HEART-IM: A Fourth-Year Humanistic Elective for Improving Medical Education

Medical education is a rigorous process, one that challenges both students and faculty in caring for themselves. For example, while the prevalence of anxiety and depression in students entering medical school is comparable to the general population, significant increases in stress, anxiety, and depression arise within months of starting medical school.^1,2 A meta-analysis demonstrated an absolute median increase of 13% in depressive symptoms during medical school.³ Faculty struggle as well; in a study of faculty at a large academic center, 46% experienced burnout.⁴ Medical education faculty face challenges in institutions that undervalue teaching expertise and where collaboration is limited among teaching staff—both in professional development and student progress—resulting in a feeling of isolation.⁵

To address these negative effects of medical education, schools have begun focusing on wellness and the need for connection over isolation, hoping that this will mitigate the deleterious health effects of medical training.⁶ While wellness has been viewed as an adjunct to medical learning, it is becoming a core competency of professional development.⁷ In addition, some wellness efforts, such as learning communities, work to better connect faculty and students. One study showed that partnering students and faculty to implement wellness strategies resulted in lower levels of burnout and perceived stress, and improved quality of life in both faculty and students.⁸ Moreover, although student-faculty connections are important for wellness efforts, student-directed initiatives seem to have the most benefit for student wellness.⁹

The Humanistic Elective in Advocacy, Reflective Transformation, and Integrative Medicine (HEART-IM) is a month-long, fourth-year medical student elective that takes place away from academia and the medical system—placing students in communal living and bringing faculty to teach within this shared learning space. The elective is hosted by the American Medical Student Association and allows up to 25 fourth-year medical students from across the United States to apply and participate. These medical students spend 4 weeks nestled at a retreat center in northern California. A key aspect of building community among students and faculty is the shift in power from faculty to students. A group of four to five student planners design the curriculum for the elective and recruit presenters based on students’ interests. A mix of lecture-style and experiential sessions are held in both the morning and afternoon; volunteer faculty, many of whom have taught in the course for years, include both physicians and other allied health professionals who serve as experts and mentors on relevant topics. Although some topics are biomedical, such as “Psychedelics in Medicine,” others focus on advocacy and humanism. See Table 1 for a week’s sample curriculum. As part of the cooperative living experience and community building, the student participants assume community chores, shopping and cooking meals for the group, and planning activities such as hiking and yoga outside the structured didactics. While the students live in the retreat center for the duration of the elective, the faculty stay for a few days at a time. The course director grades students using rubrics provided by their respective medical schools, with an emphasis on commitment to participation and community building throughout the course.

The HEART-IM elective was previously evaluated and demonstrated benefits for alumni of the course in the realms of professionalism, communication skills, and stress coping.¹⁰ In this study, we sought to evaluate the impact of the HEART-IM course on aspects of personal and professional wellness among student and faculty participants. Rather than focusing on the effectiveness of this elective, our goal was to use the unique environment of HEART-IM to elucidate how we can improve medical education to make it healthier for both learners and faculty.

We sent a retrospective, Internet-based survey to HEART-IM student and faculty participants in spring 2022. Our study was reviewed and granted exempt status by the University of New Mexico Human Research Protections Program. An email containing an Internet link to the study questionnaire was sent to all participating students (N = 17) 1 week after the program ended and after grades for the elective had been submitted. A separate email was sent to participating faculty (N = 22) 2 weeks after the program ended.

Due to the small sample sizes, we did not obtain participant demographics to avoid identifying individual respondents. Survey responses were entirely anonymous. The student survey included open-ended questions about exposure during medical school to HEART-IM curriculum components, how the program contributed to personal and professional development and wellness, and the impact of specific components of the program (Table 2).

The faculty survey included open-ended questions about what inspired faculty to teach at HEART-IM, their prior exposure to curriculum components, greatest benefits of being a faculty member, how the elective affected their sense of renewal, and their perceived benefits for students.

We used a conventional content analysis approach to analyze the qualitative data.¹¹ To reduce potential bias, two faculty authors familiar with HEART-IM immersed themselves in the student data while two medical students who were alumni of the HEART-IM program immersed themselves in the faculty data. One of the faculty authors provided training on qualitative analysis. We purposefully did not review previously published qualitative data¹⁰ on this elective prior to data analysis so that we could approach this data with a fresh perspective. The dyads reviewing student and faculty data performed individual analysis with no predetermined codes and then met with their dyad partner to formulate larger themes from the faculty and student data, respectively. After this, the four reviewers met to discuss meta themes that emerged from combining student and faculty feedback. To maintain objectivity, the authors consciously tried to set aside their own personal impressions of the program and sought to understand the perspectives expressed in the data, meeting several times to discuss emergent themes. Eventually, the team collectively identified from the data four student themes and four faculty themes, which upon further reflection and discussion among the authors, coalesced into three larger, meta themes. The qualitative analysis was not established to explore any differences between student and faculty responses.

For our survey questions that included numeric evaluations of the HEART-IM course, we used descriptive statistics to assess the numeric scales. Because the responses were almost universally highly positive, we decided to focus on the qualitative responses for student and faculty insights for this paper.

Of the 17 students in the 2022 course, 10 (59%) completed the survey. Of 24 participating faculty, 10 (42%) completed the survey. Among the faculty, 18 were primary care physicians, 56% of whom worked in academic medicine. The remaining six faculty were allied health professionals. Qualitative analysis revealed four key themes each from student (Table 3) and faculty (Table 4) data. Student and faculty themes are shared next with examples of direct quotes from participants.

Theme #1: Self-Care as Professional Development

When students were asked about the effect of HEART-IM on their professional development, they identified skills of personal wellness and self-care as tools needed to be successful in their career.

“I have left HEART-IM with tools for self-reflection, time management, interpersonal skills, and a stronger sense of self. These developments are crucial to my success in residency and being the best healer I can be.”

Theme #2: Healing From Their Medical Education

Students identified the elective as an opportunity to reflect on the experiences and trials of medical education and find healing in community.

“HEART-IM provided me a safe and comfortable space along with validation for the feelings and experiences I have had in medicine. For way too long I thought I was alone in my feelings of frustration and isolation in this medical education and medical system. . . . This elective reminded me that this is not the case.”

Theme #3: Connection With Self

In the process of healing identified in student theme #2, students also were able to connect to aspects of their identity suppressed during medical education.

“HEART-IM allowed me to access parts of my emotional self I had not explored during medical school.” “I am more than just a medical student or physician. I am me.”

Theme #4: Confidence in Being Able to Pursue Personal Wellness

Students also developed a sense of control in their personal wellness that they did not have in medical school and efficacy to prioritize self-care.

“My personal happiness is important! I don’t need to sacrifice my health and happiness to serve others. . . . I am now more in control of my personal development than I have felt in the past 5 years.” “More tests, more ‘mandatory wellness,’ more interviews, there is always more to do and rest is not seen for the positive thing that it is. . . . Now I feel more in control.”

Theme #1: Connection and Community with Students and Colleagues

When asked what they believed was the most important benefit for students who take part in HEART-IM, the majority of the faculty emphasized community.

“Through years of different students, it never fails to create an intimate community. . . . Students say that within 2 to 3 days at HEART-IM they feel a closeness with each other that they don’t feel with their medical school classmates of 4 years.”

Theme #2: Crucial Learning Outside of Current Medical Curriculum

Faculty reflected on how this program is so unique and allows for transformation and healing that is not commonly embedded in medical education.

“It sits at a point in medical training where 4 years of school have beaten many students down, taking the humanism of healing out of the equation. . . . HEART-IM is a chance to reassess, rejuvenate, renew one’s energy for self-care, activism, and healing.”

Theme #3: Faculty Inspired by Students

The majority of faculty respondents highlighted how inspired they were by the participating medical students and their perspectives.

“I felt inspired by the group of students, their overall enthusiasm for their studies and careers ahead.”

Theme #4: Renewed Passion for Medicine

Many faculty elaborated on HEART-IM allowing them to regain energy, find inner strength, and feel more connected to the art of healing.

“HEART-IM is a precious opportunity to spend time with other caring people (students and/or faculty), thinking deeply and engaging meaningfully about topics that I don’t get to explore fully in my day-to-day life. After my time at HEART-IM, I feel useful and helpful to a degree that is well beyond what I typically experience. . . . [I can] practice in a way that is more and more authentic to myself and consequently, I believe, more helpful to those I interact with.”

Cumulatively, from these eight themes identified by students and faculty emerge three larger meta themes: (a) the need for personal wellness and self-care, (b) the need for cultivating community among students and faculty, and (c) healing the disconnect between one’s whole self and one’s academic self. Following are three quotes that illustrate each of these themes.

“HEART-IM reconnected me with the spirit I initially entered medical school with and lost a large part of along the way. I didn’t even really recognize how numbed I had become by the process of medical school.” “Talking with other medical students about the medical school experience helped me feel a strong sense of community and hope for our medical system going forward. We are the future!” “For way to long I thought I was alone in my feelings of frustration and isolation in this medical education and medical system. I thought I was just ‘soft’ and needed to toughen up. This elective reminded me that this is not the case. My personal happiness is important! I don't need to sacrifice my health and happiness to serve others. I don’t need to let this medical system eat me up. I am now more in control of my personal development than I have felt in the past 5 years.”

HEART-IM is a powerful and unique medical education experience for both students and faculty. Participant reflections from the course, which takes place outside of the traditional academic setting, provide a unique perspective on medical education, with suggestions for how to improve it for both students and faculty. The eight themes from students and faculty (Table 3) cumulatively suggest three meta themes as potential areas for improvement in medical education: (a) the need for greater attention to personal wellness and self-care, (b) the need for cultivating community among students and faculty, and (c) healing the disconnect between one’s whole self and one’s academic self.

The participants in our survey identified that personal wellness should be viewed as a core competency of professional development and curriculum objectives. Medical education contributes to high levels of stress, burnout, and depression, and historically has minimized the need for self-care. The Association of American Medical Colleges Working Group on Medical Student Well-Being along with wellness offices and committees based at medical schools are important responses to address these issues.^12,13 Medical education should prioritize the development of self-efficacy in personal wellness, rather than providing prescribed or mandated wellness, so that students and faculty have the tools needed to thrive for the entirety of their medical careers.¹⁴ Student-driven wellness curricula is one way to enhance student engagement in wellness efforts.

Students and faculty also identified the need for cultivating community within and among the groups in medical education. Students and faculty are treated as separate entities within medical education, with power dynamics devaluing the opportunity for shared learning and healing. Faculty and students face many of the same mental health challenges and could benefit from greater community building among the two groups. Learning communities, which are present in most US medical schools, are one attempt to address this challenge.¹⁵ Learning communities bring faculty and students together in nongraded, mentoring relationships while also creating community among the students in the group. Both students and faculty appear to benefit from the increased sense of community that comes from learning communities.^15,16

Finally, the participants of HEART-IM found an opportunity in the course to heal the disconnect between their whole self and their academic self. We define whole self as one’s identities, beliefs, values, and communities that preceded and coexist outside of medical education (for students) and one’s medical career (for faculty). Academic self refers to one’s identity, roles and performance as a medical student or faculty. HEART-IM provides insight into how the current medical education model contributes to this disconnect via overemphasis on the academic self. While care for the whole patient is often mentioned in medical education, students and faculty are immersed in a system, and hidden curriculum,¹⁷ that presents challenges in bringing the whole self into classrooms and clinics. Novack and colleagues have written about the importance of helping medical students, as part of the medical education process, to develop self-knowledge and self-care so that they might become better healers themselves and avoid burnout.¹⁸ Losing the connection with one’s whole self early in medical education can create a longitudinal effect on one’s career, affecting long-term happiness, satisfaction, and continued passion for the field of medicine. Learning climates with an intentional focus on wholeness have been associated with reduced rates of burnout and disengagement in health professions students.¹⁹ Therefore, to reduce rates of burnout, depression, and suicide among students and physicians, the medical culture should, among other ongoing strategies, encourage physicians to bring their whole selves to the practice of medicine; even more so, physicians should embed experiences to facilitate continued access to, and exploration of, what defines their whole self.

Limitations of this study include the small sample size and moderate response rate, with no ability to assess nonresponders versus responders. Program participants were self-selected and applied to participate in HEART-IM. We did not perform a preprogram survey to assess burnout, wellness, and the like, and thus cannot say whether our participants were more or less well than average medical students and faculty. In addition, the qualitative data were reactions to the course (Kirpatrick Level 1) and would have been strengthened by assessing learning, behavior, and/or results (Kirpatrick Levels 2–4). Finally, all reviewers of the data were past faculty or student participants of HEART-IM, which may have influenced our interpretations of the data despite our attempts to maintain reflexivity and check one another. We were not able to go back to participants and confirm whether our conclusions resonated with them.

HEART-IM, provides a valuable lens for improving medical education for both learners and faculty. The eight qualitative themes identified suggest three meta themes (need for personal wellness and self-care, the need for cultivating community among students and faculty, and healing the disconnect between one’s whole self and one’s academic self) as important findings from the HEART-IM students and faculty. Innovative curricula such as HEART-IM may provide a valuable lens for improving medical education for both learners and faculty.

^*A. Hecht and S.D. analyzed the quantitative data, coded faculty qualitative data, and edited the manuscript. A. Herrera drafted the manuscript.

^**M.L.D. reviewed the surveys, provided training on qualitative data analysis to the entire team, coded student qualitative data, and critically revised the manuscript. ANF conceived the study, drafted study surveys, served as principal investigator on the protocol, coded student qualitative data, and reviewed the final manuscript.

Dr Dorsett has received royalties from UpToDate for content unrelated to this manuscript.

The data sets used and/or analyzed during the current study are available from Dr Fleg on reasonable request.