Abstract
Context:
Recent studies suggest the shortage of US primary care physicians will be more than 50,000 by the year 2025. Mindful osteopathic medical students may be more inclined to pursue a career in primary care practice than those demonstrating lower levels of mindfulness. If so, assessing mindfulness before and after admission to medical school may reduce this shortage.
Objective:
In this cross-sectional survey-based study, the authors assessed whether mindfulness among preclinical osteopathic medical students was associated with (a) their current preference for primary care practice as a residency, and (b) their choice between 2 alternative curricula.
Method:
Participants were first- and second-year osteopathic medical students enrolled at the New York Institute of Technology College of Osteopathic Medicine (NYITCOM). They completed a 7-factor questionnaire of demographic variables and the online Five Facet Mindfulness Questionnaire (FFMQ) to determine their mindfulness score. They also identified their current preference for a residency. Data were then presented using various descriptive statistics and analyzed using independent t tests, χ2 tests, and multiple logistic regression.
Results:
Among the 208 respondents, authors found that osteopathic medical students who expressed a preference for primary care practice showed no significant differences in mindfulness compared with those interested in specialist fields, as indicated by mean (SD) mindfulness scores of 3.34 (0.44) vs 3.33 (0.41), respectively (P=.88). However, among demographic variables, female students expressed a preference for primary care practice fields at significantly higher rates than male students (OR, 4.4; 95% CI, 2.2-8.5; P<.001). Also, students who matriculated less than 6 months after completing their undergraduate education were drawn to primary care practice at higher rates than those who delayed enrollment (OR, 2.3; 95% CI, 1.2-4.5; P=.016). None of the remaining demographic variables were associated with students’ residency preference.
Conclusion:
Being female and matriculating immediately after undergraduate education was associated with a preference for primary care residency. However, no significant association was found between mindfulness and either residency preference or choice of alternative curricula.
According to current calculations, by 2025 the United States will require an additional 50,000 practicing primary care physicians to meet the needs of the ever-growing and aging US population.
1 In response, medical schools are trying to recruit more students who are likely to enter primary care practice, which includes the fields of internal medicine, family medicine, and pediatrics, as defined by the American Academy of Family Physicians.
2 (There are alternative definitions of primary care, some of which include obstetrics-gynecology and emergency medicine.) To recruit new students and motivate current students, many schools are searching for indicators that can predict which students are likely to pursue primary care. However, little is known about indicators that may be used to predict which students will eventually enter certain specialties.
This preliminary study investigates whether mindfulness is associated with students’ preference for a primary care field for their residency. If so, and if we can assess mindfulness prior to matriculation, then accepting a greater number of mindful students to medical schools may help address the primary care shortage in the United States. In addition to its use in the enrollment process, a finding that high mindfulness scores is correlated with increased interest in primary care could prompt medical schools to foster this interest during students’ medical education in the hope of further increasing the number of primary care graduates.
At the time of this study, the New York Institute of Technology College of Osteopathic Medicine (NYITCOM) had an enrollment of 635 preclinical (years 1 and 2) students. Upon admission, students are required to select 1 of 2 alternative basic science curricula or tracks: lecture discussion based (LDB) and problem-based learning (PBL). The LDB track is the traditional approach to medical education in which a content expert presents lectures to students who then are tested accordingly. The PBL track stresses small-group, self-directed learning based on a case or patient presentation. Two faculty members facilitate small-group meetings, but students are free and encouraged to explore topics related to the case according to their own judgment. At the time of the study, enrollment in the LDB track was 560 (88% of preclinical students); enrollment in the PBL curriculum was 75 (12%).
The PBL curriculum seems to provide an environment conducive to primary care practice. It requires students to rely on and trust their inner resources more than does the LDB curriculum, which encourages students to follow the lead of their professors. Self-reliance requires and rewards greater levels of mindfulness than does the LDB experience. Mindfulness highlights the idea that “rules, routines and goals guide you but they don't govern you.”
11 Students in the PBL track have more freedom in their education, along with the opportunity to delve more deeply into individual cases and develop stronger relationships with their instructors and peers. This structure may facilitate interest in the areas of primary care practice, with its emphasis on multiple aspects of each case and long-term relationships with patients.
In contrast, the rigid course structure of the LDB program leaves little room for creativity, and students may lose focus on relationships during a long-term regimen of lectures. Compared with PBL, the LDB environment may discourage selection of primary care practice as a residency preference.
To measure degrees of mindfulness, we conducted a cross-sectional survey of our preclinical osteopathic medical students (year 1 and year 2) using the Five Facet Mindfulness Questionnaire (FFMQ). This 39-question instrument has been validated as a reliable measure of an individual's disposition toward the 5 facets of mindfulness (observing, describing, acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience), as well as an overall mindfulness score.
4,12 Scores for each of the 5 facets, ranging from 1 (lowest level of mindfulness) to 5 (highest level of mindfulness), as well as an overall mindfulness score, are computed by a scoring algorithm. Its internal consistency was adequate for all 5 facets and total scores, with α coefficients of 0.80 (observing), 0.92 (describing), 0.89 (acting with awareness), 0.89 (nonjudging of inner experience), 0.79 (nonreactivity to inner experience), and 0.92 (overall). Its construct validity was investigated by Baer et al,
12 who found strong relationships between the FFMQ facets and psychological symptoms such as well-being.
National norms are not available, but Baer et al
12 have reported comparative mindfulness scores from a large group of college students who regularly meditated vs another group whose members did not meditate. The average mindfulness scores were 3.1 for nonmeditating students and 3.9 for meditating students, showing a substantial difference between the groups.
In addition, a demographic question was included to obtain information on 7 variables: age, sex, preclinical year (year 1 or year 2), marital status, curriculum (LDB or PBL), undergraduate major, and time of matriculation after undergraduate education (early/within 6 months or later).
Surveys were sent via email in January 2015. Two follow-up reminders to complete the survey were sent to nonresponders 2 weeks and 4 weeks after the initial email.
To analyze the data, we computed the mean and SD for variables of continuous scale (ie, student mindfulness ratings gathered from the FFMQ). We then computed frequency and proportion for each of 7 binary categorical variables:
■ gender = female
■ matriculation within 6 months of undergraduate education = yes
■ preclinical year = year 1
■ age = 27 years or older
■ undergraduate major = biology/biological sciences
■ marital status = single
■ curriculum = PBL
For exploratory comparisons between groups, we conducted independent
t tests (appropriate for the continuous variables, ie, mindfulness facets and overall mindfulness score) and χ
2 tests (best fitted for the categorical variables). None of the scores for the 5 facets of mindfulness were statistically significant. Therefore, for our major analysis with multiple logistic regression, only the overall mindfulness score was included as a predictor. This approach avoids the issue of colinearity because the overall mindfulness score was highly correlated with all of the 5 subscores.
As a primary analysis of the association of mindfulness with residency choice, we conducted multiple logistic regression, controlling for the 7 demographic variables as possible confounding variables.
Statistical significance was evaluated at the significance level α=.05. All statistical analyses were performed using IBM SPSS Statistics 22.
First- and second-year osteopathic medical students who expressed a preference for primary care practice showed similar scores on the overall FFMQ mindfulness scale when compared with the scores of students who reported preference for a specialty field. Thus, hypothesis 1 was rejected: A mindfulness score is not a predictor of interest in a residency field. One factor may be the inclination of many students to express preference for a primary care residency anticipating that they will need this experience as a precondition for entry into one of the specialties, such as emergency medicine or surgery.
Students enrolled in NYITCOM's PBL track did not have significantly different mindfulness scores when compared with their counterparts in the LDB curriculum. Thus, hypothesis 2 was rejected: Students’ current state of mindfulness was not associated with their choice of curriculum.
In this study, mindfulness was not a predictor of student interest in primary care practice as a residency specialty. Looking forward, multiple replicative studies need to be conducted to establish a broad-based statistical foundation for the data collected. Findings from this preliminary study may be representative of the wider population of US-trained osteopathic and allopathic medical students, or they may be outliers. Likewise, the confounding areas of male vs female and early vs late matriculation call for further study.
This study did not look into mindfulness scores in osteopathic vs allopathic students or the relationship of mindfulness scores for resident physicians, attending specialists, and attending primary care specialists. These would be logical areas for future study. Future study also needs to be done to determine the degree to which students’ preclinical preference predicts their actual selection of a residency specialty upon graduation. To this end, we are currently completing a parallel study of mindfulness in clinical (years 3 and 4) osteopathic medical students and osteopathic residents.
We expect to see more investigation into the wide range of predictors of residency preference. As future studies accumulate, medical schools will be better prepared to admit students whose career goals serve both their own aspirations and the need for primary care physicians in the United States.