Promoting%20Healthy%20Behaviors:%20Linking%20Student%20Health%20to%20Prevention

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Promoting Healthy Behaviors Linking Student
Health to Prevention

Funded by The Robert Wood Johnson Foundation,
2002-2003. 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.
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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 well-being.
• 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.

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Student Well Being Programs

• What the research shows

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Are We Well in Medical School?

• Students health falters in medical school.1
• Alcohol consumption increases.
• Socialization and exercise decrease.
• Depression is related to poorer health habits.1
• Maladaptive behaviors eventually form.2
• 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 healthII. 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.

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What Do We Know About Wellness?

• Being a primary care physician and having related
  healthy habits oneself predict ones 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 dont 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

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The state of health promotion programs for
students

• 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.
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Student Wellness Programs Declining
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.
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What do preclinical students think?

• 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 cant take care of other people if we
  dont watch our own health first.
• Prevention should be integrated, not separated
  Nobody goes to those classes because theyre
  busy with the other ones
• Early clinical exposure is important In the
  clinics Ive 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.
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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.

AMSA Focus Group, 2002.
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What do Deans think about Wellness and
Prevention?
AMSA Survey of Deans, 2003.
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Who should promote healthy behaviors and
prevention?
AMSA Survey of Deans, 2003.
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Do physicians have a responsibility to promote
prevention with patients?
Emory University, Healthy Doc Survey and AMSA
Dean Survey data, 2002-2003.
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Making the Link Between Student Wellness and
Prevention in Practice

• What others have done

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Emory University Sample Curricular Interventions

• Pre-clinical
• 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.
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Emory University Sample Curricular Interventions

• Clinical
• 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.

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Emory University Sample Curricular Interventions

• 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.

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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
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Still Well Wellness ProgramSeven Components of
Wellness
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Still Well Wellness ProgramBenefits

• Physical benefits
• Preparticipation physical examination.
• Six month fitness assessment.
• 2 hours free racquetball/week.
• Free aerobic classes.
• Other benefits
• 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.

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Still Well Wellness ProgramEvaluation Results

• 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.

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Kirksville COM Prevention Curriculum

• Complete DOctor course
• Preclinical longitudinal course addressing
  prevention, wellness, clinical skills.
• Commitment to student leadership
• Leadership script documenting student
  volunteerism and leadership during and outside
  school for reference in residency application.
• Grading environment
• Percentage grades in first two years.
• Pass/Fail grades in clinical rotations.

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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.
• Counseling
• Student Assistance Program available for
  counseling.

• Mentorship
• Personal mentor for weekly meetings, friendship,
  and support.
• Reaches 40-70 students.
• Diet and exercise
• State of the art fitness complex.
• Many extracurricular sports and activities.
• Vegetarian only cafeteria.

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Loma Linda University Curriculum Ethics and
Balance

• 1st year (20 hours)
• 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.

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Orientation Wellness Workshops

• University of Louisville
• 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.

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Student Wellness Leadership

• UIC Wellness Consortium
• Participants plan wellness and health promotion
  activities each month.
• Activities include cholesterol glucose
  screening, back safety ergonomics, walking
  programs, etc.
• Creighton University Wellness Council
• 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.
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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
• Personal Professionalism and Leadership
  mentorship program.
• Promotes student well being, health and wellness.

1. Lee J, Graham A. Students perception of medical
   school stress and their evaluation of a wellness
   elective. Med Education 2001 35(7) 652-659

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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/N
ineAbil.html
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Sample Prevention Curricula

• What others have done

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Do recent graduates believe adequate time is
devoted to instruction of prevention?

• Health promotion and disease prevention
• 16.9 inadequate, 81.6 appropriate,
• 1.6 excessive.
• Screening for diseases
• 8.5 inadequate, 90.3 appropriate,
• 1.2 excessive.
• Infectious disease prevention
• 24.5 inadequate, 73.8 appropriate, 1.7
  excessive.

AAMC Graduation Questionnaire, 2002.
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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
• 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.
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Use of Case-Based Learning and Technology

• University of Massachusetts
• The McQs, a simulated standardized family.1
• Case-based modules address health promotion,
  lifestyle counseling, risk factor assessment, and
  preventive services.
• University of Kentucky
• 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 Jan74(1
Suppl)S90-7.
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What to do now

• 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.

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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.
• Peer Support Networks - Big sib/little sib
  program.
• Student-Dean Collaboration - Lunch with the Dean.

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Students Can Get Further Experience through AMSA

• 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 AMSAs
  Complementary and Alternative Medicine project
  (http//www.amsa.org/humed/CAM/)
• Director of Student Programming (dsp_at_www.amsa.org)

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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
• 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 Deans Survey, 2003.