key: cord-0019407-nzcbmujm
authors: Moss, Stephana J.; Wollny, Krista; Amarbayan, Mungunzul; Lorenzetti, Diane L.; Kassam, Aliya
title: Interventions to improve the well-being of medical learners in Canada: a scoping review
date: 2021-07-20
journal: CMAJ Open
DOI: 10.9778/cmajo.20200236
sha: 620e151f401ef7080bf1554e9e4a261efcc3ea5c
doc_id: 19407
cord_uid: nzcbmujm

BACKGROUND: Medical education affects learner well-being. We explored the breadth and depth of interventions to improve the well-being of medical learners in Canada. METHODS: We searched MEDLINE, EMBASE, CINAHL and PsycINFO from inception to July 11, 2020, using the Arksey–O’Malley, 5-stage, scoping review method. We included interventions to improve well-being across 5 wellness domains (i.e., social, mental, physical, intellectual, occupational) for medical learners in Canada, grouped as undergraduate or graduate nonmedical (i.e., health sciences) students, undergraduate medical students or postgraduate medical students (i.e., residents). We categorized interventions as targeting the individual (learner), program (i.e., in which learners are enrolled) or system (i.e., higher education or health care) levels. RESULTS: Of 1753 studies identified, we included 65 interventions that aimed to improve well-being in 10 202 medical learners, published from 1972 through 2020; 52 (80%) were uncontrolled trials. The median year for intervention implementation was 2010 (range 1971–2018) and the median length was 3 months (range 1 h–48 mo). Most (n = 34, 52%) interventions were implemented with undergraduate medical students. Two interventions included only undergraduate, nonmedical students; none included graduate nonmedical students. Most studies (n = 51, 78%) targeted intellectual well-being, followed by occupational (n = 32, 49%) and social (n = 17, 26%) well-being. Among 19 interventions implemented for individuals, 14 (74%) were for medical students; of the 27 program-level interventions, 17 (63%) were for resident physicians. Most (n = 58, 89%) interventions reported positive well-being outcomes. INTERPRETATION: Many Canadian medical schools address intellectual, occupational and social well-being by targeting interventions at medical learners. Important emphasis on the mental and physical well-being of medical learners in Canada warrants further exploration.

We searched MEDLINE, EMBASE, CINAHL and PsycINFO from inception to July 11, 2020. We developed search strategies with an experienced medical librarian (D.L.L.), which combined synonyms and subject headings from 3 concepts: medical learners in Canada, well-being and interventions. We also searched review databases to identify review articles to screen reference lists for studies missed in our initial search. One author (S.J.M.) conducted all searches and reviewed reference lists. The complete MEDLINE search strategy is provided in Appendix 1, Supplemental Table 1 , available at www.cmajopen. ca/content/9/3/E765/suppl/DC1.

Our inclusion criteria were that studies from any publication year be primary research of interventions (e.g., mentoring, or educational interventions) for medical learners in Canada that aimed to improve well-being. We excluded studies if they were not primary research (e.g., editorials) or did not report any outcome from an intervention aimed to improve well-being. We defined a medical learner as an individual registered in an academic institution whose program is housed in a Canadian medical school and pertains to research or treatment of diseases and injuries or relating to medicine (i.e., undergraduate medical student, postgraduate medical student [resident physician], undergraduate nonmedical [health sciences] student, graduate science [MSc or PhD] student). 20 We defined an intervention as any randomized or nonrandomized experimental study. We included studies if wellbeing was 1 component of a multicomponent intervention (e.g., education intervention to address intellectual well-being, not just clinical skills). We selected domains of well-being (i.e., social, mental, physical, intellectual, occupational) 14 for our scoping review based on a needs assessment performed among medical learners at a Canadian medical institution; we validated operational definitions for domains. 21 We used broad inclusion criteria (inclusive of all medical learners) to explore the breadth and depth of well-being support among medical learners as they transition through their studies into a health care profession. Understanding the comprehensiveness of well-being support throughout the academic trajectory will benefit efforts to develop effective interventions for students as they transition through medical education. 22 

Three authors (S.J.M., K.W., M.A.) reviewed titles and abstracts, independently and in duplicate, after achieving 100% agreement on a pilot test of 50 random studies. The same authors reviewed the full text of selected articles, independently and in duplicate; we included articles in the final review if both reviewers agreed on inclusion. A fourth author (A.K.) resolved disagreements.

Independently and in duplicate, we (S.J.M., K.W., M.A., A.K.) charted data for included studies using a data collection sheet that was developed and piloted by the review team, resolving discrepancies through discussion. We collected information on document characteristics (e.g., year, geographic location), study characteristics (e.g., medical school, time frame), learner group, intervention domains (i.e., social, mental, physical, intellectual, occupational), level of intervention (i.e., individual, program, system), outcomes (e.g., assessment measures, themes or theories), limitations and conclusions.

We synthesized findings descriptively (Table 1 ) and categorized the level of intervention as targeted to the individual (i.e., the individual learner or group of individual learners), program (i.e., the program in which the learner is enrolled) or system (i.e., the academic institution or health care system in which learners learn or work). We recorded the primary level for each intervention. We categorized outcomes within 5 validated domains of well-being 21 that represent part of the multidimensional construct of well-being: social (e.g., equity, diversity), mental (e.g., mindfulness, emotions), physical (e.g., exercise, nutrition), intellectual (e.g., tools, education) and occupational (e.g., research, resident rotation). Multiple outcomes (within multiple domains) could be recorded for each intervention.

We (S.J.M., K.W., M.A., A.K.) synthesized results from included qualitative studies using thematic synthesis for reviews on health research. 23, 24 We developed discrete themes that represented findings reported in primary studies, and considered these themes to generate new interpretive constructs, explanations or hypotheses. 25 We integrated our qualitative and quantitative findings by using qualitative results to interrogate quantitative results, to identify research gaps and to synthesize lines of inquiry. 26 We classified reported outcomes for each well-being domain as statistically significant if p < 0.05. We calculated descriptive statistics using STATA IC15 (StataCorp).

We did not require ethics approval as all data were available in published records.

Of 1753 relevant studies identified, we included 65 interventions that aimed to improved medical learner well-being (Figure 1) . Characteristics of included studies are in Appendix 2, Supplemental Table 2 , available at www.cmajopen.ca/ content/9/3/E765/suppl/DC1. The 65 included studies were published between 1973 and 2020, and were conducted most frequently at University of Toronto (n = 16, 25%) or McGill University (n = 8, 12%) with undergraduate (n = 34, 52%) or postgraduate medical education students (n = 31, 48%) (Figure 2) . Figure 3 illustrates the cumulative number of published studies on interventions. Among 44 studies that reported implementation year, the median was 2010 (range 1971-2018). The median intervention duration, reported from 47 studies, was 3 months (range 1 h-48 mo). Most studies (n = 52, 80%) were uncontrolled trials, of which half were implemented with undergraduate medical students (n = 26). We included 16 qualitative studies; most (n = 9) were conducted with undergraduate medical students. Resident physicians were commonly from family medicine (n = 6) and pediatrics (n = 6), which included pediatric subspecialties (n = 2); generalist practice was more broadly defined (n = 4).

Fifty-one (78%) interventions targeted intellectual (e.g., clinical skills modules 46 ) well-being and 32 (49%) targeted occupational well-being (e.g., resident rotation bundle 47 ); 23 (35%) targeted both domains (e.g., specialty exploration and discovery programs 92 ). Among 19 interventions for individuals, most (n = 14) were for medical students. Program interventions (n = 27) were primarily for resident physicians (n = 17). Medical students and residents were represented similarly in system interventions (undergraduate, n = 9; postgraduate, n = 10). Two system interventions were for undergraduate health sciences students. Few studies (n = 2) incorporated formal mentorship programs in their intervention as a method to promote learner well-being. Only 3 studies considered barriers or stigma among medical learners to accessing appropriate mental health services.

Quantitative outcomes are reported in Appendix 3, Supplemental Table 3 , available at www.cmajopen.ca/content/9/3/ State of well-being in which individuals and communities feel they understand, are a part of, and are accepted by their social environment, and are comfortable expressing their feelings, needs, identities and opinions. 16 This includes processes (methods) and outcomes (experiences) of social well-being.

Isolation, imposterism, equity, diversity, discrimination, race, religion, ethnicity, family support

State of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. 23 Mindfulness, mental health, mental illness or disorder, anger, sadness, emotions Physical Perception and expectation of well-being of an individual's body, including the active and continuous effort to maintain optimum levels of physical activity and focus on nutrition, as well as self-care and maintenance of a healthy lifestyle. 16 This acknowledges physical health and limitations can coexist in a healthy environment.

Exercise, physical activity, physical health, nutrition, symptoms of burnout Intellectual State of well-being in which individuals are enabled to pursue creative, mentally stimulating activities that expand their knowledge, develop skills, and foster life-long learning and teaching, toward a goal of self-actualization. 16 This includes processes (how) and outcomes (deliverables) of intellectual well-being.

Learning, tools, outcomes, teaching, goals, learning needs Occupational Protection and promotion of workers or learners by preventing and controlling occupational diseases and accidents, and by elimination of conditions hazardous to health and safety at work or school, and the development and promotion of healthy and safe work or learning, work or learning environments and organizations. 24 This includes processes (responsibilities) and outcomes (trajectories) of occupational well-being.

Work, (resident) rotation, job, laboratory, research (assistantship or similar) E765/suppl/DC1. Statistical evaluation of interventions was explored extensively (n = 41, 63%), namely evaluating perceptions of well-being pre-and postintervention, satisfaction with the intervention, and determining attitudes and agreement regarding use of interventions. Figure 4 illustrates the number of studies that reported a significantly positive effect of interventions by well-being domain, level of intervention and learner group. In Appendix 4, available at www.cmajopen.ca/content/9/3/E765/suppl/DC1, we provide summaries on assessment tools used to measure outcomes within well-being domains, as well as a summary of statistical findings.

Sixteen studies explored well-being qualitatively. Most (n = 12) focused on promoting and understanding intellectual well-being in medical education ( Table 2) . Five qualitative studies reported favourable outcomes; 3 studies concluded that formal audit is needed 34,79,77 and 2 studies uncovered shortcomings related to postgraduate education content (i.e., intellectual, occupational well-being) 84 and undergraduate medical education leadership (i.e., social, intellectual well-being). 33 A key finding was that well-being among learners is a multidimensional construct that includes 4 components: genuine sense of personal fulfillment and gratification in medical education, grounded understanding of requirements for medical education programs, enhanced peer cohesion and functionality, and promoting cognitive flexibility to strengthen knowledge for diverse perspectives. Three conditions were identified as predicting and promoting well-being: effective coping and emotional regulation through individual strategies, individual and program affirmation of the role of being a learner in a medical school, and systems that favour attributing meaning to being a learner. Qualitative studies provided insight into catalyzing the shift from reducing manifestations of distress to proactively optimizing well-being.

We conducted a scoping review of published interventions conducted in Canadian medical schools to improve the well-being of medical learners. Our review shows that many Canadian medical schools address intellectual, occupational and social well-being through interventions targeted to individual medical learners and their respective programs, within the medical education system. The well-being of graduate students in health sciences programs does not appear to have been addressed through targeted interventions. Across all medical learners in Canada, mental and physical well-being is an important area that requires further exploration. Few included studies used formal faculty adviser or mentor programs as a method to promote social well-being. Mentorship is an interactive process to encourage learning and development, grounded in social learning principles, 93,94 that has been used extensively in medical schools in the United States. 12 Academic mentors model the importance of key components of social well-being -inclusion, diversity and professionalism -in medical education. 95 Formal mentorship programs that are integrated with curricular content can be used to offer career guidance to graduate science researchers, 96, 97 or to develop clinical skills among medical students 98 and resident physicians. 99 Mentorship programs for social well-being report high satisfaction, 100,101 career promotion, 102 improved clinical performance 103 and patient safety. 104 We encourage Canadian medical schools to consider social wellbeing among their medical learners.

Barriers to mental health treatment for medical learners are common 105, 106 and important to recognize for effective mental health interventions. 107, 108 Learners with mental health disorders and symptoms are often undiagnosed and undertreated. 109 We found a gap in increasing access and reducing stigma around mental health interventions within Canadian medical schools. In 2019, Wilkes and colleagues surveyed 69 undergraduate medical students and reported that 83% of students considered medical education a source of stress, and 70% met criteria for exhaustion; however, only 36% of students reported seeing a mental health professional to address mental health concerns. 110 There is a need for formal programs focused on mental well-being, inclusive of increasing awareness, reducing stigma and improving access to mental health services. Although such programs are associated with lower depression and suicidal ideation rates in the United States, the effectiveness of this approach in Canadian medical schools is unknown. 111 We found a scarcity of interventions aimed to improve the physical well-being of medical learners. 112 Physical wellbeing does not have comparable widespread acceptance as an aspect of physician well-being. 113, 114 Adherence to various dimensions of physical well-being is low among undergraduate medical education students. 115 In an online cross-sectional survey of fourth-year medical students at the University of British Columbia, Holtz and colleagues showed that those who perceived exercise counselling to be highly important to clinical practice participated in daily physical activity. 116 Although it may be hubristic to suggest interventions to improve learner physical well-being will improve patient outcomes, 117 we contend that encouraging physical well-being should be a core component in developing competent and professional future physicians. 118 Many interventions in Canadian medical schools promote collectives of learners to encourage a collaborative state of mind rather than peer-to-peer competition. All but 2 Canadian medical schools have adopted a pass/fail grading system for medical education. 119 A pass/fail system has been shown to improve intellectual well-being, 120 enhancing teamwork among learners 121 without negative impact on academic performance. 122 Pass/fail grading systems, complemented by standards-based evaluations, are a step along the continuum to recognizing learners as professionals, enhancing intellectual well-being and preparing medical students for life as enduring learners. 123, 124 Further, many studies reported that medical learners have higher satisfaction and greater achievement of knowledge-related outcomes when skills are taught in condensed workshops, ranging from 2 hours, 59 to 5 days, 41 to 2 weeks. 51 More research is needed to understand massed versus dispersed learning to maximize intellectual well-being.

Occupational well-being is an increasingly researched area in Canadian medical schools, particularly in resident trainees. 125 Compared with physicians, residents in Canada have a 48% increased risk of burnout, 95% increased risk of depression and 72% increased risk of suicidal thoughts. 126 Residency programs play a predominant role in the occupational wellbeing of residents; medical leaders have stressed the need for universities to make occupational well-being a core competency of medicine by redesigning medical programs. 127 We found many interventions that aimed to improve occupational well-being at the program and system level by addressing culture, learning and work environments; however, more research is needed to ensure that efficacious interventions are effectively implemented in a contextually adaptive manner to respond to individual learner needs.

We suggest 3 key directions when considering future interventions. First, positive psychological outcomes are important, 128 given that positive psychological adaptations evolve to meet the demands of stressful experiences. 129, 130 Highly resilient individuals are known to cultivate positive adaptations proactively; 131,132 it is unknown whether or not positive psychological adaptations are by-products of interventions or whether they improve coping. Future interventions for improved mental well-being should consider the aggregate of negative and positive mental well-being outcomes.

Second, the well-being of graduate science education students in Canada has not been considered widely. Scientific research is an important element in graduate science education programs, and learners conducting scientific research may face unique well-being challenges. 133, 134 In Canada, the integrative MD-PhD program is a popular approach for training physician-scientists, 135 representing a substantial investment of institutional, federal and societal resources. 136 Medical schools might consider interventions for all learners conducting scientific medical research to augment their success as future investigators.

Lastly, process evaluation is needed to assess the implementation of interventions and outcomes over time. Though most studies reported positive improvements, it is possible that interventions were not reliably delivered or consistently adhered to. 137 As others have mentioned, 12 we suggest that intervention evaluations include the study of sequential 

Social well-being Mental well-being Physical well-being Intellectual well-being Occupational well-being phases of implementation to determine synergies among well-being domains associated with improvement in learner well-being. Interventions may have adverse effects that should be weighed against potential benefits, 138 and success during one stage of training may not be helpful during the next stage of training. 139

The protocol for our review was not registered; we included only primary studies and did not search grey literature, which may fill gaps we identified or report interventions with negative outcomes. Our definition of medical learner is not a validated definition. 20 We categorized studies based on 5 domains of well-being, but there may be other well-being domains related to medical learning (e.g., spirituality). 140 We found authors nearly exclusively reported successes and few failures, which suggests positive publication bias. Given the multidimensional constructs of interventions, it was not possible to determine specific components of interventions associated with more favourable outcomes. The lack of a universal definition for learner well-being added complexity to study selection, but our broad inclusion criteria allowed us to produce a comprehensive summary of literature. Our review was limited to medical learners in Canada and the included studies did not report on subpopulations of learners (e.g., Indigenous students, international students). We were unable to comment on different race and ethnocultural factors influencing the learning experience. 141

Interventions to improve the well-being of medical learners in Canadian medical schools vary. Many Canadian medical schools have addressed intellectual, occupational and social well-being through interventions targeted to individual medical learners, their medical learning programs or the educational or health care systems. The well-being of graduate students in health sciences programs does not appear to have been addressed through targeted interventions. Across all medical learners in Canada, mental and physical well-being is an important area for further exploration. Comprehensive and inclusive interventions aimed to improve well-being for medical learners in Canada are needed. 

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