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The Development of a Wellness Curriculum at a New Regional Campus: A Pilot
Study
Katelyn Edel, MPH, Michael Flanagan, MD, Juan Qiu, MD, Jacqueline Gardner
DOI: https://doi.org/10.24926/jrmc.v4i2.3620
Journal of Regional Medical Campuses, Vol. 4, Issue 2 (2021)
z.umn.edu/JRMC
All work in JRMC is licensed under CC BY-NC
Katelyn Edel, MPH
Michael Flanagan, MD
Juan Qiu, MD
Jacqueline Gardner
All work in JRMC is licensed under CC BY-NC
Volume 4, Issue 2 (2021) Journal of Regional Medical Campuses Original Report
The Development of a Wellness Curriculum at a New Regional Campus: A Pilot
Study
Katelyn Edel, MPH, Michael Flanagan, MD, Juan Qiu, MD, Jacqueline Gardner
Introduction
With burnout on the rise for healthcare professionals in
both practice and training alike, there has recently been
an increased focus on student wellbeing and resilience in
medical education. Burnout is characterized by several
symptoms, including emotional exhaustion, decreased
empathy, and cynicism.1 Burnout can also be
accompanied by other mental health conditions, such as
depression and anxiety. It is well documented that the
demands associated with medical school challenge the
personal wellness of students, leading to significant
distress.2,3,4 In one study, a survey of fourth-year students
from 6 medical schools revealed that 50% of the
students expressed signs of burnout at graduation.5 This
is especially remarkable given that matriculating medical
students, when compared to age-matched controls, have
lower rates of burnout and depression symptoms,6
suggesting that issues with burnout and mental health
manifest over the course of a student’s medical
education.
A number of factors related to medical education are
thought to contribute to the deterioration of personal
wellbeing among medical students, including academic
pressure, cognitive and physical workload, poor support
systems, and sleep deprivation.3 In an effort to combat
the decline in personal wellness, medical schools started
to examine ways in which they could better support their
students. As early as 2004, governing bodies such as the
American Association of Medical Colleges (AAMC) and
the Liaison Committee on Medical Education (LCME)
called for “schools to rise to the challenge of the new
understanding of the risks of medical training for
trainees”.2,7,8 A statement from the AAMC suggested that
the medical education system prioritize the “health and
well-being of students” in an effort to “improve the
overall experience of medical education in the United
States”.7
Many of the early initiatives to address student burnout
and distress have been described as “reactive” and took
the form of increasing access to mental health services
on campus.9 Additionally, school-wide campaigns
focused on reducing the stigma related to seeking
mental health counseling.9 More recent efforts have
taken a proactive approach to medical student wellness,
including a wide variety of initiatives such as
comprehensive wellness programs administered through
the Office of Student Affairs, curricular changes, faculty
development sessions about student wellness, and the
incorporation of mindfulness-based stress reduction.9,10
Two schools, Vanderbilt School of Medicine and Saint
Louis University School of Medicine, have described their
initiatives in depth.
At Vanderbilt School of Medicine, a 3-tier program
consisting of intensive advising, a school-wide “wellness
cup” activity competition, and a longitudinal curriculum
designed to emphasize personal and professional
development for physicians-in-training was developed.10
The program is primarily administered through the
Office of Student Affairs but has significant student
involvement in the form of leadership and committee
development. Fully incorporated in 2005, the program is
based on the National Wellness Institute’s Six
Dimensions of Wellness.10,11 These 6 domains include
Social, Physical, Spiritual, Occupational, Emotional, and
Intellectual. The program has been well-received by
students and continues to grow and evolve with student
input.
Saint Louis University School of Medicine has developed
a similarly comprehensive program. Over the course of 3
years, a “wellness curriculum” was incorporated into the
pre-existing medical education structure. These changes
include transitioning from a hierarchical grading
structure to pass/fail grading, faculty development
sessions about the importance of prioritizing student
wellness, learning communities to increase levels of
student engagement and strengthening relationships
with faculty and peers, and a resilience program for
students with sessions about stress reduction, imposter
syndrome, optimistic explanatory styles, and energy
management.9 The curriculum is administered over the 4
years of medical school. By starting to introduce
concepts of resilience and wellness in the first year of
Journal of Regional Medical Campuses, Vol. 4, Issue 2
Original Report
training, it is believed that “good habits can be part of a
daily schedule” and may help to slow or prevent the
decline of mental health often observed in medical
students between matriculation and graduation.10
Given that many medical schools are developing
wellness programs such as those described above, it is
important to capture the students’ experience of
wellness. The Graduation Questionnaire (GQ),
administered to all graduating medical students through
the AAMC, now includes a section about “wellness” and
seeks to ascertain how well a medical school addresses
student concerns related to personal wellbeing and
resilience.10 Saint Louis School of Medicine used the
results of the GQ to assess the success of their program.
Student satisfaction with the school’s wellness program
increased on the Graduation Questionnaire from 3.6 to
4.4, with 5.0 being “completely satisfied” after
implementation of the curricular changes.9
The integration of wellness and resilience into medical
school curricula draws heavily on previous research
about burnout and poor mental health outcomes in both
health professionals and physicians-in-training.1 It also
reflects the understanding of what constitutes a
comprehensive medical education and acknowledges the
changing attitudes in regard to a medical school’s
responsibilities for supporting and protecting student
mental health. By focusing on how wellness programs
are implemented and how successful they are at
positively impacting students, more schools can develop
curricula to meet the needs of their student bodies.
Specific Aims/Objectives
While the Graduation Questionnaire can be used to
determine the impact of completely integrated wellness
programs, and medical schools such as Vanderbilt
School of Medicine and Saint Louis University School of
Medicine have written about the short- and long-term
effects of their curricular changes, there is little research
describing the implementation and refinement of a
wellness curriculum at a regional campus of an academic
medical center. The relatively new Penn State College of
Medicine University Park Campus (established as a 4-
year campus in 2017) represents a unique opportunity to
develop a comprehensive wellness program because of
the flexibility of our curriculum and the small number of
students. We sought to pilot a longitudinal wellness
curriculum, run primarily through the Office of Student
Affairs, for the 36 first, second, and fourth year students
at the campus (at the time of the project, there were no
third-year students). The project was modelled on the Six
Dimensions of Wellness from the National Wellness
Institute (Social, Physical, Spiritual, Occupational,
Emotional, and Intellectual), as was done by Vanderbilt
School of Medicine.10,11 There was also a resilience and
mindfulness focus that started in the first year of medical
school, as was done by Saint Louis University School of
Medicine.9
The specific objectives for our project included the
following: 1) Develop a dedicated wellness program
specific to first-year (MS1) students in their second
semester, which did not previously exist, and 2) Create a
companion program of inter-professional wellness
exercises open to all teaching faculty (both academic
and community-based), and all learners (residents,
medical, physician assistant (PA), and nurse practitioner
(NP) students) at the Penn State College of Medicine
University Park Campus. Using the results from this pilot
program, we plan to develop a more formal curriculum
that is accessible, helpful, and convenient for all
members of the University Park regional campus
community.
Methods
In order to develop a wellness program for all students,
resident physicians, faculty and staff at the Penn State
College of Medicine University Park Campus, a number
of different “project arms” were implemented. Those
developing the pilot curriculum felt that the current
wellness program was incomplete. Prior to the
implementation of the pilot curriculum, second-year and
fourth-year medical students attended Kienle Groups
(named after Drs. Lawrence F. and Jane Witmer Kienle).
These interactive sessions provide a dedicated time each
week for self-reflection, group dialogue about humanism
in medicine, and professional development for students
actively involved in patient care and are believed to
contribute to overall student wellness; the groups are
typically well-received. Before the pilot program, there
were also sporadic activities advertised as “wellness
workshops” offered to all members of the University Park
regional campus community. While certainly providing
some benefit, the Kienle sessions and various wellness
activities did not constitute a comprehensive wellness
program and overall there lacked a formalized,
consistent curriculum. We felt it was especially important
to have a wellness curriculum in place for first-year
medical students to create a culture of vitality upon
matriculation and to fully maximize the possibility for a
longitudinal wellness curriculum offered throughout all 4
years of medical training.
Journal of Regional Medical Campuses, Vol. 4, Issue 2
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An institutional grant created to specifically advance
wellness and vitality among healthcare professionals
within the Penn State College of Medicine was secured
for the development and implementation of this pilot
program. This competitive grant was funded by the
College of Medicine’s Office of Faculty Development. It
was entitled the Office of Faculty and Professional
Development Wellness Mini-Grant Program.
The first part of the project included a series of required
formal sessions for first-year medical students during
regularly scheduled class time. There were 4 sessions in
total, led by a community-based professional health and
wellness coach. A portion of the grant was used to pay
for the coach’s services. Each session focused on a
different domain from the National Wellness Institute’s
Six Dimensions of Wellness.11 Session One was
“Professional;” Session Two was “Intellectual,” Session
Three was “Spiritual,” and Session Four was “Emotional.”
Each session was co-created by the wellness curriculum
designers, the medical education team, and the
professional health and wellness coach. These
mandatory sessions were offered during a regularly
scheduled course in the MS1 curriculum, 4 times
throughout the second semester. Students completed an
anonymous paper pre-survey for each session,
containing questions addressing the topic for that
session. After the completion of the 4 sessions, students
completed an anonymous post-survey. Paper surveys
were used for convenience. Students could complete the
survey at the beginning of class, thus ensuring that all
responses were collected in a timely fashion. A pre-
survey was given before each of the 4 sessions and one
post-survey was given at the completion of the last
session. Each pre-survey had general wellness questions
as well as questions specific to the professional,
intellectual, spiritual, and emotional domains of wellness.
The second part of the project focused on the “Physical”
wellness domain and included students, faculty, and
staff. A 10-session traditional Tai Chi course was offered
in the evenings from 6:00pm to 7:30pm at the main
University Park educational facility. The courses were
taught by a Tai Chi practitioner experienced in teaching
Tai Chi to beginner-level students. A portion of the grant
was used to pay for the instructor’s time. The Tai Chi
classes were advertised to all members of the University
Park community, including all learners, residents,
attending physicians, teaching faculty, and staff. The
sessions were optional and individuals could attend as
many or as few times as their schedules allowed, at no
charge. It was a flexible initiative offered at a convenient
time in the evenings. Before their first session,
participants completed a paper pre-survey with
questions about wellness and physical activity and their
prior experience with Tai Chi. After their class,
participants were asked to complete a post-survey. Paper
surveys were used because participants often did not
have a computer with them during class and the
researchers wanted to ensure that all participants
completed a survey promptly. Hot tea and flavored water
were offered at all sessions.
Lastly, the third part of the project was designed to
address the “Social” wellness domain. Several watercolor
sessions were advertised to all members of the University
Park campus community. The watercolor sessions were
offered in the evening from 6:00pm to 7:30pm at the
main University Park campus facility. Sessions were
facilitated by a wellness curriculum designer and faculty
member who has experience with teaching painting and
creative arts to students of all levels. The sessions were
advertised as an informal space for people to “relax,
paint, and talk”. All of the supplies for the sessions were
provided at no cost to the participants. At the start of the
session, participants were asked to complete an
anonymous paper pre-survey. At the completion of the
session, participants completed a post-survey. If a
participant attended more than one session, they
completed the corresponding pre- and post-survey.
Some of the later sessions focused on a specific medical
topic, including ophthalmology, infectious diseases, and
pathology, where students painted images associated
with each specialty, such as retinal hemorrhages, Staph
aureus and melanoma. Collectively, each arm of the
project contributed to one of the Six Dimensions of
Wellness in an effort to create a well-rounded curriculum
for all students. The pre- and post-surveys from the
formal MS1 educational sessions, the Tai Chi sessions,
and the painting sessions were reviewed on REDCap to
assess the reach and impact of each project component.
Results
All pre- and post-surveys from the watercolor sessions,
Tai Chi sessions, and mandatory MS1 sessions were
reviewed on REDCap, a secure web application for
building and managing online surveys and databases.
Information from the surveys was collected to better
understand the student, faculty, and staff response to
the variety of new wellness programs at the University
Park regional campus. There were 34 unique participants
across the 3 study arms. For the mandatory wellness
classes, all 13 first-year students attended because it was
Journal of Regional Medical Campuses, Vol. 4, Issue 2
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a curriculum requirement. A total of 20 individuals
participated in the watercolor sessions. There were 15
participants for the Tai Chi sessions (Table 1).
Table 1. Participants in MS1 sessions, Tai Chi sessions,
and Watercolor sessions.
Session Type Number of
Participants
Percent
Medical
Student
MS1 Lecture
Session
13 100% (13/13)
Tai Chi
Session
15 27% (4/15)
Water Color
Session
20 60% (12/20)
A. Mandatory Wellness Didactic Sessions (Professional,
Intellectual, Spiritual, and Emotional Domains of
Wellness)
Of the 13 student participants, 10 students stated that
they had a consistent wellness practice (Graph 1). Of the
students with a wellness practice, there were a wide
variety of activities in which the students participated,
including physical exercise, meditation and/or prayer,
socializing with friends, and watching television. For
students with a wellness practice, the amount of time
devoted to the practice ranged from 2 times per week to
7 times per week. Eight students indicated that their
wellness practice was moderately or somewhat effective
at helping them maintain their wellbeing. For students
without a wellness practice (N=3), the limiting factors
included lack of available time and lack of interest in
developing a wellness practice. A majority of students
(58%) stated they were “extremely open” to making a
regular wellness practice part of their lifestyle.
In the post-survey, the first-year students were again
asked about general wellness (Graph 2). Interestingly, a
fewer number of students stated they had a consistent
wellness practice (N=5, compared to the 10 students
who had a consistent wellness practice at the time of the
pre-survey).
Graph 1. Pre-survey results of students with a consistent
wellness practice.
Graph 2. Posts-survey results of students with a
consistent wellness practice.
When asked what types of wellness activities they would
like to see offered at the University Park campus, most
students indicated they would enjoy arts-based activities
and physical activity. There was also a request from 2
students to have “less forced wellness” and more “time
alone”. Six students did not feel the mandatory 4
sessions on wellness were a valuable part of their
medical education. However, more than half (55%) of the
students strongly agreed or agreed somewhat that a
dedicated first-year wellness curriculum would be a
critical component of the Penn State College of Medicine
University Park Campus curriculum. Similarly, 89% of
students indicated that it was the responsibility of the
medical school to provide wellness activities as part of
the curriculum.
77%
23%
PERCENT OF STUDENTS WITH
CONSISTENT WELLNESS
PRACTICE
Yes No
38%
62%
PERCENT OF STUDENTS WITH
CONSISTENT WELLNESS
PRACTICE
Yes No
Journal of Regional Medical Campuses, Vol. 4, Issue 2
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B. Tai Chi Sessions (Physical Domain of Wellness)
There were 15 total participants in the Tai Chi sessions.
Four of the participants were students and the remaining
11 were clinical faculty or staff. For the Tai Chi pre-
survey, the majority of participants indicated they had a
wellness practice (N=9). The wellness practices listed
were overwhelmingly fitness and exercise-based. All
respondents stated that their wellness practices were
only somewhat or moderately effective at achieving or
maintaining wellness. The biggest limitations to a
consistent effective wellness practice were time,
motivation/sustained commitment, and knowledge
about effective wellness activities and resources.
Participants attended the Tai Chi classes for a number of
different reasons, most commonly stress relief (Table 2).
Table 2. Reasons for participating in Tai Chi sessions
(percent total is less than 100 as some respondents did
not select a reason).
Reason for attending Percent (N)
Exercise/fitness 13% (2)
Stress relief 34% (5)
Maintaining balance 20% (3)
Promoting wellness at
school and/or my
workplace
13% (2)
Social connection 8% (1)
At the time of the Tai Chi post-survey, 6 participants
indicated that they had a regular wellness practice, which
was a decline from the number of people in the pre-
survey. Five people stated that Tai Chi was moderately or
somewhat effective at stress relief and/or as an exercise
class, and 2 people said they would be extremely likely
to attend Tai Chi classes if they were regularly offered at
the University Park campus, although none of these
respondents were students.
C. Watercolor Painting Sessions (Social Domain of
Wellness)
Twenty participants were involved with the watercolor
sessions. Twelve were students. Of the 12 students who
participated, 9 were first year students. Eleven people
stated that their current wellness practice was only
somewhat or moderately effective at maintaining
wellness. Student participants indicated that the biggest
limiting factor that they have in maintaining their own
wellness is time. Fourteen participants indicated that
they attended the watercolor session primarily for stress
relief (Table 3).
Table 3. Reasons for participating in watercolor sessions
(percent total is greater than 100 as respondents could
select more than one reason for attending).
Reason for attending Percent (N)
Stress relief 70% (14)
Maintaining balance 40% (8)
Promoting wellness at
school and/or my
workplace
40% (8)
Social connections with
colleagues
45% (9)
Fifty percent of participants felt that the watercolor
workshop was an effective wellness-based activity. When
asked about additional wellness activities that could be
offered at the University Park campus, the overwhelming
response was for creative activities, such as arts and
crafts nights, sculpture, or photography. Nineteen of 20
(95%) of these respondents felt that a health system,
such as those associated with an academic medical
center, are moderately or extremely responsible for
providing wellness-based activities to students, faculty,
and staff.
Of the 34 study participants, 20 (58.8%) indicated they
would be extremely or moderately likely to attend future
wellness activities offered at the University Park Regional
Campus.
Discussion
The pilot program spanned a period of 6 months, from
January 2019 to June 2019. Overall, attendance at the
events was low; this was especially true for the Tai Chi
sessions. A very small number of students attended the
Tai Chi sessions. Faculty and staff participated in the Tai
Chi sessions more than students, suggesting that certain
wellness-related activities might be of interest to
different groups at the regional campus.
There are a number of ways that could improve the
implementation of a formal wellness curriculum in order
to maximize attendance. Many students indicated that
one of the reasons they didn’t have a formal wellness
practice was due to lack of time. The time constraint
component may be the reason attendance at the
optional events was limited. When thinking about a
wellness program for medical students, it is certainly
Journal of Regional Medical Campuses, Vol. 4, Issue 2
Original Report
difficult to reconcile the challenge of available time.
Medical school itself is a demanding, time-intensive
endeavor and the traditional curricular components of
classwork and clinical experiences leave little room for
additional activities. As such, students may choose to
spend what limited time they do have pursuing their
own personal interests rather than engaging in school-
based wellness events. This was captured in the survey
responses of students requesting less “forced” wellness
and more time to pursue their own interests.
A student’s wish for more personal time and fewer
school-sanctioned wellness activities must be balanced
with the responsibility of medical schools and medical
educators to support students in ways that extend
beyond academics. It is unclear how medical schools can
devote an appropriate amount of time to wellness
activities while not overwhelming a student’s already full
schedule. The fact that some survey responses indicated
that it was a health system’s responsibility to provide
wellness activities, as well as the responses from some
students stating they didn’t have the knowledge or tools
to develop their own wellness activities, suggests there is
some expectation and responsibility for a medical school
to provide these resources to students regardless of the
challenges related to time constraints or other barriers to
wellness.
Similarly, a major challenge of implementing a formal
wellness curriculum is that the effect of the program is
limited by the number of students who choose to
engage. This is well-described by other individuals who
have attempted to design such programs.9 It is possible
that the students who selectively choose to attend
wellness-focused programs are those who already have
an interest in wellness, while those who do not attend
are the ones who may be struggling with balancing the
competing demands on their time. The very fact that
students aren’t attending a wellness event might suggest
that they feel they don’t have room for wellness activities
in their daily life, given the other numerous personal and
academic demands facing a medical student. In the pre-
and post-surveys completed by MS1s, there was a 50%
decrease in the number of students consistently
prioritizing wellness over the course of a semester which
may represent growing time pressures and other
obligations. Similarly, more people attending the Tai Chi
sessions indicated they had a consistent wellness
practice at the time of the pre-survey compared to the
post-survey. This suggests a possible decline in wellness-
related activities over a several month period. The
challenge, therefore, is how to reach the people who
need the most help without adding additional stressors
and further monopolizing their time. It may require an
overall change in the culture of medical education and
academic medicine in order to give students and faculty
peace of mind when they choose to devote time to their
own wellbeing rather than continue to strive to meet the
exceptionally high educational demands of medical
school.
This 6-month long pilot program was designed to inform
the development of a more robust, long-term wellness
curriculum. After the project was underway, it became
clear that it would have been helpful to first conduct a
formal needs assessment of the student body. This could
have made it easier to develop more impactful
programming that was specifically suited to students’
needs. It would have likely been more focused on
creativity and the arts, as these types of activities were
predominantly favored by students. Other limitations
associated with this pilot program included the low
attendance, which makes it difficult to generalize these
findings to larger medical schools. Additionally, this pilot
program was completed at a regional medical campus;
students who are interested in a unique medical
education program self-select to interview and attend
school at the regional campus. As such, as a whole the
students surveyed in this study may differ fundamentally
from students who choose to attend a more traditional
curricular program.
Despite these challenges and limitations this pilot
program served an important purpose. It provided
insight into the understanding of student wellness and
the academic medical center’s role in promoting student
wellness. With this knowledge, the appropriate next
steps can be taken to more effectively address the
wellness needs of medical students. Certainly, the first
step for any school interested in designing a wellness
curriculum should be to conduct a Needs Assessment of
the students to better understand preferences related to
activity type, frequency of activity, and time of activity.
Our post-survey data indicated that the watercolor
painting sessions were extremely popular, so a decision
was made to optimize students’ exposure to the creative
arts. Consequently, a focus on the arts will be the
foundation for the next iteration of a formal, longitudinal
wellness curriculum at our regional campus. While the
institutional grant funding used for the original pilot
program described here ceased in June of 2019, other
avenues of funding are being explored for future
curricula. Additionally, the limited student response to
this program suggests the need for increased student
Journal of Regional Medical Campuses, Vol. 4, Issue 2
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involvement in the planning and implementation of
wellness programs. As such, a goal of the University Park
campus is to establish a student-led Wellness
Committee, charged with organizing wellness-oriented
events and maintaining a sense of morale among the
student body.
It is imperative to continue to think intentionally about
developing helpful and sustainable wellness curricula in
medical schools. In order to effectively address the
challenges of burnout, and the high rates of depression
and anxiety among medical students, the status quo
must change. It is not acceptable for medical school
curricula to place such high demands on medical
students without providing concurrent instruction for
balancing those demands with personal wellbeing and
resilience. Providing support for work-life balance and
overall wellness is likely to create physicians in both
training and practice who are more effective and
resilient.
References
1. Maslach C, Jackson S. The measurement of
experienced burnout. J Occup Behav. 1981; 2:99-
113.
2. Ludwig AB, Burton W, Weingarten J, Milan F,
Myers DC, Kligler B. Depression and stress
amongst undergraduate medical students. BMC
Medical Education, 15. 2015. Retrieved from
http://ezaccess.libraries.psu.edu/login?url=https:
//search-proquest-
com.ezaccess.libraries.psu.edu/docview/1780257
365?accountid=13158.
3. Dyrbye LN, Thomas MR, Shanafelt TD.
Systematic review of depression, anxiety, and
other indicators of psychological distress among
U.S. and Canadian medical students. Academic
Medicine. 2006; 81(4):354-373.
4. Brazeau C, Schroeder R, Rovi S, Boyd L, Harrell H,
Yudkowsky R. Relationships between medical
student burnout, empathy, and professionalism
climate. Academic Medicine. 2010; 85(10):S33-
S36. doi: 10.1097/ACM.0b013e3181ed4c47.
5. Dyrbye LN, Thomas MR, Massie FS et al. Burnout
and suicidal ideation among U.S. medical
students. Ann Intern Med. 2008; 149:334-341.
6. Brazeau CM, Shanafelt T, Durning SJ, Massie FS,
Eacker A, Moutier C, Satele DV, Sloan JA, Dyrbye
LN. Distress among matriculating medical
students relative to the general population.
Academic Medicine. 2014; 89(11):1520–1525. doi:
10.1097/ACM.0000000000000482.
7. Educating Doctors to Provide High Quality
Medical Care: A Vision for Medical Education in
the United States. Report of the Ad Hoc
Committee of Deans. Washington, DC.
Association of American Medical Colleges.
https://med.fsu.edu/sites/default/files/userFiles/f
ile/FacultyDevelopment_AAMC_Report_Educatin
g_Doctors.pdf. Updated 2004. Accessed July 27,
2020.
8. LCME. Accreditation Standards.
http://www.lcme.org/publications.htm. Updated
2012. Accessed July 27, 2020.
9. Slavin SJ, Schindler DL, Chibnall JT. Medical
student mental health 3.0. Academic Medicine.
2014; 89(4):573–577. doi:
10.1097/ACM.0000000000000166.
10. Drolet BC, Rodgers S. A comprehensive medical
student wellness program—design and
implementation at Vanderbilt School of
Medicine. Academic Medicine. 2010; 85(1):103-
110. doi: 10.1097/ACM.0b013e3181c46963.
11. Hettler B. Six Dimensional Model of Wellness.
https://nationalwellness.org/resources/six-
dimensions-of-wellness]. Accessed June 22,
2020.