For dozens of first-year students at the University of Pennsylvania's Perelman School of Medicine, a recent afternoon of stretching was a welcome break from their studies.
The students, dressed in athletic shorts, leggings and T-shirts, unrolled yoga mats in front of a window showcasing the Philadelphia skyline and prepared for Yoganatomy, a yoga class that reinforces what they're learning in anatomy.
Nicole Robinson, the anatomy instructor who runs the class, asked the students to protract their scapulas rather than move their shoulder blades towards their spines, or to show her the full power of the medial deltoid, a shoulder muscle.
"When your knee is flexed, what's keeping your tibia from moving towards the window?" Robinson asked as she adjusted a student's pose. "Yep, the ACL," the anterior cruciate ligament that is the bane of so many athletes when it tears.
Yoganatomy, which started four years ago, is part of Penn's ongoing efforts to integrate student wellness into the curriculum, in hopes of teaching medical students to manage stress. It now draws not only students, but faculty members as well.
"This is particularly powerful because we see our professors engaging in it with us, because those are the people who we are striving hard for," said Isabelle Mullen, a 25-year-old first-year medical student who is taking Yoganatomy. "It's nice for them to remind us that regardless of the assignments we have coming up for them, that wellness is important and valuable."
Other medical schools in the Philadelphia area have similar initiatives: Thomas Jefferson University's Sidney Kimmel Medical College holds a week of wellness activities for first-year students each fall, Temple University's Lewis Katz School of Medicine offers art and writing classes that encourage self-expression, and the Drexel University College of Medicine hosts weekly "wellness group" meetings for first and second-year students, where they can support each other.
What they all have in common is the realization by medical school administrators that for any physician to be successful in their career, they have to be mentally and physically well.
Doctors have the highest suicide rate of all professions, with an average of one physician every day dying by suicide, according to a 2018 review presented at the American Psychiatric Association's annual meeting. Overall, physicians' suicide rate is more than double that of the general public.
Burnout, a state of exhaustion caused by excessive and prolonged stress, often starts early for physicians. Among practicing physicians, some of the main drivers of burnout are inefficient processes, lack of control over issues affecting their work lives and heavy workloads. Even though research has not linked workload to burnout in medical students, studies from 1990 to 2015 revealed that 35% to 45% of medical students report high emotional exhaustion, and 45% to 56% have at least one symptom of burnout.
Research shows that burnout can negatively affect the care that patients receive, as exhausted medical residents may struggle with concentrating at work.
"There's currently a big push in psychiatry to look at the high suicide and burnout rates in people who work in healthcare," said Sarah Miller, a psychiatry resident at Temple University Hospitals who directs a course on art appreciation and mindfulness at the medical school with staff members at the Philadelphia Museum of Art. "How do you care for patients when you have a high difficulty caring for yourself?"
Last year, Miller collected data from the course for the first time, measuring students' mindfulness, burnout and exhaustion levels. Even though the sample group was small, her findings suggested that the course had a protective effect—students who took the course improved their exhaustion scores afterwards.
The National Academy of Medicine released a 332-page report earlier this year on clinician burnout, recommending that medical schools change their grading systems or implement formal faculty advisor-mentor programs.
"Burnout is not limited to medicine, but it's really bad in medicine," said Jessica Yang, a first-year medical student at Rowan University School of Osteopathic Medicine in Stratford, N.J. "Part of the issue is that mental health issues and stress don't end after medical school. That's just the beginning."
Some medical schools have made curriculum changes to promote stress management, like a pass-fail grading system or adding electives that allow students to explore other interests, and required mindfulness programs. Others have added more ways for students to get counseling when they need it and moved exams to Fridays to minimize studying over the weekend.
"We want students to start building these stress management habits that will last through their medical careers," said Nethra Ankam, an associate professor of rehabilitation medicine and the wellness thread director at Jefferson. "So many times, for students to get to medical school, they're like, 'Delay gratification, delay gratification, and then I'll rest.' But now they're here, so they need to continue at a speed that works for them."
Jefferson's wellness week, held midway through the semester, is part of the medical college's revamped curriculum, which launched in 2017. First-year students meet in small groups with second-years to share experiences; attend lectures on nutrition, exercise and sleep; and participate in knitting, cooking and mindfulness electives, often alongside faculty members. Wellness week ends on Wednesday with a story slam on resilience, so students have a chance to rest or travel home for what Ankam calls a "mini fall break."
"The idea behind this week is that it's a structured way for the fire hose of information that students have been going through for the last 10 weeks to turn off for a bit," Ankam said. "Students can recenter, figure out what's working, what's not working, and how they want to move forward."
Each semester, the College of Medicine at Drexel offers all medical students unlimited sessions with a psychologist or a psychiatrist based on campus. Their services are in high demand, according to Lisa Chang, a 25-year-old second-year medical student.
"Sometimes there are waits to see them," she said.
Chang said that besides counseling sessions, Drexel also has mandatory wellness lectures where students learn about relaxation tools, like meditation. The mandatory nature of those lectures can occasionally cause stress, she said, but students appreciate the support administrators are trying to provide.
"It's just not convenient sometimes when we're so busy, like the week before an exam," Chang said. "But I do find it helpful."