58.
Slavin  SJ, Schindler  DL, Chibnall  JT.  Medical student mental health 3.0: improving student wellness through curricular changes.  Acad Med. 2014;89(4):573-577.PubMedGoogle ScholarCrossref
59.
Strayhorn  G.  Effect of a major curriculum revision on students’ perceptions of well-being.  Acad Med. 1989;64(1):25-29.PubMedGoogle ScholarCrossref
60.
Rothman  AI, Ayoade  F.  The development of a learning environment: a questionnaire for use in curriculum evaluation.  J Med Educ. 1970;45(10):754-759.PubMedGoogle Scholar
61.
Brook  RH, Ware  JE, Davies  AR,  et al.  Conceptualization and Measurement of Health for Adults in the Health Insurance Study. Vol VIII. Santa Monica, CA: RAND Corp; 1979.
62.
Whitehouse  WG, Dinges  DF, Orne  EC,  et al.  Psychosocial and immune effects of self-hypnosis training for stress management throughout the first semester of medical school.  Psychosom Med. 1996;58(3):249-263.PubMedGoogle ScholarCrossref
63.
Goetzel  RZ, Croen  LG, Shelov  S, Boufford  JI, Levin  G.  Evaluating self-help support groups for medical students.  J Med Educ. 1984;59(4):331-340.PubMedGoogle Scholar
64.
Lee  J, Graham  AV.  Students’ perception of medical school stress and their evaluation of a wellness elective.  Med Educ. 2001;35(7):652-659.PubMedGoogle ScholarCrossref
65.
Kushner  RF, Kessler  S, McGaghie  WC.  Using behavior change plans to improve medical student self-care.  Acad Med. 2011;86(7):901-906.PubMedGoogle ScholarCrossref
66.
Sastre  EA, Burke  EE, Silverstein  E,  et al.  Improvements in medical school wellness and career counseling: a comparison of one-on-one advising to an advisory college program.  Med Teach. 2010;32(10):e429-e435.PubMedGoogle ScholarCrossref
67.
Coates  WC, Crooks  K, Slavin  SJ, Guiton  G, Wilkerson  L.  Medical school curricular reform: fourth-year colleges improve access to career mentoring and overall satisfaction.  Acad Med. 2008;83(8):754-760.PubMedGoogle ScholarCrossref
68.
Ficklin  FL, Hazelwood  JD, Carter  JE, Shellhamer  RH.  Evaluation of a small-group support program for first-year medical students.  J Med Educ. 1983;58(10):817-819.PubMedGoogle Scholar
69.
Egger  M, Smith  GD, Phillips  AN.  Meta-analysis: principles and procedures.  BMJ. 1997;315(7121):1533-1537.PubMedGoogle ScholarCrossref
70.
Derogatis  LR, Melisaratos  N.  The Brief Symptom Inventory: an introductory report.  Psychol Med. 1983;13(3):595-605.PubMedGoogle ScholarCrossref
71.
Jones  KG, Pedersen  RL, Carmichael  SW, Pawlina  W.  Effects of pass/fail grading system on academic performance of first year medical students in gross anatomy course.  FASEB J. 2003;17:A385.Google Scholar
72.
Vosti  KL, Jacobs  CD.  Outcome measurement in postgraduate year one of graduates from a medical school with a pass/fail grading system.  Acad Med. 1999;74(5):547-549.PubMedGoogle ScholarCrossref
73.
Robins  LS, Fantone  JC, Oh  MS, Alexander  GL, Shlafer  M, Davis  WK.  The effect of pass/fail grading and weekly quizzes on first-year students’ performances and satisfaction.  Acad Med. 1995;70(4):327-329.PubMedGoogle ScholarCrossref
74.
Association of American Medical Colleges. Number of Medical Schools Using Selected Grading Systems in Pre-Clerkship Courses (Excluding Physical Diagnosis/Clinical Skills). https://www.aamc.org/initiatives/cir/406418/11.html. Accessed October 16, 2016.
75.
Dyrbye  LN, Thomas  MR, Shanafelt  TD.  Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students.  Acad Med. 2006;81(4):354-373.PubMedGoogle ScholarCrossref
76.
Givens  JL, Tjia  J.  Depressed medical students’ use of mental health services and barriers to use.  Acad Med. 2002;77(9):918-921.PubMedGoogle ScholarCrossref
77.
Gentile  JP, Roman  B.  Medical student mental health services: psychiatrists treating medical students.  Psychiatry (Edgmont). 2009;6(5):38-45.PubMedGoogle Scholar
78.
Rose  GL, Rukstalis  MR, Schuckit  MA.  Informal mentoring between faculty and medical students.  Acad Med. 2005;80(4):344-348.PubMedGoogle ScholarCrossref
79.
Mosteller  F, Boruch  RF.  Evidence Matters: Randomized Trials in Education Research. Washington, DC: Brookings Institution Press; 2002.
80.
Green  JL, Camilli  G, Elmore  PB.  Handbook of Complementary Methods in Education Research. 3rd ed. Washington, DC: American Educational Research Association; 2006.
81.
US Department of Health and Human Services. Federal Policy for the Protection of Human Subjects. In: Federal Register. http://archive.hhs.gov/ohrp/documents/19881110.pdf. Accessed October 16, 2016.
82.
Johansson  AC, Durning  SJ, Gruppen  LD, Olson  ME, Schwartzstein  RM, Higgins  PA.  Perspective: medical education research and the institutional review board: reexamining the process.  Acad Med. 2011;86(7):809-817.PubMedGoogle ScholarCrossref
83.
Keune  JD, Brunsvold  ME, Hohmann  E, Korndorffer  JR  Jr, Weinstein  DF, Smink  DS.  The ethics of conducting graduate medical education research on residents.  Acad Med. 2013;88(4):449-453.PubMedGoogle ScholarCrossref
84.
Russell  DW.  UCLA Loneliness Scale (Version 3): reliability, validity, and factor structure.  J Pers Assess. 1996;66(1):20-40.PubMedGoogle ScholarCrossref
85.
Moos  RH.  The assessment of the social climate of correctional institutions.  J Res Crime Delinq. 1968;5:174-188.Google ScholarCrossref
86.
Moos  RH, Houts  PS.  Assessment of the social atmospheres of psychiatric wards.  J Abnorm Psychol. 1968;73(6):595-604.PubMedGoogle ScholarCrossref
87.
Moos  RH, Insel  PM, Humphrey  B.  Preliminary Manual for Family Environment Scale, Work Environment Scale, Group Environment Scale. Palo Alto, CA: Consulting Psychologists Press; 1974.
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