JAMA | OriginalInvestigation … · 2021. 1. 19. ·...

Association Between Learning Environment Interventionsand Medical Student Well-beingA Systematic ReviewLauren T. Wasson, MD, MPH; Amberle Cusmano, MA; Laura Meli, MSEd; Irene Louh, MD, PhD;Louise Falzon, PGDipInf; Meghan Hampsey; Geoffrey Young, PhD; Jonathan Shaffer, PhD, MS;Karina W. Davidson, PhD, MASc

IMPORTANCE Concerns exist about the current quality of undergraduate medical educationand its effect on students’ well-being.

OBJECTIVE To identify best practices for undergraduate medical education learningenvironment interventions that are associated with improved emotional well-beingof students.

DATA SOURCES Learning environment interventions were identified by searching thebiomedical electronic databases Ovid MEDLINE, EMBASE, the Cochrane Library, and ERICfrom database inception dates to October 2016. Studies examined any intervention designedto promote medical students’ emotional well-being in the setting of a US academic medicalschool, 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 andfull-text articles. Data were extracted into tables to summarize results. Study quality wasassessed by the Medical Education Research Study Quality Instrument (MERQSI), which hasa possible range of 5 to 18; higher scores indicate higher design and methods qualityand 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-grouppretest/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 was10.3 (SD, 2.11; range, 5-13). Studies encompassed a variety of interventions, including thosefocused on pass/fail grading systems (n = 3; mean MERSQI score, 12.0), mental healthprograms (n = 4; mean MERSQI score, 11.9), mind-body skills programs (n = 7; mean MERSQIscore, 11.3), curriculum structure (n = 3; mean MERSQI score, 9.5), multicomponent programreform (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 thatsome specific learning environment interventions were associated with improved emotionalwell-being among medical students. However, the overall quality of the evidence was low,highlighting the need for high-quality medical education research.

JAMA. 2016;316(21):2237-2252. doi:10.1001/jama.2016.17573Corrected on February 19, 2019.

Editorial page 2195

Related article page 2214

Supplemental content

CME Quiz atjamanetworkcme.com

Author Affiliations: Center forBehavioral Cardiovascular Health,Columbia University Medical Center,New York, New York (Wasson,Cusmano, Meli, Louh, Falzon,Davidson); George WashingtonUniversity, Washington, DC(Hampsey); Association of AmericanMedical Colleges, Washington, DC(Young); Department of Psychology,College of Liberal Arts and Sciences,University of Colorado at Denver(Shaffer); NewYork–PresbyterianHospital, New York, New York(Davidson).

Corresponding Author: Karina W.Davidson, PhD, MASc, Center forBehavioral Cardiovascular Health,Columbia University Medical Center,622 W 168th St, PH 9-314,New York, NY 10032([email protected]).

Research

JAMA | Original Investigation

(Reprinted) 2237

© 2016 American Medical Association. All rights reserved.

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M edical schools strive to educate knowledgeable, car-ing, and professional physicians and pay particularattention to opportunities for improving the under-graduate medical education (UME) learning environment asthey realize its influence on the education of future physicians.1

A critical element of the learning environment is its ef-fect on student well-being. Although matriculating US medi-cal students begin training with significantly lower rates of de-pression and burnout and report better mental and emotional

quality of life than othercollege-educated youngadults,2 their reportedwell-being decreases dur-ing the UME years. The re-ported rate of moderate tosevere depression is ap-proximately 14% and of

burnout symptoms is 52%—higher than reported by othergraduate students or population control samples.3,4 Studies in-dicate that up to 11% of medical students report suicidalideation.5

The Association of American Medical Colleges includes inits vision for improving medical education “the health and well-being of learners.”6 This systematic review evaluated the as-sociation between UME learning environment interventionsand the emotional well-being of students.

MethodsSearch StrategyPotentially relevant articles were identified (Figure) by search-ing the biomedical electronic databases Ovid MEDLINE,EMBASE, the Cochrane Library, and ERIC from database in-ception dates to October 2016 (eAppendix in the Supple-ment). Additional records were identified by scanning the ref-erence lists of relevant studies and reviews published betweenMay 2011 and October 2016 and by using the “similar ar-ticles” feature in PubMed and the “cited reference search” inWeb of Science. We searched for gray literature (“that whichis produced on all levels of government, academics, businessand industry in print and electronic formats, but which is notcontrolled by commercial publishers”)7 through ongoing trialregistries, academic dissertations, and websites of relevant or-ganizations (eg, Association of American Medical Colleges)(eAppendix in the Supplement).

Selection CriteriaStudies had to have examined the outcomes associated withany intervention aiming to promote students’ emotionalwell-being in the setting of an academic US medical school.The well-being outcome had to be obtained through surveys,semistructured interviews, or other quantitative methods.Open-ended response formats were excluded because theirmethodologic quality could not be appraised with the instru-ment used in this review. Medical education interventionsmeasured with open-ended responses have been reviewedand appraised elsewhere.8,9

Methodologic Quality RatingStudy quality was assessed using the Medical EducationResearch Study Quality Instrument (MERSQI), which wasdeveloped to appraise the methodologic quality of quantita-tive medical education research.10 MERSQI scores have beenpositively correlated with editorial decisions to publish andwith the presence of external funding for the researchconducted.10 The instrument is based on 10 design andmethods criteria: study design, number of institutions stud-ied, response rate, data type, internal structure, contentvalidity, criterion validity, appropriateness of data analysis,complexity of analysis, and outcome level. These criteriaform 6 domains, each with a maximum score of 3 and aminimum of 0 or 1, that sum to produce a total score thatranges from 5 to 18.

The MERSQI was preferred to the Newcastle-OttawaScale–Education (NOS-E), another assessment tool for medi-cal education research quality, because it was found to have

GWB General Well-Being Schedule

MERSQI Medical Education ResearchStudy Quality Instrument

NOS-E Newcastle-OttawaScale–Education

UME undergraduate medicaleducation

Figure. Review and Selection of Articles on the Association BetweenLearning Environment Interventions and Medical Student Well-being

4207 Records identified throughdatabase searching

3676 Records remaining and screenedafter duplicates removed

59 Full-text articles excluded23 Irrelevant intervention

7 Non–medical studentpopulation

3 Awaiting study results

15 Irrelevant outcomes11 Excluded study design

3589 Records excluded

30 Additional records identifiedthrough other sources

28 Studies included inqualitative synthesis

87 Full-text articles assessedfor eligibility

Key PointsQuestion What undergraduate medical education learningenvironment interventions are associated with improvedemotional well-being among medical students?

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

Meaning There is limited evidence to support learningenvironment interventions for improvement of emotionalwell-being among medical students. High-quality researchis needed.

Research Original Investigation Learning Environment Interventions and Medical Student Well-being

2238 JAMA December 6, 2016 Volume 316, Number 21 (Reprinted) jama.com



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Learning Environment Interventions and Medical Student Well-being Original Investigation Research

jama.com (Reprinted) JAMA December 6, 2016 Volume 316, Number 21 2239



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rm

edic

alst

uden

ts

Min

d-bo

dypr

ogra

mvs

cont

rol

(ran

dom

ized

)

N=

40In

terv

entio

n=

20Co

ntro

l=20

Spie

lber

gerS

tate

-Tra

itAn

xiet

yIn

vent

ory3

5

Anxi

ety

inte

stan

dso

cial

situ

atio

nqu

estio

nnai

reTe

nsio

nan

dde

pres

sion

ques

tionn

aire

Self-

este

emm

easu

reSt

ress

ques

tionn

aire

Inte

rven

tion

vsco

ntro

latf

ollo

w-u

p(s

core

)M

ore

awar

eof

tens

ion:

F 5,1

8=

37.1

6(P

<.0

01);

deal

ing

bett

erw

ithsc

hool

stre

ss:

F 5,1

8=

5.05

(P<

.04)

;anx

iety

befo

rete

st:F

1,2

2=

10.4

2(P

<.0

05)

Krae

mer

etal

,36

2016

Nonr

ando

miz

ed2-

grou

pFi

rst-

and

seco

nd-y

ear

med

ical

stud

ents

Min

d-bo

dypr

ogra

mvs

cont

rol

(non

rand

omiz

ed)

N=

52In

terv

entio

n=

28Co

ntro

l=24

Dist

ress

Tole

ranc

eSc

ale3

7

Perc

eive

dSt

ress

Scal

e10

16

,17

Posi

tive

Affe

ctNe

gativ

eAf

fect

Sche

dule

38

Chan

gesi

ndi

stre

ssto

lera

nce

(cha

nge

scor

e):

Min

d-bo

dy,0

.53;

t=−2

.81;

95%

CI,0

.92-

0.14

(P=

.01)

;con

trol

:0.2

5;t=

−1.6

695%

CI,−

0.06

to0.

55(P

=.1

1)

Rose

nzw

eig

etal

,39

2003

Nonr

ando

miz

ed2-

grou

pSe

cond

-yea

rm

edic

alst

uden

tsM

indf

ulne

ss-b

ased

stre

ssre

duct

ion

prog

ram

vsco

ntro

l(n

onra

ndom

ized

)

N=

302

Inte

rven

tion

=14

0Co

ntro

l=16

2

Prof

ileof

Moo

dSt

ates

18

Prof

ileof

Moo

dSt

ates

tota

lmoo

ddi

stur

banc

efo

rint

erve

ntio

nvs

cont

rol(

scor

e):

Inte

rven

tion,

38.7

(SD,

33.3

)vs3

1.8

(SD,

33.8

)(P

=.0

5);c

ontr

ol:2

8.0

(SD,

31.2

)vs

38.6

(SD,

32.8

)(P

<.0

01);

inte

ract

ion:

d=

−0.1

8(P

<.0

01)

Fink

elst

ein

etal

,40

2007

Nonr

ando

miz

ed2-

grou

pSe

cond

-yea

rm

edic

alst

uden

tsM

ind-

body

elec

tive

vsco

ntro

l(n

onra

ndom

ized

)

N=

72In

terv

entio

n=

26Co

ntro

l=46

Sym

ptom

Chec

klis

t90

Anxi

ety

Subs

cale

41

Prof

ileof

Moo

dSt

ates

18

Perc

eive

dSt

ress

ofM

edic

alSc

hool

Scal

e42

2-Ite

mDe

pres

sion

Inde

x43

Tim

e/gr

oup

inte

ract

ion

fors

core

s:An

xiet

y(S

ympt

omCh

eckl

ist-

90):

F 1,2

=3.

95(P

<.0

5);P

rofil

eof

Moo

dSt

ates

:F 1

,2=

3.77

(P<

.05)

;Per

ceiv

edSt

ress

ofM

edic

alSc

hool

Scal

e:F 1

,2=

.11

(Pva

lue

repo

rted

as“n

onsi

gnifi

cant

”)

Gree

son

etal

,44

2015

Sing

le-g

roup

pret

est/

post

test

Ally

ears

Befo

revs

afte

rm

ind-

body

skill

sin

terv

entio

n

N=

44Co

gniti

vean

dAf

fect

ive

Min

dful

ness

Scal

e–Re

vise

d45

Perc

eive

dSt

ress

Scal

e16

,17

Ope

n-en

ded

feed

back

Pre-

/pos

tinte

rven

tion

(sco

re):

Perc

eive

dSt

ress

Scal

e,29

.73

(SD,

9.61

)vs2

0.25

(SD,

9.03

);t(

33)

=7.

90;

d=

1.38

(P<

.001

)M

indf

ulne

ss:2

9.24

(SD,

5.54

)vs3

3.88

(SD,

6.13

);t(

33)

=5.

27;d

=0.

92(P

<.0

01)

Bond

etal

,46

2013

Sing

legr

oup

pret

est/

post

test

Firs

t-an

dse

cond

-yea

rm

edic

alst

uden

ts

Befo

revs

afte

rm

ind-

body

cour

seN

=27

Cohe

n’sP

erce

ived

Stre

ssSc

ale4

7,4

8

Self-

Regu

latio

nQ

uest

ionn

aire

49

Self-

Com

pass

ion

Scal

e33

Jeff

erso

nSc

ale

ofPh

ysic

ian

Empa

thy5

0

Pre-

/pos

tinte

rven

tion

(cha

nge

scor

e):

Perc

eive

dst

ress

:−0.

05(S

D,0.

62);

d=

.14

(P=

.70)

;sel

f-re

gula

tion:

0.13

(SD,

0.2)

;d

=−0

.41

(P=

.003

);se

lf-co

mpa

ssio

n:0.

28(S

D,0.

61);

d=

−0.5

5(P

=.0

4);

empa

thy:

0.11

(SD,

0.5)

;d=

−0.1

3(P

=.3

0)Cu

rric

ulum

Stru

ctur

e

(con

tinue

d)






Tabl

e1.

Stud

yCo

mpa

rison

and

Out

com

eM

easu

res(

cont

inue

d)

Sour

ceDe

sign

Popu

latio

nCo

mpa

rison

sSa

mpl

eSi

zes

Out

com

eM

easu

res

Mai

nRe

sults

Reed

etal

,20

2011

Nonr

ando

miz

ed≥2

-gro

upFi

rst-

and

seco

nd-y

ear

med

ical

stud

ents

7In

stitu

tions

’cu

rric

ulum

stru

ctur

esN

=20

56(1

192

resp

onde

d)M

asla

chBu

rnou

tInv

ento

ry2

1

Perc

eive

dSt

ress

Scal

e16

,17

Med

ical

Out

com

esSt

udy

Shor

tFor

m2

2,2

3

Asso

ciat

ion

betw

een

clin

ical

expe

rienc

esan

dth

efo

llow

ing

scor

es:

Perc

eive

dst

ress

:β=

0.02

;95%

CI,−

0.10

to0.

13(P

=.7

9);b

urno

ut:O

R,1.

01;9

5%CI

,0.9

8-1.

05(P

=.4

2;m

enta

lqua

lity

oflif

e:β

=0.

00;9

5%CI

,−0.

16to

0.16

(P=

.98)

;ser

ious

thou

ghts

ofdr

oppi

ngou

t:O

R,0.

96;9

5%CI

,0.9

3-1.

00(P

=.0

3)As

soci

atio

nbe

twee

nte

stin

gex

perie

nces

and

the

follo

win

gsc

ores

:Pe

rcei

ved

stre

ss:β

=0.

29;9

5%CI

,0.1

0-0.

84(P

=.0

03);

burn

out:

OR,

1.10

;95%

CI,

0.89

-1.2

3(P

=.0

9);m

enta

lqua

lity

oflif

e:b

–β

=−0

.63;

95%

CI,−

0.29

1to

0.96

(P<

.001

);se

rious

thou

ghts

ofdr

oppi

ngou

t:O

R,1.

19;9

5%CI

,1.1

2-1.

27(P

<.0

01)

Asso

ciat

ion

betw

een

No.o

ftes

tsan

dth

efo

llow

ing

scor

es:

Perc

eive

dst

ress

:β=

−0.0

2;95

%CI

,−0.

6to

0.03

(P=

.48)

;bur

nout

:OR,

0.99

;95%

CI,0

.97-

1.01

(P=

.19)

;men

talq

ualit

yof

life:

β=

0.03

;95%

CI,−

0.05

to0.

04(P

=44

);se

rious

thou

ghts

ofdr

oppi

ngou

t:O

R,1.

00;9

5%CI

,0.9

7-1.

02(P

=.8

2)Ca

mp

etal

,51

1994

Nonr

ando

miz

ed2-

grou

pFi

rst-

and

seco

nd-y

ear

med

ical

stud

ents

Prob

lem

-bas

edvs

lect

ure-

base

dle

arni

ng

N=

275

Prob

lem

-bas

edle

arni

ng=

60Le

ctur

e-ba

sed

lear

ning

=21

5

Zung

Self-

Ratin

gDe

pres

sion

Scal

e52

Depr

essi

onpr

oble

m-b

ased

lear

ning

vsle

ctur

e-ba

sed

lear

ning

(sco

re):

Ove

rall:

OR,

0.42

;95%

CI,0

.14-

1.21

(P=

.07)

;adj

ustm

entf

orse

xan

dse

lf-ac

tual

izat

ion:

OR,

0.45

;95%

CI,0

.14-

1.42

(P=

.14)

Korn

itzer

etal

,53

2005

Cros

s-se

ctio

nal

post

test

only

Allc

ohor

tsN

=92

Que

stio

nsre

gard

ing

prog

ram

atte

ndan

cefa

ctor

s,su

bjec

tive

med

ical

scho

oltr

ansi

tion

fact

ors,

prog

ram

ratin

gsan

dst

uden

tper

cept

ions

,and

acad

emic

bene

fits

ofpr

ogra

m

Unde

rrep

rese

nted

inm

edic

ine

grou

p(N

o.no

tpro

vide

d):

Gain

edco

nfid

ence

:85.

7%;m

ade

tran

sitio

nea

sier

:100

%;m

ade

frie

nds:

100%

Hum

aniti

esan

dm

edic

ine

grou

p(N

o.no

tpro

vide

d):

Gain

edco

nfid

ence

:97%

;mad

etr

ansi

tion

easi

er:9

7%;m

ade

frie

nds:

93.9

%

Mul

ticom

pone

ntPr

ogra

mRe

form

Drol

etan

dRo

dger

s,5

4

2010

Sing

le-g

roup

cros

s-se

ctio

nal

orpo

stte

ston

ly

Ally

ears

N=

116

Satis

fact

ion

surv

eyPo

sitiv

eex

perie

nce

with

Stud

entw

elln

essc

omm

ittee

:95%

(No.

notp

rovi

ded)

Flem

ing

etal

,55

2013

Sing

le-g

roup

cros

s-se

ctio

nal

orpo

stte

ston

ly(f

orth

eou

tcom

em

easu

rere

leva

ntto

this

revi

ew)

Ally

ears

N=

245

Vand

erbi

ltUn

iver

sity

stud

enta

ffai

rssu

rvey

Repo

rted

that

colle

ge’s

desi

gnco

ntrib

uted

mea

ning

fully

orso

mew

hatm

eani

ngfu

llyto

univ

ersi

tyex

perie

nce:

91%

(No.

notp

rovi

ded)

Real

etal

,56

2015

Sing

le-g

roup

cros

s-se

ctio

nal

orpo

stte

ston

ly

Ally

ears

N=

450

Mas

lach

Burn

outI

nven

tory

21

Prim

ary

Care

Eval

uatio

nof

Men

tal

Diso

rder

s27

,57

Part

icip

atio

nsu

rvey

Perc

eptio

nof

burn

outs

urve

y

Leve

lofb

urno

utw

ithin

aspe

ctso

fpro

gram

(sco

re:0

=m

ore

burn

out;

100

=le

ssbu

rnou

t):

Facu

ltym

ento

rs:7

0;an

nual

retr

eats

:58.

6;st

uden

t-le

dpr

ogra

mm

ing

com

mitt

ee:6

4;ov

eral

lwel

lnes

spro

gram

:69.

2Fa

culty

men

tors

corr

elat

ion

with

the

follo

win

gsc

ores

:em

otio

nale

xhau

stio

n:r=

−0.2

7;de

pers

onal

izat

ion:

r=−0

.22;

pers

onal

acco

mpl

ishm

ent:

r=0.

19An

nual

retr

eats

corr

elat

ion

with

the

follo

win

gsc

ores

:Em

otio

nale

xhau

stio

n:r=

−0.3

2;de

pers

onal

izat

ion:

r=−0

.32;

pers

onal

acco

mpl

ishm

ent:

r=0.

16St

uden

t-le

dpr

ogra

mm

ing

com

mitt

eeco

rrel

atio

nw

ithth

efo

llow

ing

scor

es:

Emot

iona

lexh

aust

ion:

r=−0

.31;

depe

rson

aliz

atio

n:r=

−0.3

;per

sona

lac

com

plis

hmen

t:r=

0.23

Ove

rall

wel

lnes

spro

gram

corr

elat

ion

with

the

follo

win

gsc

ores

:Em

otio

nale

xhau

stio

n:r=

−0.3

2;de

pers

onal

izat

ion:

r=−0

.23;

pers

onal

acco

mpl

ishm

ent:

r=0.

1M

ultic

ompo

nent

Prog

ram

Refo

rm(c

ontin

ued)

(con

tinue

d)






Tabl

e1.

Stud

yCo

mpa

rison

and

Out

com

eM

easu

res(

cont

inue

d)

Sour

ceDe

sign

Popu

latio

nCo

mpa

rison

sSa

mpl

eSi

zes

Out

com

eM

easu

res

Mai

nRe

sults

Slav

inet

al,5

820

14No

nran

dom

ized

>2-g

roup

Firs

t-an

dse

cond

-yea

rm

edic

alst

uden

ts

Coho

rtsw

ithdi

ffer

entp

hase

sof

mul

tipro

gram

refo

rmim

plem

enta

tion

N=

875-

890

Cent

erfo

rEpi

dem

iolo

gica

lStu

dies

Depr

essi

onSc

ale2

5

Spie

lber

gerS

tate

-Tra

itAn

xiet

yIn

vent

ory3

5

Perc

eive

dSt

ress

Scal

e16

,17

Perc

eive

dCo

hesi

onSc

ale1

9

Amer

ican

Med

ical

Colle

gesG

radu

atio

nQ

uest

ionn

aire

30

Mod

erat

eor

seve

rede

pres

sion

acco

rdin

gto

the

Cent

erfo

rEpi

dem

iolo

gica

lSt

udie

sDep

ress

ion

Scal

e(N

o.no

tpro

vide

d):

End

year

1:Cr

amér

V=

0.16

;pha

se1

vsco

ntro

l:21

%vs

27%

(Pva

lue

repo

rted

as“n

onsi

gnifi

cant

”);p

hase

1/2

vsco

ntro

l:18

%vs

27%

(Pva

lue

repo

rted

as“n

onsi

gnifi

cant

”);p

hase

1/2/

3vs

cont

rol:

11%

vs27

%(P

<.0

5)En

dye

ar2:

Cram

érV

=0.

18;p

hase

1vs

cont

rol:

17%

vs32

%(P

<.0

5);

phas

e1/

2vs

cont

rol:

18%

vs32

(P<

.05)

;pha

se1/

2/3

vsco

ntro

l:16

%vs

32%

32(P

<.0

5)An

xiet

y(N

o.no

tpro

vide

d):

End

year

1:Cr

amér

V=

0.23

;pha

se1

vsco

ntro

l:45

%vs

55%

(Pva

lue

repo

rted

as“n

onsi

gnifi

cant

”);p

hase

1/2

vsco

ntro

l:31

%vs

55%

(P<

.05)

;pha

se1/

2/3

vsco

ntro

l:31

%vs

55%

(P<

.05)

End

year

2:Cr

amér

V=

0.18

;pha

se1

vsco

ntro

l:61

%vs

60%

(Pva

lue

repo

rted

as“n

onsi

gnifi

cant

”);p

hase

1/2

vsco

ntro

l:39

%vs

60%

(P<

.05)

;pha

se1/

2/3

vsco

ntro

l:46

%vs

60%

(P<

.05)

Stre

ss(s

core

):En

dye

ar1:

η2=

0.06

;pha

se1

vsco

ntro

l:14

.9(S

D,6.

7)vs

16.3

(SD,

7.4)

(Pva

lue

repo

rted

as“n

onsi

gnifi

cant

”);p

hase

1/2

vsco

ntro

l:13

(SD,

6.8)

vs16

.3(S

D,7.

4)(P

<.0

5);p

hase

1/2/

3vs

cont

rol:

12.1

(SD,

6.1)

vs16

.3(S

D,7.

4)(P

<.0

5)En

dye

ar2:

part

ialη

2=

0.05

;pha

se1

vsco

ntro

l:14

.4(S

D,5.

8)vs

16.9

(SD,

7.3)

(P<

.05)

;pha

se1/

2vs

cont

rol:

13.9

(SD,

6.4)

vs16

.9(S

D,7.

3(P

<.0

5));

phas

e1/

2/3

vsco

ntro

l:13

.5(S

D,6.

8)vs

16.9

(SD,

7.3)

(P<

.05)

Cohe

sion

(sco

re):

End

year

1:pa

rtia

lη2

=0.

03;p

hase

1vs

cont

rol:

8.1

(SD,

1.7)

vs7.

9(S

D,2.

1)(P

valu

ere

port

edas

“non

sign

ifica

nt”)

;pha

se1/

2vs

cont

rol:

8.5

(SD,

2.1)

vs7.

9(S

D,2.

1)(P

<.0

5);p

hase

1/2/

3vs

cont

rol:

8.8

(SD,

1.8)

vs7.

9(S

D,2.

1)(P

<.0

5)En

dye

ar2:

part

ialη

2=

0.02

;pha

se1

vsco

ntro

l:8.

2(S

D,1.

6)vs

7.7

(SD,

2.0)

(P<

.05)

;pha

se1/

2vs

cont

rol:

8.5

(SD,

2.2)

vs7.

7(S

D,2.

0)(P

<.0

5);

phas

e1/

2/3

vsco

ntro

l:8.

1(S

D,2.

0)vs

7.7

(SD,

2.0)

(P<

.05)

Stra

yhor

n,5

9

1989

Nonr

ando

miz

ed2-

grou

pFi

rst-

year

med

ical

stud

ents

Coho

rtw

ithm

ultic

ompo

nent

prog

ram

refo

rmvs

earli

erco

hort

Univ

ersi

tyof

Nort

hCa

rolin

a,Ch

apel

Hill

vsco

mpa

rison

scho

ol

Resp

onde

rs=

478

(orig

inal

sam

ple

size

notr

epor

ted)

Lear

ning

Envi

ronm

entQ

uest

ionn

aire

60

Rand

Heal

thIn

sura

nce

Que

stio

nnai

res6

1

Envi

ronm

ents

tres

sesq

uest

ionn

aire

Soci

alsu

ppor

tque

stio

nnai

re

New

vsol

dcu

rric

ulum

stre

ssqu

estio

nnai

re:

Ove

rall

few

erst

ress

es:t

22

3=

−1.7

(P=

.09)

;les

sper

ceiv

edst

ress

from

soci

alan

dre

crea

tiona

lsou

rces

(P=

.03)

;no

redu

ctio

nin

finan

cial

-rel

ated

stre

ss(P

valu

eno

trep

orte

d)Ne

wvs

old

curr

icul

umm

enta

lwel

l-be

ing:

Grea

tero

vera

llw

ell-

bein

g:t 1

97

=−2

.04

(P=

.04)

;gre

ater

sens

eof

posi

tive

wel

l-be

ing

(P<

.001

);gr

eate

rsen

seof

vita

lity

(P<

.001

);le

ssde

pres

sion

(P<

.001

);le

ssan

xiet

y(P

<.0

01);

soci

alw

ell-

bein

g:t 2

23

=−1

.66

(P=

.10)

New

vsol

dcu

rric

ulum

soci

alsu

ppor

t:No

perc

eive

ddi

ffer

ence

inav

aila

bilit

yof

soci

alsu

ppor

ts:t

22

7=

−0.3

6(P

=.7

2);

less

clas

sadv

isor

supp

ort(

P=

.002

);cl

assa

dvis

orsl

essw

illin

gto

liste

n(P

=00

3);

clas

sadv

isor

sles

swill

ing

tohe

lpw

ithpe

rson

alpr

oble

ms(

P<

.001

);co

ncer

ned

abou

tstu

dent

s’w

elfa

re(P

=.0

03);

grea

ters

uppo

rtfr

omad

min

istr

ator

s(P

=.0

5);c

ould

rely

onad

min

istr

ator

swhe

nth

ings

gott

ough

(P=

.01)

;pe

rcei

ved

leve

lofs

uppo

rtfr

omfe

llow

stud

ents

,frie

nds,

sign

ifica

ntot

hers

(Pva

lue

notr

epor

ted)

Tim

e-co

ntro

l(Un

iver

sity

ofNo

rth

Caro

lina,

Chap

elHi

llvs

com

paris

on)l

earn

ing

envi

ronm

ent:

Few

eren

viro

nmen

tals

tres

sors

:F1

46

7=

6.41

(P=

.01)

;gre

ater

men

talw

ell-

bein

g:F 1

46

0=

9.32

(P=

.002

);gr

eate

rsoc

ialw

ell-

bein

g:F 1

46

6=

5.37

(P=

.02)

;no

diff

eren

cein

soci

alsu

ppor

t:F 1

47

7=

0.01

(P=

.91)

Mis

cella

neou

sWel

lnes

sPro

gram

s

(con

tinue

d)






Tabl

e1.

Stud

yCo

mpa

rison

and

Out

com

eM

easu

res(

cont

inue

d)

Sour

ceDe

sign

Popu

latio

nCo

mpa

rison

sSa

mpl

eSi

zes

Out

com

eM

easu

res

Mai

nRe

sults

Whi

teho

use

etal

,62

1996

Rand

omiz

edcl

inic

altr

ial

Firs

t-ye

arm

edic

alst

uden

tsSe

lf-hy

pnos

isin

terv

entio

nvs

cont

rol(

rand

omiz

ed)

N=

35In

terv

entio

n=

21Co

ntro

l=14

Med

ical

hist

ory

Prof

ileof

Moo

dSt

ates

Brie

fSym

ptom

Inve

ntor

yUn

iver

sity

ofCa

lifor

nia,

LosA

ngel

esLo

nelin

essS

cale

Tim

e-gr

oup

inte

rven

tion

anal

ysis

ofsc

ore:

Brie

fSym

ptom

Inve

ntor

yAn

xiet

y:F 3

,96

=2.

96(P

<.0

5)At

exam

inat

ion

perio

d,se

lf-hy

pnos

ispa

rtic

ipan

tsha

dsi

gnifi

cant

lylo

wer

stre

ssfu

lnes

ssc

ores

:t3

0=

2.11

(P<

.05)

Goet

zel

etal

,63

1984

Sing

le-g

roup

cros

s-se

ctio

nal

orpo

stte

ston

ly

Firs

t-,s

econ

d-,

and

third

-yea

rm

edic

alst

uden

ts

N=

26Gr

oup

Envi

ronm

entS

cale

Agre

emen

twith

stat

emen

ton

1-to

5-po

intL

iker

tsca

le:“

Iam

nolo

nger

aslo

nely

;Ife

elm

ore

toge

ther

with

peop

le”:

3.33

of5

(Pva

lue

notr

epor

ted)

Lee

and

Grah

am,6

4

2001

Sing

le-g

roup

cros

s-se

ctio

nal

orpo

stte

ston

ly

Firs

t-an

dse

cond

-yea

rm

edic

alst

uden

ts

N=

66Q

uest

ionn

aire

rela

ted

toth

ew

elln

esse

lect

ive

Stud

ents

appr

ecia

ted

that

the

wel

lnes

sele

ctiv

ehe

lped

them

real

ize

the

impo

rtan

ceof

pers

onal

wel

l-be

ing,

gave

perm

issi

onfo

rsel

f-ca

rean

dan

oppo

rtun

ityto

find

colle

gial

ity,a

ndpr

ovid

edva

rious

copi

ngst

rate

gies

:4/2

2(1

8.2%

)str

ongl

yag

ree;

17/2

2(7

7.3%

)agr

ee(P

valu

eno

trep

orte

d)St

uden

tsfe

ltth

atth

ew

elln

esse

lect

ive

over

emph

asiz

edst

ress

itsel

fand

deva

lued

the

wor

thof

hard

wor

k;re

alis

ticex

pect

atio

nsof

fere

din

this

cour

sese

emed

disc

oura

ging

:1/

22(4

.5%

)agr

ee(P

valu

eno

trep

orte

d)Ku

shne

ret

al,6

520

11Si

ngle

-gro

upcr

oss-

sect

iona

lor

post

test

only

Seco

nd-y

ear

med

ical

stud

ents

N=

343

(9re

late

dto

men

tala

ndem

otio

nal

heal

th)

Form

rela

ting

togo

alan

dac

hiev

emen

tSe

lf-re

port

edac

hiev

emen

tofm

enta

l/em

otio

nalh

ealth

beha

vior

chan

gego

als:

6/9

(66.

7%)a

gree

(Pva

lue

notr

epor

ted)

Grou

p-Ba

sed

Facu

ltyAd

viso

r/M

ento

rPro

gram

s

Sast

reet

al,6

620

10No

nran

dom

ized

2-gr

oup

Firs

t-,s

econ

d-,

and

third

-yea

rm

edic

alst

uden

ts

Coho

rtin

anad

viso

ryco

llege

prog

ram

vsea

rlier

coho

rtin

afa

culty

advi

sory

prog

ram

N=

318

Coho

rtin

prog

ram

=10

3Ea

rlier

coho

rt=

215

Que

stio

nnai

reso

npe

rcei

ved

effe

ctiv

enes

sof

the

syst

eman

dro

leof

advi

sori

npr

omot

ing

wel

lnes

sand

care

erco

unse

ling

Advi

sory

colle

gepr

ogra

mvs

facu

ltyad

viso

rypr

ogra

mw

elln

essa

dvis

ing

(No.

notp

rovi

ded)

Ifee

lcom

fort

able

disc

ussi

ngm

ype

rson

alst

ress

with

my

advi

sor:

62%

vs24

%;

χ2=

40.9

(P<

.001

)If

eelc

omfo

rtab

ledi

scus

sing

my

men

talh

ealth

with

my

advi

sor:

51%

vs27

%;

χ2=

31.8

4(P

<.0

01)

Satis

fact

ion

with

how

wel

ladv

isor

spro

mot

edw

elln

ess(

No.n

otpr

ovid

ed)2

7%vs

72%

(P<

.001

)Co

ates

etal

,67

2008

Nonr

ando

miz

ed2-

grou

pFo

urth

-yea

rm

edic

alst

uden

tsCo

hort

ina

men

torin

gpr

ogra

mvs

earli

erco

hort

N=

100

Coho

rtin

prog

ram

=70

Earli

erco

hort

=30

25-I

tem

tele

phon

esu

rvey

Coho

rtw

ithm

ento

ring

prog

ram

vsea

rlier

coho

rt:

Feel

scon

nect

edw

ithfa

culty

:14/

30(4

7%)v

s49/

70(7

0%)

Feel

scon

nect

edw

ithcl

assm

ates

:11/

30(3

7%)v

s30/

70(4

3%)

Fick

linet

al,6

819

83Si

ngle

-gro

upcr

oss-

sect

iona

lor

post

test

only

Firs

t-ye

arm

edic

alst

uden

tsN

=15

1Su

rvey

asse

ssin

g12

pers

onal

need

sof

first

-yea

rmed

ical

stud

ents

Prog

ram

help

fuln

ess(

only

desc

riptiv

esu

mm

ary

ofre

sults

prov

ided

):Be

com

ing

bett

erac

quai

nted

with

peer

sBe

com

ing

clos

eto

som

ecl

assm

ates

Help

ing

stud

ents

with

anxi

etie

sofs

tart

ing

scho

ol

Abbr

evia

tions

:ACG

ME,

Accr

edita

tion

Coun

cilf

orGr

adua

teM

edic

alEd

ucat

ion;

OR,

odds

ratio

.






generally higher interrater reliability (0.68-0.89)11 than theNOS-E. This may be due to its more objective assessments ofdesign strengths and weaknesses, although it omits items onthe comparability of groups and blinding.11 Although thereare no defined cutoff values differentiating high-quality fromlow-quality study methods, 1 study used a MERSQI score of14.0 or higher as an a priori cutoff of high quality.12

Data ExtractionTwo review authors (L.M. and L.F.) independently scannedthe title or abstract of all search results to determine whichstudies required further assessment, investigated all poten-tially relevant articles as full text, selected studies toinclude in this review, assigned a MERSQI score for each,and calculated a mean quality score across studies. Data dis-agreements were resolved by consultation with the thirdand fourth review authors (L.T.W. and I.L.). The originalintention noted in the study protocol was to conduct ameta-analysis, but because of the considerable variation inthe interventions, study designs, and outcomes, we did notpool the studies quantitatively, as they were judged to notbe combinable.69

ResultsThe literature search yielded 4207 publications, of which 28met the eligibility criteria for this systematic review (Figure).Publications were excluded if they were irrelevant or did notmeet the inclusion criteria; for example, we excluded publi-cations that focused on medical residents rather than medi-cal students, measured academic rather than well-being out-comes, or contained interventions not focused on thelearning environment. The studies included at least 8224student participants (1 study did not report a sample size)and encompassed a variety of designs, including single-group cross-sectional or posttest only (n = 10), single-grouppretest/posttest (n = 2), nonrandomized 2-group (n = 13),and randomized clinical trial (RCT; n = 3) designs; 89.2%were conducted at a single site. They had a wide range ofapproaches to improving students’ well-being that are cat-egorized and described below (pass-fail grading systems[n = 3], mental health programs [n = 4], mind-body skillseducation/training [n = 7], curriculum structure [n = 3], mul-ticomponent program reform [n = 5], wellness programs[n = 4], and group-based faculty advisor/mentor programs[n = 3]). Individual study results are described below andstatistical details are provided for many key findings; addi-tional results and methods are shown in Table 1 and Table 2.The included studies’ methodologic rigor varied, withMERSQI scores ranging from 5.0 to 13.0 (mean score, 10.3;SD, 2.11 [n = 28]). The mean MERSQI score in publishedmedical education studies, as assessed in another review,was 10.0.10 The studies with the highest-quality methodscrossed all types of interventions and all types of outcomemeasures. The highest-scored categories tested interven-tions involving pass/fail grading, mental health programs,and mind-body skills education/training.

Pass/Fail Grading System (Mean MERSQI Score, 12.0)Bloodgood et al13 (n = 281; MERSQI, 11.5) and Rohe et al15

(n = 81; MERSQI, 12.0) each described that a cohort of pre-clinical students graded according to a pass/fail grading sys-tem, compared with an earlier student cohort evaluatedaccording to a 5-interval grading system (A/B/C/D/F),reported statistically significantly better well-being. Theyreported less anxiety, depression,13 and stress15 and betterwell-being13 and group cohesion scores at various studytime points.15 These 2 studies differed, however, in thedurability of improvements. Bloodgood et al13 found no dif-ference at 2 years between the cohort of students with a2-year pass/fail system compared with a cohort of studentswith a 5-interval system on measures of anxiety (GeneralWell-Being Schedule [GWB]14 anxiety subscore [range, 3-28;lower scores indicate more severe distress]; mean, 14.08 vs14.20; P = .86), depression (GWB14 depression subscore[range, 2-22; lower scores indicate more severe distress];mean, 15.56 vs 15.35; P = .71), or well-being (GWB14 well-being subscore [range, 3-18; lower scores indicate moresevere distress]; mean, 10.59 vs 10.40; P = .67). Rohe et al15

reported a persistent difference at 2 years between gradingcohorts on a measure of stress (Perceived Stress Scale16

[range, 0-40; higher score indicates more stress]; mean, 15.8[SD, 6.8] vs 20.5 [SD, 7.8]; P = .01) and speculated that thisdifference was due to continuing reports of elevated groupcohesion (Perceived Cohesion Scale19 [range, 0-36; higherscores indicate more cohesion]; mean, 33.8 [SD, 8.0] vs 29.0[SD, 9.9]; P = .02).

Reed et al20 (n = 2056; MERSQI, 12.5) compared well-being among students at different medical schools withgrading systems that were categorized as either having 3 ormore intervals (eg, honors/pass/fail) or pass/fail and foundthat systems with 3 or more intervals were associated withstatistically significantly more stress (β = 1.91; 95% CI, 1.05-2.78; P < .001) and burnout (odds ratio, 1.58; 95% CI, 1.24 to2.01; P < .001), and a higher likelihood of considering with-drawing from medical school (odds ratio, 1.91; 95% CI, 1.30-2.80; P = .001).

Mental Health Programs (Mean MERSQI Score, 11.9)Thompson et al24 (n = 120; MERSQI, 11.5) evaluated a multi-pronged program aimed at reducing mental health stigmaand making services more accessible. The study found thatsignificantly smaller proportions of the student cohortexposed to the program compared with the prior studentcohort reported symptoms of mild or probable depression(14/58 [24.1%] vs 26/44 [59.1%]; P < .01) and suicidal ideation(1/33 [3.0%] vs 13/43 [30.2%]; P < .001).26 Seritan et al29

(number of participants not reported; MERSQI, 11.5) exam-ined a different multipronged mental health/wellness pro-gram offering prevention, support, and enhanced clinical ser-vices, which was associated with improved student ratingsof personal counseling, mental health, and stress manage-ment services.29 Percentages of self-referral to mental healthservices increased from a baseline rate of 50% to a postinter-vention rate of 91%. For both findings, statistical significancewas not reported.29






Tabl

e2.

Met

hods

ofIn

clud

edSt

udie

s

Sour

ceN

o.of

Site

sO

vera

llSa

mpl

eSi

zeW

omen

,No.

(%)

Inte

rven

tion

Eval

uatio

nM

ERSQ

ISco

reAi

mPa

ss/F

ailG

radi

ngSy

stem

s

Bloo

dgoo

det

al,1

320

09Si

ngle

site

N=

281

5-In

terv

al(A

/B/C

/D/F

):62

%Pa

ss/f

ail:

46%

Chan

ged

first

-and

seco

nd-y

earg

radi

ngsy

stem

from

5-in

terv

alle

tter

grad

esto

pass

/fai

lgra

ding

syst

emin

first

2pr

eclin

ical

year

sSe

lf-as

sess

men

t11

.5M

easu

reth

eas

soci

atio

nof

chan

gein

grad

ing

syst

emso

nm

edic

alst

uden

tsa

tisfa

ctio

nan

dps

ycho

logi

calw

ell-

bein

gRo

heet

al,1

5

2006

Sing

lesi

teN

=81

5-In

terv

al(A

/B/C

/D/F

):26

/41

(63%

)Pa

ss/f

ail:

20/4

0(5

0%)

Repl

aced

5-in

terv

algr

adin

gsy

stem

forf

irstp

recl

inic

alye

arw

itha

mod

ified

pass

/fai

lsys

tem

(gra

ding

incl

uded

pass

/mar

gina

lpas

sreq

uirin

gst

uden

tact

ion

forr

emed

iatio

n/fa

il)du

ring

first

prec

linic

alye

ar

Self-

asse

ssm

ent

12M

easu

reth

esu

stai

ned

and

imm

edia

teef

fect

sofa

pass

/fai

lgra

ding

syst

emon

stre

ss,m

ood,

grou

pco

hesi

on,a

ndte

stan

xiet

yRe

edet

al,2

0

2011

Mul

tisite

N=

2056

(119

2re

spon

ded)

550/

1192

(47%

)M

ultis

itesu

rvey

of2

diff

eren

tgra

ding

scal

es:p

ass/

fail

and

≥3-i

nter

val

(eg,

hono

rs/p

ass/

fail,

hono

rs/h

igh

pass

/pas

s/m

argi

nalp

ass/

fail)

Self-

asse

ssm

ent

12.5

Exam

ine

the

rela

tions

hip

amon

gcu

rric

ulum

stru

ctur

e,gr

adin

gsc

ales

,and

stud

entw

ell-

bein

gM

enta

lHea

lthPr

ogra

ms

Thom

pson

etal

,24

2010

Sing

lesi

teN

=12

0M

ultip

rong

edin

terv

entio

nfo

rthi

rd-y

ears

tude

ntsa

imed

at(1

)red

ucin

gba

rrie

rsto

men

talh

ealth

trea

tmen

tby

redu

cing

stig

ma

via

facu

ltyed

ucat

ion,

men

talh

ealth

curr

icul

um,i

nclu

ding

lect

ures

and

ast

uden

tha

ndbo

okan

d(2

)ful

lyco

nfid

entia

land

redu

ced/

no-c

ostc

ouns

elin

gse

rvic

es

Self-

asse

ssm

ent

11.5

Test

the

effe

ctiv

enes

sofa

nin

terv

entio

nm

eant

tore

duce

depr

essi

vesy

mpt

oms

and

suic

idal

idea

tion

Dow

nset

al,2

6

2014

Sing

lesi

teN

=10

08(p

rogr

am)

n=

343

(pro

gram

and

scre

en)

Year

1:93

/148

(63%

)Ye

ar2:

34/6

5(5

2%)

Year

3:27

/49

(55%

)Ye

ar4:

49/7

9(6

2%)

Four

-yea

rint

erve

ntio

nin

clud

ing

aned

ucat

iona

lgro

uppr

ogra

m(le

ctur

es,

wor

ksho

ps,t

rain

ings

)and

aw

eb-b

ased

men

talh

ealth

scre

enin

gsu

rvey

Self-

asse

ssm

ent

and

surv

ey13

Educ

ate,

dest

igm

atiz

e,id

entif

y,re

fer,

and

trea

tind

ivid

uals

with

depr

essi

onan

din

crea

sed

suic

ide

risk

Serit

anet

al,2

9

2015

Sing

lesi

teM

ultip

rong

edm

enta

lhea

lth/w

elln

essp

rogr

amof

ferin

gpr

even

tion,

supp

ort,

and

enha

nced

clin

ical

serv

ices

(ie,h

iring

aps

ychi

atris

tto

offe

rm

edic

atio

nm

anag

emen

t)th

roug

hde

velo

pmen

tofa

new

Off

ice

ofSt

uden

tWel

lnes

swith

even

ing

hour

sand

stric

tcon

fiden

tialit

y

Surv

ey11

.5Pr

esen

tatio

nof

am

odel

fore

ffec

tive

prev

entiv

est

uden

twel

lnes

s

Mou

tier

etal

,31

2012

Sing

lesi

teN

=49

8(1

32sc

reen

ed)

Two-

pron

ged

inte

rven

tion

cons

istin

gof

gran

dro

unds

lect

ure

onm

enta

lhe

alth

and

aw

eb-b

ased

men

talh

ealth

scre

enin

gsu

rvey

Self-

asse

ssm

ent

11.5

Deve

lop

am

enta

lhea

lthpr

ogra

mto

addr

essp

hysi

cian

and

med

ical

stud

ent

depr

essi

onan

dsu

icid

eM

ind-

Body

Skill

sEdu

catio

n/Tr

aini

ngPr

ogra

ms

Erog

ulet

al,3

2

2014

Sing

lesi

teN

=58

26/5

8(4

5.6%

)Ei

ght-

wee

km

indf

ulne

ss-b

ased

stre

ssre

duct

ion

inte

rven

tion

for

first

-yea

rmed

ical

stud

ents

Self-

asse

ssm

ent

12As

sess

whe

ther

anab

ridge

dm

indf

ulne

ss-b

ased

stre

ssre

duct

ion

inte

rven

tion

can

impr

ove

wel

lnes

sHo

ltzw

orth

-M

unro

eet

al,3

419

85

Sing

lesi

teN

=40

Six

wee

kly

mee

tings

focu

sed

onte

achi

ngsk

illst

ore

duce

stre

ssle

vels

(pro

gres

sive

mus

cle

rela

xatio

n,sk

illst

ohe

lpre

cogn

ize

and

chan

gem

alad

aptiv

eth

ough

ts,a

ndm

edita

tion

tech

niqu

es)

Self-

asse

ssm

ent

10He

lpst

uden

tsac

quire

and

deve

lop

skill

sto

cope

with

stre

ss

Krae

mer

etal

,36

2016

Sing

lesi

teN

=52

62.7

%M

ind-

body

prog

ram

cons

istin

gof

11w

eekl

ysk

illtr

aini

nggr

oups

focu

sing

onm

ind-

body

skill

s(bi

ofee

dbac

k,gu

ided

imag

ery,

rela

xatio

n,br

eath

ing

exer

cise

s,au

toge

nic

trai

ning

,and

med

itatio

n)

Self-

asse

ssm

ent

and

surv

ey12

Desc

ribe

chan

gesi

ndi

stre

ssto

lera

nce

afte

rcom

plet

ing

am

ind-

body

skill

str

aini

nggr

oup

Rose

nzw

eig

etal

,39

2003

Sing

lesi

teN

=30

2M

indf

ulne

ss-b

ased

stre

ssre

duct

ion

incl

udin

g10

wee

kly

90-m

inut

ese

ssio

nste

achi

ngm

indf

ulne

ssm

edita

tion

prac

tices

and

daily

,in

depe

nden

tmed

itatio

n

Self-

asse

ssm

ent

11Ex

amin

eth

eef

fect

iven

esso

fm

indf

ulne

ss-b

ased

stre

ssre

duct

ion

sem

inar

Min

d-Bo

dySk

illsE

duca

tion/

Trai

ning

Prog

ram

s(co

ntin

ued)

(con

tinue

d)






Tabl

e2.

Met

hods

ofIn

clud

edSt

udie

s(co

ntin

ued)

Sour

ceN

o.of

Site

sO

vera

llSa

mpl

eSi

zeW

omen

,No.

(%)

Inte

rven

tion

Eval

uatio

nM

ERSQ

ISco

reAi

mFi

nkel

stei

net

al,4

020

07Si

ngle

site

N=

72Ti

me

1:in

terv

entio

n,17

/26

(77.

3%);

cont

rol,

22/4

6(6

1.1%

)Ti

me

2:in

terv

entio

n,17

/26

(77.

3%);

cont

rol,

16/2

5(8

0%)

Tim

e3:

inte

rven

tion,

15/2

3(7

5%);

cont

rol,

20/4

0(6

2.5%

)

“Min

d-Bo

dyM

edic

ine:

AnEx

perie

ntia

lEle

ctiv

e,”

incl

udin

g10

sess

ions

ofdi

dact

ican

dsm

all-

grou

pin

stru

ctio

nSe

lf-as

sess

men

t11

Asse

ssth

eef

fect

iven

esso

fast

ress

redu

ctio

nel

ectiv

eon

seco

nd-y

ear

med

ical

stud

ents

Gree

son

etal

,44

2015

Sing

lesi

teN

=44

29/4

4(6

5)Fo

urw

eekl

y1.

5-ho

ursm

all-

grou

pse

ssio

nsan

dho

me

prac

tice

ofm

ind-

body

skill

sin

addi

tion

tom

onito

ring

aw

eekl

yse

lf-ca

rego

alSe

lf-as

sess

men

tan

dse

mis

truc

ture

din

terv

iew

11.5

Eval

uate

the

feas

ibili

ty,a

ccep

tabi

lity,

and

effe

ctiv

enes

sofa

stre

ss-m

anag

emen

tan

dse

lf-ca

sew

orks

hop

Bond

etal

,46

2013

Sing

lesi

teN

=27

Elev

en-w

eek

embo

died

heal

thco

urse

com

bini

ngyo

gam

edita

tion

and

neur

osci

ence

dida

ctic

sSe

lf-as

sess

men

tan

dse

mis

truc

ture

din

terv

iew

11.5

Eval

uate

the

psyc

holo

gica

leff

ects

ofan

11-w

eek

min

d-bo

dyel

ectiv

eco

urse

Curr

icul

umSt

ruct

ure

Reed

etal

,20

2011

Mul

tisite

N=

2056

(119

2re

spon

ded)

550/

1192

(47%

)M

ultis

itesu

rvey

of2

diff

eren

tgra

ding

scal

es:p

ass/

fail

and

≥3-i

nter

val

(eg,

hono

rs/p

ass/

fail,

hono

rs/h

igh

pass

/pas

s/m

argi

nalp

ass/

fail)

Self-

asse

ssm

ent

12.5

Exam

ine

the

rela

tions

hip

amon

gcu

rric

ulum

stru

ctur

e,gr

adin

gsc

ales

,an

dst

uden

twel

l-be

ing

Cam

pet

al,5

1

1994

Sing

lesi

teN

=27

593

/275

(33.

8%)

Stud

ent-

dire

cted

,pro

ject

-bas

edle

arni

ngap

proa

chfe

atur

ing

smal

l-gr

oup,

prob

lem

-bas

edse

ssio

nsin

whi

chbo

thba

sic

and

clin

ical

scie

nce

lear

ning

issu

esar

ege

nera

ted;

lect

ure-

base

dle

arni

ngis

anin

stru

ctor

-dire

cted

,did

actic

appr

oach

Self-

asse

ssm

ent

12As

sess

chan

gesi

nde

pres

sion

amon

gm

edic

alst

uden

tsen

rolle

din

ale

ctur

e-ba

sed

vspr

oble

m-b

ased

lear

ning

prog

ram

Korn

itzer

etal

,53

2005

Sing

lesi

teN

=92

Six-

wee

kpr

emat

ricul

atio

nen

richm

entp

rogr

amta

rget

ing

educ

atio

nally

disa

dvan

tage

dst

uden

ts(d

idac

ticse

ssio

nsan

dla

bora

tory

com

pone

nt)

Surv

ey7

Dete

rmin

ew

heth

ered

ucat

iona

llydi

sadv

anta

ged

stud

ents

part

icip

atin

gin

asu

mm

eren

richm

entp

rogr

amw

ere

repo

rted

toha

veha

dan

easi

ertim

ead

just

ing

tom

edic

alsc

hool

Mul

ticom

pone

ntPr

ogra

mRe

form

Drol

etan

dRo

dger

s,5

4

2010

Sing

lesi

teN

=11

6Va

nder

bilt

med

ical

stud

entw

elln

essp

rogr

amto

prom

ote

stud

enth

ealth

and

wel

l-be

ing

thro

ugh

chan

ges,

incl

udin

gfa

culty

men

torin

g(a

dvis

ory

colle

gepr

ogra

man

dVa

nder

bilt

Med

ical

Stud

entC

aree

rsin

Med

icin

e),

curr

icul

um(V

MS

Live

Prog

ram

),an

dst

uden

twel

l-be

ing

(stu

dent

wel

lnes

scom

mitt

ee)

Surv

ey6.

5Ev

alua

tea

mul

ticom

pone

ntw

elln

ess

prog

ram

Flem

ing

etal

,55

2013

Sing

lesi

teN

=24

5In

itiat

ives

,act

iviti

es,a

ndre

sour

cesi

nclu

ding

(1)a

dvis

ory

colle

gepr

ogra

mfo

rstu

dent

wel

l-be

ing

and

care

erm

ento

ring/

advi

sing

with

anad

ditio

nala

imof

esta

blis

hing

rela

tions

hips

betw

een

stud

ents

and

facu

ltyse

rvin

gas

both

teac

hers

and

role

mod

els;

(2)s

tude

nt-l

edst

uden

tw

elln

essc

omm

ittee

focu

sed

onpe

erm

ento

ring,

soci

alco

mm

unity

,and

min

d/bo

dyw

elln

essp

rogr

amm

ing;

(3)V

ande

rbilt

Med

ical

Stud

ent

Care

ersi

nM

edic

ine

forc

aree

rexp

lora

tion,

advi

sing

,and

plan

ning

asw

ell

asre

side

ncy

appl

icat

ion

prep

arat

ion;

(4)V

MS

Live

Prog

ram

focu

sed

onpe

rson

alde

velo

pmen

tofp

hysi

cian

sin

trai

ning

;and

(5)4

-yea

rCol

lege

Collo

quiu

mCo

urse

focu

sed

onm

edic

alhu

man

ities

and

form

ally

addr

essi

ngpr

ofes

sion

alis

m,e

thic

s,an

dle

ader

ship

skill

s

Surv

ey6

Refle

cton

and

desc

ribe

lear

ning

com

mun

itysy

stem

and

effe

cton

stud

ent

satis

fact

ion

Mul

ticom

pone

ntPr

ogra

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