Medical school can be a stressful experience for students, resulting in stress-related mental health problems. Policy recommendations from the General Medical Council (GMC), the body responsible for improving medical education in the UK, recommend the use of mindfulness training to increase well-being and resilience to stress. Students participating in an eight-week mindfulness training between Autumn 2011 and Spring 2015 were invited to complete a free text survey at the end of their mindfulness course. In addition, six qualitative interviews were conducted lasting between 60 and 90 minutes. Interviews used a topic guide and were recorded and transcribed verbatim. We used the framework approach to analyse the data. Students reported a new relationship to their thoughts and feelings which gave a greater sense of control and resiliency, an ability to manage their workload better, and more acceptance of their limitations as learners. The small group context was important. Students described improved empathy and communication skills through building inner awareness of thoughts and feelings, noticing judgments, and developing attentive observation. The findings show how resiliency and coping reserve can be developed within medical education and the role of mindfulness in this process. We present a conceptual model of a learnt cycle of specific vulnerability and describe how MBCT intercepts at various junctures in this self-reinforcing cycle through the development of new coping strategies that embrace an “allowed vulnerability.”
Students across disciplines have higher levels of anxiety and low mood compared to the general population [
There is increasing emphasis on emotional well-being in the educational policy in the UK. Policy recommendations from the General Medical Council (GMC), the body responsible for improving medical education in the UK by setting standards for students and doctors, recommend the use of mindfulness training to increase well-being and resilience to stress [
The integration of mindfulness in medical training has been related to fostering reflective practice and professionalism [
Our overall aim in this study was to explore UK medical students’ experience of taking part in a 8-week course of mindfulness training delivered by a qualified teacher who adhered to the Good Practice Guidelines for Mindfulness Teachers [
Course content of the 8-week mindfulness training.
Week | Theme | Mindfulness meditation practices and cognitive exercises |
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1 | Automatic pilot | Mindfulness of eating |
Mindfulness of body sensation | ||
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2 | Barriers to awareness | Mapping thoughts/feelings/sensations/impulses |
Mindfulness of daily activity | ||
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3 | Mindfulness of breath and body | Mindfulness of breathing and movement |
3-minute breathing space regular practice | ||
Exploring our reactions to the pleasant | ||
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4 | Staying present | Seeing and hearing meditation |
Looking at reactivity and maladaptive coping strategies | ||
Using the breath as an anchor to awareness | ||
Exploring our reactions to the unpleasant | ||
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5 | Allowing and accepting | Mindfulness of breathing-extended instructions |
Relating differently to difficulty sea of reactions | ||
3-minute breathing space coping response | ||
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6 | Thoughts are not facts | Introducing difficulty within a meditation |
Sea of reactions working with automatic negative thoughts | ||
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7 | Self-care and action plans | Mindfulness of breath- and body-extended instructions |
Links between activity and mood-nourishing and -depleting activities | ||
Identifying a stress signature | ||
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8 | Using what has been learnt | Review of course using what has been learnt |
Finalise action plan |
Mindfulness training took place within one medical faculty in the southwest of the UK. 57 students were referred to a mindfulness group either by their GP or student advisor between 2011 and 2015. For recruitment to the qualitative interviews, students gave verbal consent to their mindfulness teacher to be contacted by a researcher after the mindfulness course had finished. LR invited students to take part in an interview by e-mail, and students gave written consent for their data to be analysed before the interview was conducted. 12 students were approached for an interview and six students agreed (Table
Recruitment to the qualitative study.
Year of study when attending the mindfulness course | Gender | Reasons for attending the course | Who referred them to the mindfulness course |
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2 | F | Shift from academic learning to clinical placements in year 2 was stressful | Student advisor |
3 | F | Feeling stressed. Wanting to manage thoughts/feelings. Seeing benefit of mindfulness in a friend | Student advisor |
1 | F | Feeling stressed, isolated, withdrawn | Student advisor |
2 | F | Feeling down, subdued, and actively stressed | Student advisor |
2 | M | Finding the course stressful. Wanting to learn coping mechanisms. | Student advisor |
3 | F | Recovery from eating disorder and learning |
Student GP |
LR conducted all the interviews face-to-face which lasted between 60 and 90 minutes. LR was a final year medical student and so had “insider” knowledge on the medical school culture and curriculum in which the participants were located. Insider knowledge is discussed in the literature as both a potential strength and weakness [
Interviews used a topic guide (Table
Topic guide for qualitative interviews.
Reasons for joining the course |
Self-care and coping strategies before the course |
Attitudes to help-seeking |
Previous experience of barriers to help-seeking |
Stigma surrounding help-seeking |
Challenges of the course |
Managing the commitment of the course |
Experience of group context |
Experience of mindfulness practices and cognitive exercises |
What has been learnt |
Impacts and changes |
Ongoing practice |
Course content and structure |
Implementation within curriculum |
Open-ended survey questions for free text responses.
Why did you come on this course and why did you stay? |
What if anything have you learned that has been useful? |
What changes, if any, have you noticed? |
If you plan to continue to use mindfulness, what will you use in daily life? |
What were your biggest obstacles? |
On a scale of 1 (not at all important) to 10 (extremely important), how important has this course been to you? Please say why you have given it this rating |
What was it like learning mindfulness in a small group? |
What have you found least helpful about the course? |
Any other comments? |
We used the framework approach [
The survey data show that, of the 57 students who attended a mindfulness course, 15 were male and over half the students attending an 8-week course were from years 2 and 3 although students from all year groups attended mindfulness training (Table
Year of study of 57 survey responders who attended an 8-week course on mindfulness between 2011 and 2015.
Year of study | Number of students, |
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1 | 8 |
2 | 15 |
3 | 17 |
4 | 7 |
5 | 3 |
Unknown/not recorded | 4 |
Our findings on motivations for attending a mindfulness course illustrate some of the individual and systemic factors of stress discussed in the literature that may predispose medical students more to developing mental health issues than their non-medical student peers. For example, interviewees described perfectionism, being a high achiever and the impact of a competitive environment: I think all medics are really driven, they set high expectations and try and do a lot of things so maybe we get more overwhelmed because there’s so much to do. I think you are used to being the best, I am the clever person that is my identity ... I’m not the funny one, the loud one, the party one, I’m the clever one and then you come into Uni and you’re not the clever one anymore because everyone’s clever and everything’s hard and you can’t keep up with it all so you completely lose who you are and at the same time there’s no-one to help you. (E, 1st year, C1)
For one student, an existing maladaptive coping strategy was intensified by the context of studying medicine, which had led her to suspend her studies after a period in hospital for an eating disorder: I mean I say I was fine before uni, it depends how you look at an eating disorder, like if you look at it in terms of food and exercise, I was fine before uni, my favourite food was pork pie sandwiches. But in terms of work I was not fine before uni, I’ve always been, a perfectionist, “I need to work really, really hard and I need to get high grades” and I guess at uni that just exploded a bit more and just came out through eating [disorder] I think. So in terms of my work life balance I never really had that right but at uni its almost like I just latched onto food as a way of managing I suppose. (R, 2nd year, C4)
This student took the mindfulness course during her year of suspended study to support her return to medicine.
The 8-week course teaches students to recognise their unique early warning signs that indicate they may be slipping into maladaptive coping strategies in response to stress: I now notice more when I’m getting stressed and try and do something about it rather than just letting it be there and I am better at knowing what kind of things stress me out. (Yr3, IJ)
Being able to self-monitor their stress levels enabled students to prevent feeling overwhelmed: Recognizing triggering events and stress cycles has really helped prevent “melt downs.” (Yr2, S3)
This self-knowledge provided students with a sense of control: I feel more in control now, like I have a resource to fall back on, something to help me. (Yr2, S30)
This feeling for a fifth-year student left her “more resilient to difficulties” (Yr5, S22) and for a first-year student she felt she had “new and better ways of coping” (Yr1, S25).
Identifying early warning signs could be achieved through noticing thoughts and having a new relationship to them: I realised I was always exploding everything into a global thought, creating a big story and stressing myself out. ... the course has changed my mindset, how I think of myself, how I react to situations, before I would be sitting doing some work, thinking “oh my god this is so hard, I don’t understand it, I’m not going to do well, I’m going to fail my exams.” [Now] as soon as those thoughts start, I recognise them, and can cut them off, instead of wasting my time stressing, I just think, “look, its not going to happen (failure),” I think “ok, what can I do differently?” if I don’t understand, get another text book, I recognise when I’m starting on that downward spiral [of negative thoughts] ... (Yr1, IN)
Realising “thoughts are not facts” enabled students to take a step back from negative thought patterns and respond in new ways: If I don’t get work done I don’t beat myself up about it. Mindfulness teaches me to be kinder to myself. (Yr2, S4)
Students recognised that their negative thoughts were related to habits of striving for perfection that no longer served them: I was very judgemental with myself and was striving towards an idea of perfection that I couldn’t achieve. I’ve noticed I am a lot more accepting of my imperfections … I’ve learnt I need to be kinder to myself. (Yr2, S31)
Many students realised how their thoughts were unhelpful, even “manipulative” (Yr1, S26): I understand that you can have separation from your thoughts, they aren’t certainties, they don’t run your life and maybe they aren’t always helping you. (Yr2, S24)
As a result of a new relationship to negative thoughts, students managed their workload differently, giving them a greater sense of efficiency: I just recognise when I’ve got to that point where I’m not going to take anything else in, where I just need some time out to go away and come back ... in terms of workload it’s just helped me be more efficient in my studies. (Yr1, IN)
Mindfulness techniques helped students unwind after working all day as well as refresh and regain concentration during the day: I was using the three minute breathing space, at night it felt quite invaluable for helping me get to sleep, helping me to detach myself from my work and wind down a bit. … During the day it was quite a useful tool to refresh myself, allow myself to kind of regain concentration and get back to work. (Yr2, IP)
Mindfulness helped students achieve a sense of balance and flexibility in relation to work: I was very scared about changing how I worked, [mindfulness] gave me the flexibility to try something different, so I did stuff like not working in the evenings, and not working in the mornings [before lectures] and I found that (a) I was happier, (b) I did better academically and (c) I had time to do other stuff with my life ... the neuro exam was the first test of doing things differently and that was the best exam result I’ve had in medicine, I worked hard for it but a realistic level of hard. (Yr3, IJ)
Underlying students’ experience of having greater balance and flexibility in managing their workload was a shift in attitude, to give themselves permission to find things hard and for this not to be interpreted as a sign of failure: Well I think accepting that things are difficult. You can’t do everything ... everyone finds things difficult and it’s okay to find it difficult. So I think I took that [judgement] away. (Yr 2, IB)
Coupled with this sense of acceptance was a distancing from the competitive and comparative culture of medicine: “no-one needs to be compared to” (Yr2, S3) because “everybody is different and deals with things in a different way” (Yr3, S27).
A facilitator of the personal and work-related impacts of mindfulness is the small group learning environment. Despite at the beginning of an 8-week course students feeling “worried and nervous about sharing in a group” (Yr2, S3), nearly all students commented on the group as an “accepting, warm” (Yr2, S9), “welcoming, intimate and safe space” (Yr2, S4) in which they “bonded and developed” (Yr2, S10) with their peers. This process was described as “very empowering” (Yr2, S3) and “constructive” (Yr2, S6). The group space offered a source of hope: I felt I came to a safe place each week where I could learn to be ok so it gave me hope. (Yr3, S15)
Students found listening to each other helpful. The group space normalised automatic negative thought patterns which helped students begin to view their thoughts differently: The group discussions were helpful it was comforting to know other people had very similar thought patterns. (Yr1, S27)
Students found they are not alone in finding their course difficult, allowing them to let go of self-judgments that they are “not good enough”: It helped me learn, I’m not the only one in my situation, at the beginning I thought I might be the most stressed person, over time everyone started opening up, everyone seemed quite receptive, open to each other, quite supportive. (Yr2, IE)
The result of a greater sense of self-acceptance is that students begin to spend more time improving their social support networks: When I’m stressed I have a tendency to withdraw and not socialise but now I invest in relationships ... when I started medical school I cut off from everyone, saying “I don’t have time, I just need to work,” I had to make the conscious effort of pushing myself, saying, “building relationships is important, it’s part of self care and having people supporting you.” Now, when I’m socialising with people, instead of sitting there and thinking, “oh, I could be at home doing work,” I am now saying, “you’re looking after yourself, time out is good,” allowing me to enjoy that instead of feeling guilty about it. (Yr1, IN)
The mindfulness course invites students to consider the balance of nourishing and depleting activities in their lives and to make some changes. For some students, this works as an important encouragement and permission to self-care: The course made me think about how to look after myself better what’s good about Mindfulness is that it’s someone telling you to look after yourself and I think that’s quite important. (Yr2, IE)
For some students, mindfulness had helped them cultivate empathy through noticing their reactions towards patients: I’m mindful of my own reaction towards patients and their stories and the hospital situation and thinking about patient’s conditions and their suffering ... I’d like to say that it’s improved my ability to empathise with patients and what’s going on with them. (Yr2, IP)
The ability to relate to what patients are saying is connected to students being aware of their own thought patterns: I think mindfulness has helped make me more empathetic, I wasn’t ever nasty before, I was very sympathetic, but I probably couldn’t actually relate to what somebody was saying as much, whereas now I notice more, I think becoming more aware of how I think about things has made me more aware of how other people might think about things, I guess that would make me a better practitioner. (Yr3, IJ)
The key here is the link the student has made between developing inner awareness and patient care.
Mindfulness training had helped students notice and step back from “judging thoughts.” This translated into clinical contexts as noticing when other doctors were judging patients: I hear a lot of doctors say things like, “oh you know one of those typical middle aged, overweight, chronic fatigue type patients” and now when I hear someone say that I’m “ok well you might have that sort of judgement about that person” but that person is still living with an illness that’s affecting them, so that’s probably the important bit right now, it’s just made me a bit more aware. (Yr3, IJ)
The link in our data between empathy and awareness of judging thoughts resonates with work that theorises the link between mindfulness and empathy: “to be empathic I must witness and understand the patient’s suffering and my [or others] reactions to the patients suffering” (p. 836) [
Students valued mindfulness communication styles, seeing their relevance for clinical practice: Through observing how the sessions were run but also through personal practice. Its not necessarily something that would be acknowledged as a communication skill under the traditional framework but [mindfulness leads to] feeling more confident in talking about feelings the approach of the [mindfulness] sessions was an open, friendly, exploration of thoughts and feelings and maybe that’s helped me give patients the space to express themselves. (Yr2, IP)
Mindfulness training teaches students to be curious about their own feelings and thoughts, and this then grows into a curiosity about the patient’s feelings and thoughts. Epstein suggests “curiosity is central both to caring about the patient as well as solving problems” (p. 836) [
Throughout an 8-week mindfulness course, students are invited to inhabit their body and are asked to locate thoughts, feelings, and impulses as sensations in the body. For medical students, invitations to come into contact with the body were sometimes met with difficulty, as for many of them “medical neutrality had spilt over into their personal lives” (p. 65) [
Although students found the theme “thoughts are not facts,” one of the most helpful themes on the course, noticing self-critical thoughts and relating differently to thoughts were often challenging and described as an obstacle. Some experienced a “reluctance to let negative thoughts and feelings in” (Yr2, S3), whilst others felt they were “battling” (Yr2, S4) with their thoughts. For some students, the course was the first time they saw clearly their self-judgemental thought patterns and felt their biggest obstacle was “their own mind, berating myself” (Yr3, S28), from which they wanted to “run away” (Yr3, S18) to avoid feeling “overwhelmed” (Yr2, S33). Most students overtime were able to work through this obstacle: I found alot of the course very challenging as it brought up and amplified a lot of thoughts that were very difficult for me to deal with. However it has helped me to look at them differently and although its still very hard I have noticed changes and improvements. (Yr1, S25)
Figure
An initial model of learnt vulnerability amongst medical students: how MBCT may help.
A recent review of ongoing mindfulness training in medical schools only reported on training in the USA, Australia, and Canada, overlooking activity in the UK [
Other research interested in students’ well-being describes a “coping reservoir” which can be replenished or drained by various factors, both individually and systemically, leading to either burnout or greater resilience [
Our findings on the impact of mindfulness training upon empathy and communication skills relate to work exploring mindfulness and professionalism [
Our sample size for the qualitative study was small although each interview was long and in-depth. Combined with the free text survey data, we reached saturation in key themes during analysis. At the time of data collection, LR was a final year medical student. Her “social and clinical proximity” [
The GMC report “Supporting Medical Students with Mental Health Conditions” (2013) wants medical students to seek help before it becomes a “fitness to practice” concern and wants medical schools to put preventive measures in place to promote good mental health and well-being in their students, including “providing sessions on techniques such as mindfulness and meditation, which some people find useful to help them manage their stress levels” (p. 22) [
The qualitative data used to support the findings of this study are available from the corresponding author upon request.
(i) Mindfulness training went beyond learning a set of tools for coping with emotional difficulty. (ii) Students described a complete change in attitude, discovering a new way of looking at their clinical work, studying, and well-being. (iii) The small group context was an important facilitator for observed changes in well-being, resiliency, and outlook.
Ethical approval for the study was obtained from the Ethics Committee for Faculty of Dentistry and Medicine, University of Bristol, UK (Applic. no. 111224-01-02-12).
The authors declare that there are no conflicts of interest in the publication of this article.
We would like to thank Sarah Millband and Julia Wallond for teaching mindfulness to medical students at Bristol University. During the drafting of this article, Dr. Alice Malpass and Kate Binnie were supported by the Life of Breath project, funded by the Wellcome Trust (grant number 103340).