Scientific Papers

Self-care strategies for medical students: an uncontrolled mixed-methods evaluation of a mind-body-medicine group course | BMC Medical Education

Sample and baseline characteristics

This study included quantitative and qualitative data, each gathered from 11 MBM courses conducted between October 2012 and February 2019. However, between 2013 and 2014, quantitative and qualitative data collection was not upheld for two consecutive courses. Demographic characteristics and SF−12 scores were introduced from October 2015 onwards. A total of 112 medical students were included in the quantitative data analysis. Since the first evaluation of demographic characteristics in 2015, there were 48 female (70.1%) and 20 male (29.9%) participants with a mean age of 26.2 years (range = 19–42, SD = 4.9). Qualitative data were collected from 11 focus groups comprising 87 participants (62 females, 25 males), with an average interview duration of 52.8 min.

At baseline, participants scored about one standard deviation above the mean of the standard PSS for German students [21], indicating a high stress load (see Table 3).

Correspondingly, the mean baseline values for the mental subscale of SF−12 were registered below the 25th percentile of the published norms for their age group [36], indicating a reduced psychological QoL.

Table 3 Baseline characteristics

Quantitative findings

An overview of results is provided in Table 4. In the pre-post analysis, participants’ level of perceived stress measured by PSS was found to decrease (PSS: T1 15.3, ΔT0-T1−4.1, [CI:−5.3,−2.8]), along with increased self-efficacy (GSE: T1 3.1, ΔT0-T1 0.2, [CI: 0.1, 0.3]). However, there were no meaningful changes in health-related QoL, both PCS or MCS (PCS: T1 54.1, ΔT0-T1 1.8, [CI:−0.8, 4.3] / MCS: T1 43.8, Δ T0-T1 1.8, [CI:−1.3, 4.9]). Participants’ level of mindfulness showed improvements for both measures of mindfulness appraisal (FMI: T1 40.3, ΔT0-T1 5.1, [CI: 4.0, 6.2] / MAAS: T1 4.0, ΔT0-T1 0.4, [CI: 0.3, 0.6]), and an increased reflection ability (GRAS: T1 93.5, ΔT0-T1 4.3, [CI: 1.7, 7.0]). After course completion, participants’ empathy measures showed an increased ability to consider others’ perspectives (PT: T1 15.6, ΔT0-T1 0.6, [CI: 0.1, 1.1]) and experienced lower distress when confronting other people’s suffering (PD: T1 10.5, ΔT0-T1−0.8, [CI:−1.5,−0.1]). However, there were no changes in the remaining SPF empathy subscales (FN: T1 14.5, ΔT0-T1 0.01, [CI:−0.4, 0.5] / EC: T1 16.1, ΔT0-T1 0.2, [CI:−0.2, 0.5] / ES: T1 46.2, ΔT0-T1 0.9 [CI:−0.02, 1.8]).

Table 4 Quantitative outcomes of the MBM course evaluation (mean and SD)

Qualitative findings

Our qualitative analysis yielded four distinct main themes: “connections and relationships,” “well-being and stress reduction,” “self-awareness and personal growth,” and “mind-body-medicine in medical education.”

Connections and relationships

Students described how social interactions and group dynamics in the course were different from their usual social experiences at university, where the academic rigor and competitive culture of medical education could render them isolated and lonely. They appreciated how the MBM course fostered a non-judgmental, open, and non-discursive communication style, that could hold space for the suffering of others. A further analysis of the group discourse yielded a common pattern of inspiring empathy: Following the example of faculty members during check-ins, students expressed themselves openly and authentically to the group. They described how such acts of self-exposure lead to a new recognition of self in the other, supported by perceived implicit and explicit expressions of authentic interest in the well-being of one another.

Simply to have two professors sitting here, who opened up [to us] and who also experienced stressful days—that helped me sometimes when I went to class and told myself, ‘These people are experiencing the same thing on the other side’[even though] no one [at university] wants to admit what its really like’. (FGSS18.F2)

Building on these empathic encounters, students reported how connections formed with other course members inspired them to find new and different ways to encounter and connect with others.

This safe space […] has played such an important part for me and […]I want to […] encounter other people, strangers, the way that we encountered each other here. (FGWS18.F3)

Students also reflected on the relationship between patients and themselves as future doctors. They expressed a heightened sense of importance in establishing a doctor–patient relationship grounded in empathy, trust, and mutual recognition. Participants recognized their own therapeutic experiences and vulnerability as tools for establishing trust and authenticity with patients to facilitate healing.

[Relating to the patient from your own experience] creates a completely different impression than working from book [knowledge].(FGWS16.F1).

Well-being & stress reduction

An analysis of course motivation revealed that students’ desire for improved well-being and reduced perception of everyday life stress was a main motivator for participation. Anxiety was commonly reported among participants, brought on by exam periods, feelings of falling behind on academic achievement in a competitive environment, even causing strain on students’ personal lives. Some students complained of experiencing physical symptoms, such as nausea, tinnitus, high blood pressure, and insomnia.

Students reported an increased awareness of how personal and academic stress affected their overall well-being and the value of practicing self-care. They recounted how practicing MBM exercises allowed them to achieve inner calmness. The gradual introduction of different MBM practices throughout the course was described as a process of “building their own toolkit” of techniques for reducing and self-regulating mental distress. Successful implementation of this toolkit produced a sense of empowerment and reduced the feeling of helplessness in the face of stressful situations.

To make the experience that stress is a state [of mind] that can be changed and not something you have no control over at allthat already is a pretty cool thing. (FGWS14.M2)

Some students remained critical of how the medical field held little regard for MBM and self-care practices and provided limited opportunities for engaging in them. Many students reported difficulties with implementing a sustained self-care practice. Perceived lack of time was the most commonly stated reason, as they struggled to balance their time between overloaded daily schedules and MBM practice.

Self-awareness & personal growth

Students commonly described MBM exercises as tools and opportunities for self-reflection and increased self-awareness resulting from a perceived increase in mindfulness of their own emotions and mental states.

I tried to remember the thoughts that would come up [during meditation] and take them with me. I had the feeling, ‘What’s coming up in my mind there […] is really [what is] concerning me at the moment, even if I do not realize it usually’. And that has helped me a lot. (FGWS18.PF)

For some students, this process had a real-life impact on how they related to themselves. For example, they made changes to their nutritional and other daily habits or developed a more generally increased sense of self-acceptance. Higher degrees of self-awareness also affected relationships formed by students in their social environment. These changes in relationships with others were mostly based on increased emotional openness, empathic recognition of the other, authenticity, and vulnerability. However, the course also lead to challenging experiences, as some students reported confronting individual emotional struggles or personal problems during MBM practice.

Mind-body-medicine in medical education

Learning about MBM and CIM as disciplines of modern medicine was reported as a primary motivation for course enrollment. Some participants sought to acquire proficiency in MBM techniques as tools for their future patient care. Students reported increased knowledge of MBM techniques as a main benefit of the course, emphasizing the value of practical experience. New perspectives on the value of MBM and CIM gained through the course led to what students described as a broader, “more holistic” view of the scope of medical practice and the relationship between healthcare professionals and their patients.

Triangulation—experiences of self and the other

Qualitative findings corroborate the quantitative results of increased mindfulness, self-reflection, and empathy, providing a narrative that relates these three outcome values. Students’ accounts of their course experience link their exposure to mindfulness and other MBM practices to increased self-reflection, empathy, and recognition of self in the other. An interdependence between individual and group experiences constitutes the core of these findings, present on three levels. (see Fig. 1):

  1. I.

    At an organizational level, the MBM course structure alternates between individual exercises and shared group reflections.

  2. II.

    At a relational level, students` descriptions of group discourse reflect qualities of individual mental states fostered by MBM mindfulness practices such as openness, non-discursiveness and non-judgemental attitude.

  3. III.

    At a cognitive level, mindfulness practices promote students’ experiences of self-reflection, which create and are in turn created by experiences of empathy, promoted by voluntary self-exposition during group sessions. Recognition of self leads to recognition of the other and, ultimately, recognition of self in the other.

Fig. 1
figure 1

Model for the reciprocative relation between individual and group

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