Virtual Wellness Workshop for Medical Students: Effects on Healthy Lifestyle Behavior

Medical students experience high levels of stress, burnout, depression, suicidal ideation, and compassion fatigue.^1-5 Medical students’ mental health tends to decline over time in medical school and may diminish their ability to provide compassionate care.^4,6-9

Some medical schools have implemented wellness programs to reduce deleterious effects of medical eduation.^10-13 Such programs often focus on stress management skills and mindfulness.^8,14-17 Evaluations of these programs have demonstrated significant pre/post improvements in depression, stress, anxiety, compassion, resilience, empathy, self-compassion, and burnout.^13,18-21  

However, it is unclear if these immediate psychological benefits are sustained. There is also a lack of research evaluating effects of such programs on habitual healthy lifestyle behavior. Healthy lifestyle behaviors include health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, and stress management. These may be key factors influencing maintenance of skills and sustaining benefits. Therefore, we developed a new intervention, the Self-compassion, Yoga, and Mindfulness for Burnout: Integrating Online Sessions and Interpersonal Support (SYMBIOSIS) program. Specific aims of our study of this program were to (1) assess feasibility and acceptability of the virtual SYMBIOSIS program for medical students, and (2) evaluate preliminary healthy lifestyle behaviors and psychological outcomes from preprogram to postprogram and 4-week follow-up.

We recruited medical students (n=20) at a Midwestern US medical college through email. Participants completed an online screening survey and consent form. Participants were enrolled into one of two groups based on availability and compensated with $30 Amazon e-gift cards. Affiliated institutions provided institutional review board approval.

We developed the innovative program, SYMBIOSIS (outlined in Table 1) utilizing established models, evidence-based interventions, and focus group data collected from medical students.^13,20-24 The program was optional and not affiliated with the medical school. Structure of sessions included teaching, experiential learning, social support, and motivational interviewing. The program consisted of 8 weekly, 50-minute synchronous virtual sessions via Webex. Two groups ran consecutively between October 2020 and December 2020. Sessions were cofacilitated by two clinical psychology doctoral trainees. Both facilitators were also certified yoga teachers.

Participants completed the online surveys at preprogram, postprogram, and 4-week follow-up. All surveys measured the following constructs utilizing validated measures (Table 4): healthy lifestyle behaviors (subscales: health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, stress management),²⁵ self-compassion,^26-27 burnout,²⁸ stress,^29-31 and mindfulness.^32-33 The preprogram survey included demographic questions. The postprogram survey included 5-point Likert-scaled and open-ended questions to assess feasibility and acceptability.^34-35 Both cofacilitators completed a treatment fidelity checklist (14 adapted items) after each session.³⁶

Adequate treatment fidelity was assumed if at least 80% of intervention items were included in each session.³⁶ Feasibility was assessed with enrollment, retention, and attendance rates. Feasibility and acceptability results included averaged quantitative scores and themed qualitative responses (two independent raters). Repeated measures analyses of variance were conducted for all outcome measures. Significant main effects were evaluated with pairwise comparisons with Bonferroni correction. We used Mauchly’s test to evaluate each measure. For measures violating sphericity, we adjusted degrees of freedom using Greenhouse-Geisser correction.

Twenty participants enrolled, with 10 in each group; 19 participants completed program. Participant demographics are shown Table 2. Treatment fidelity results met the cutoff for fidelity adherence (96% agreement). 

Full recruitment (n=20) was met within 4 days. All participants who completed the intervention (n=19) attended at least six of eight sessions (average attendance rate=90%; retention rate=95%). Participants rated the program content as “Very easy to use,” and the overall program as “Very helpful,” “Very valuable,” and participants were “Very satisfied” (0=not at all, 5=extremely).

Qualitive responses are shown in Table 3. Themes regarding the most appreciated aspects of program included peer/social support; scheduled time dedicated to wellness; developing coping and mindfulness skills; and facilitators were calm, knowledgeable, and created a safe space. Themes regarding least appreciated parts of program included group setting/structure/timing concerns, lack of time/other responsibilities, and virtual format. All participants reported an overall positive experience.

Table 4 summarizes main outcome data. Participants reported significant improvements in healthy lifestyle behaviors (pre/post: P<.01, d=.65; pre-follow-up: P<.001, d=.87), self-compassion (pre/post: P<.01, d=.59; pre-follow-up: P<.01, d =.92), burnout (pre/post: P<.05, d=.67; pre-follow-up: P<.01, d=.75), and perceived stress (pre-follow-up: P<.01, d=1.13). No changes in mindfulness were observed.

Results indicated the SYMBIOSIS virtual program was both feasible and acceptable to medical students. Compared to similar studies, we obtained stronger feasibility results.^35,37 Our retention and attendance rates mirror rates in well-funded, integrated, in-person programs.³⁸ This is promising for medical schools interested in smaller-scale virtual programs that are effective, accessible, and affordable.

 The program demonstrated significant improvements in healthy lifestyle behaviors (health responsibility, nutrition, spiritual growth, interpersonal support, stress management), self-compassion, burnout, and stress. The program did not target improving nutrition, spiritual growth, or health responsibility, yet participants also reported significant improvements in these areas. All improvements occurred pre/post and continued to improve at 4-week follow-up. Given that effects sizes improved to a greater extent at follow-up, this suggests that participants continued to utilize and benefit from the program after conclusion. This may be due to the program’s focus on integrating practical, routine wellness practices into daily life across time and improvements in healthy lifestyle behaviors. Results were comparable to similar trials and meta-analytic findings, with several of our effect sizes being larger.^{12-13,21,35,39-44} This is notable given that our program was virtual, not part of curriculum or for credit, and conducted by a research group not affiliated with the medical school.

Our study demonstrates positive outcomes within a virtual format, which has meaningful implications. Virtual formats increase accessibility for decentralized programs with students in several geographical areas. It also allows opportunity for cross-medical school interventions. The program structure could easily accommodate booster sessions over time, specifically targeting times of increased risk of stress and burnout.

Limitations include small sample size, participants from one university, self-selection, lack of control group, and potential history effects from the COVID-19 pandemic. These factors limit causal inferences and generalizability of results.  

Lower levels of stress and burnout are correlated with better quality of life, mental health, job performance, patient care, and fewer medical errors.^14,45-52 Our study supports that programs like SYMBIOSIS may benefit medical students personally and professionally.

These findings suggest that an 8-week virtual wellness intervention was acceptable, feasible, and also improved healthy lifestyle behaviors, self-compassion, burnout, and stress in medical students at postprogram and continued to improve at 4-week follow-up. In future research, it will be important to investigate effects of SYMBIOSIS on academic performance and clinical skill acquisition. Additionally, exploration of specific components and longer-term effects of the SYMBIOSIS program are warranted.