Two years ago, Stuart Slavin, MD, MEd, stepped onto the podium at the Association of American Medical Colleges’ annual meeting to pick up one of the nation’s most prestigious teaching awards for his career accomplishments, most notably spearheading a plan to restructure Saint Louis University’s medical school curriculum to help students reduce stress, depression and anxiety – and to make a dent in reversing the national trend of rising medical student suicides. The revised four-year curriculum has been heralded as a national model.

“Dr. Slavin is very courageous,” said Keith Frederick, DO, a Missouri state representative who proposed legislation also aimed at reversing the trend via the “Show-Me Compassionate Medical Education Act.” “Academics were concerned about test scores going down as a result of changes, but it didn’t happen. In fact, it had the opposite effect and blew the lid off this problem.”

Slavin took an interest in medical students’ mental wellbeing soon after joining Saint Louis University (SLU) School of Medicine as director of curriculum, after a 21-year run at UCLA, where he logged 75 to 80 hours a week as a professor of pediatrics and full-time pediatrician.

“No singular event occurred to pique my interest,” said Slavin, who gave up a pediatric practice to focus on his administrative role. “I kept reading in medical education literature about problems with mental health issues among students, interns, residents and physicians. I viewed medical student mental health as my responsibility. Medical schools place a great deal of emphasis on academic outcomes … if a medical student comes out of four years with good clinical skills, has done well on all exams, but they’re depressed and suicidal, what’s really been accomplished?”

Slavin began walking the campus, talking to students about their medical school experiences. “Our students seemed really happy,” he said. “They smiled a lot, seemed pleased with administration and education. I developed good relationships with them.”

Still, Slavin wanted hard numbers. “Trying to understand what students are experiencing traditionally hasn’t been part of the medical education culture,” he said.

In May 2008, he dispatched program evaluation questionnaires to SLU’s 175 medical students to be answered anonymously.

“I remember the day I got the survey results,” he said, shaking his head. “It was like a kick in the gut. It was devastating to see how many negative mental health outcomes we had in the school. Medical students are very good at hiding the pain they’re suffering. It can be very invisible from faculty and administration, and they’re hiding it from each other. I felt a sense of urgency with this problem.”

Survey results showed that, in the first year of medical school, 57 percent of students expressed moderate-to-high symptoms of anxiety; 27 percent reported moderate-to-severe symptoms of depression. Similar results were found for second-year students. They cited the volume of material, level of detail of material, and competition for grades among their greatest stressors in the first two years of the curriculum.

“I really started thinking about ways to design and implement curricular changes that would directly address these stressors and produce a less toxic educational environment,” said Slavin. “I knew if we let students get further down the road without addressing this issue, the problem would only grow worse.”

With the blessing of SLU leaders, Slavin implemented initial curricular changes in the 2009-10 academic year for the incoming class of 2013. First, a pass/fail grading system for preclinical courses replaced the existing grading system. Second, contact hours were reduced across the first two years of the curriculum by 10 percent to allow students more time to participate in new learning communities and longitudinal electives. Third, longitudinal electives were instituted.

“Before, electives for first- and second-year students included a half-day per week over seven weeks,” said Slavin. “In the new system, electives extended across the majority of years 1 and 2, with a half-day session every two weeks for a total of 12 days per academic year. This change allowed students more freedom to explore their interests, to create mentorship relationships with faculty and School of Medicine alumni, and to engage in service and/or research with more continuity. We retrofitted existing electives to fit the new system and developed new electives designed specifically to take advantage of the longitudinal nature of the experience.”

Fourth, five learning communities were established – service and advocacy, research, global health, wellness, and medical education – to include students and faculty who share common interests and passions for research and/or service beyond the classroom.

“We charged the learning communities with designing and implementing new electives, developing a lunch lecture series, identifying faculty mentors, and expanding service and research opportunities,” said Slavin.

In the 2010-11 academic year for the incoming class of 2014, Slavin implemented additional curricular changes. A required resilience and mindfulness (R/M) program, spanning six hours of curricular time in the fall semester, was added to the Applied Clinical Skills 1 course. R/M sessions, Slavin explained, focus on energy management, mindfulness cultivation, stress reduction, cognitive distortions/restructuring, optimistic explanatory styles, and character strengths.

Slavin also refined the pass/fail grading system by eliminating norm-referenced exam performance data from feedback given to students.

In the 2011-12 academic year for the incoming class of 2015, SLU implemented a third set of changes. For example, after students identified the Human Anatomy course as the most demanding and challenging in the preclinical curriculum – and a major source of stress – Slavin made two changes to the course. The medical school dean instructed course directors to produce exams that yielded a higher mean score, to be consistent with other courses in the preclinical curriculum “so that fewer students would feel at risk of failing,” Slavin noted. Also, the course was moved from its traditional position as the first course in the first year to follow courses in Cell Biology and Metabolism.

Because students typically have less than three months to choose a specialty, “we allowed them more time,” said Slavin.

Slavin has continued surveying students with questionnaires, resulting in improvement every year.

“In first year students, we have it down to 8 percent (moderate-to-severe symptoms of depression),” he said. “Moderate-to-severe symptoms of anxiety are down to 23 percent in our first-year students.”

“We wanted to impact the curriculum in a completely different way to give students better coping skills and to reduce stressors in the environment,” said Slavin. “Other medical schools haven’t looked at (this issue) hard enough.”

Editor’s Note: Please see series companion articles in this month’s edition: “Missouri Leads States on Medical Student Well-Being Advocacy” and “The Plight of Physicians-in-Training.”

LINKS:

Saint Louis University School of Medicine: http://www.slu.edu/medschool.xml