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Abstract
Undergraduate medical education (UGME) is the time when doctors' attitudes toward patients and their profession are formed. It is also a period of tremendous stress for future physicians, including high levels of negative stress. Such stress can be maladaptive and may sow the seeds of burnout and long-term dissatisfaction. We believe that the introduction of yoga practice in the 1st year of medical school could ameliorate the negative stressors to which undergraduate medical students are exposed. Although there are some studies in the U.S. and internationally that support the use of Yoga in UGME, they do not provide sufficient data to make a compelling case for widespread implementation of yoga programs in undergraduate curricula. We, therefore, wish to advocate for conducting a trial of the integration of yoga in the undergraduate medical curriculum to combine yoga's ancient health wisdom into the context of modern scientific medicine. Large, prospective, multicenter, and multi-method pilot projects are needed to identify how a program of yoga practice and theory could counter the UGME environment that ultimately produces depression, anxiety, and non-effective coping strategies among medical students. A curriculum for yoga for undergraduate medical students deserves serious consideration and a prominent place among efforts to improve UGME.
Keywords: American education, medical school, yoga
How to cite this article: Current state of medical education 
Undergraduate medical education (UGME) is the momentous period of a doctors' transformation from a lay person to a fully qualified physician. This period requires the development of the capacity to build trust, rapport, and therapeutic relationships with patients. Such relationships require knowledge, skill, ethical practice, and excellent communication. It is not surprising that this transformation is associated with periods of stress. Healthy stress involves accepting the challenges and uncertainties that arise as medical students reach for competencies in data acquisition and engage in emotional and meaningful communications. However, it is widely recognized that medical education is exceedingly stressful, with elevated levels of negative stress. The process can lead to harmful psychological changes in students.[1] Sources of stress for students include the excessive academic pressures associated with the rigorous preclinical curriculum while navigating issues that often include emotionally difficult experiences.
Stress can cause negative effects on cognitive functioning and learning. Medical students in the United States also experienced a higher prevalence of emotional exhaustion, depersonalization, burnout, symptoms of depression, and levels of fatigue compared to nonmedical students.[2],[3] Studies with the survey of lifestyle and health habits of 4th-year medical students at the University of Western Australia indicated that 23% of students had poor health habits with lack of exercise, frequent consumption of junk food, and skipping breakfast. Another 23% of students were reported to be impatient, 13% always anxious, and 30% reported more than three stressful events in the 1st year.[4],[5]
Results of two studies from Egypt and Saudi Arabia document the high rates of anxiety and depression among medical students. The prevalence of total stress among all students was 63%, and the prevalence of severe stress was 25%, with even higher levels among females (75.7%) than among males (57%) (odds ratio = 2.3, chi 2 = 27.2, P < 0.0001).[6],[7] Another study from New Zealand suggests two-thirds of students had at least one adverse experience, with humiliation being the most common and having the greatest adverse impact. The most common perpetrators of these offenses were senior doctors or nurses. Unwanted sexual advances toward medical students most commonly originated from other students or patients.[8]
In many medical schools, the environment itself creates an all-prevailing pressured situation, with authoritarian and rigid systems which encourage competition rather than cooperation between learners. Moreover, stress in the undergraduate medical study period may extend into postgraduate training and continue into physicians' practices. The stress may reach burnout levels producing adverse effects of professional life on the health of doctors and their families. These can include drug dependence and alcoholism as well as increased rates of suicide and domestic problems.
Success in healing depends on extending a warm caring hand, a compassionate heart, and good listening skills. However, recent reports highlight the lack of humanistic values in medical professionals. Whereas at one time, doctors were admonished to treat the patient as a person and not just a disease. Current threats include such emphasis on testing that doctors are in danger of centering the doctor–patient relationship on patients' test reports. This will further diminish the possibilities for healing.
Improving undergraduate medical education The goal of our initiative is to both reduce debilitating stress and strengthen the development of person-centered care during UGME. We believe that medical schools should identify distress, and both strive to lessen it and to promote well-being for all students. Well-being is distinct from the mere absence of distress and includes achieving a high quality of life (QOL) in multiple domains (physical, mental, emotional, communal, and spiritual health). Medical student engagement in self-care behaviors has a mitigating effect on the negative impact of perceived stress on both physical and psychological QOL.[9]
Teaching skills for stress management and promoting self-awareness and using adaptive coping mechanisms, such as acceptance, planning, positive reinterpretation, and self-distraction, can reduce psychological morbidity. Encouraging students to promote personal health with regular physical activity and adequate sleep is important. There are no doubt many approaches to addressing stress and burnout in medical students, and we believe that engaging in a program of yoga tailored to the needs of medical students is one of them.[10]
Multiple studies support the practice of yoga in UGME. A study of U.S. medical students (n = 27) at Weill Cornell Medical School with a 6-week yoga education course on student stress and well-being showed a statistically significant reduction in scores on the Perceived Stress Scale for students and reported improvement in their feelings of happiness, positivity, personal satisfaction, and self-confidence.[11] Other randomized studies of 64 medical students pairing self-care techniques of yoga sessions as an adjunct with anatomy lecture material reduced stress levels and subjective feelings of knowledge improvement.[12]
Effects of 11-week mind–body course combining yoga and meditation with neuroscience didactics on 27 1st- and 2nd-year medical students showed increased self-regulation and self-compassion.[10] A study of 1st-year MBBS students (n = 50) was conducted to determine the benefit of yoga practices on anxiety status during routine activities and before examinations. Feedback scores and Spielberger's anxiety scale showed a statistically significant reduction following yogic practices among 1st-year medical students. This research validates incorporating ancient yoga practice with the integration of mind, body, and spirit balance function as self-care and health maintenance and promotion. Medical and allied health educational institutions should use yoga discipline as part of therapy for long-term recovery and yoga can complement modern therapy at institutions.[13],[14]
There is also evidence among nonmedical students in support of yoga practice. Beneficial effects of yoga training were evaluated with a 6-month comprehensive course of yoga training for nursing students. This study showed changes in QOL as well as hematological biological parameters. There was a significant improvement in quality-of-life index score both at mid-training (3 months) and posttraining (6 months) and includes health function, psychospiritual, family, and socioeconomic categories. Hemoglobin and blood components (white blood cells, red blood cells, and platelets) showed significant increases that were positively correlated to the student's frequency of attendance in classes.[15] A 6-week yoga intervention including students in a doctor of pharmacy program (n = 9) and undergraduate students (n = 8) found an average 9.6 point decrease in stress using the Beck Anxiety Inventory, average 7.9 point decrease in stress using the Perceived Stress Scale, and average of 4.6 point increase in mindfulness using the Five Facet Mindfulness Questionnaire after students completed weekly 60 min Vinyasa flow yoga class followed by 10–30 min guided meditation sessions. A systematic review of yoga interventions on helping health providers (HHP) and HHP students found the most reported benefits of yoga practice to include a reduction in stress, anxiety, depression, and musculoskeletal pain. In addition, students are open to using holistic methods, including yoga, to manage stress although they often report a lack of time and a lack of knowledge as barriers to practice.[16],[17],[18]
Considering these studies, the goal of our initiative is to conduct a trial of the integration of yoga into the undergraduate medical curriculum to combine yoga's ancient healing wisdom with modern scientific medicine. Starting such training in UGME would also have the possibility of extending into lifelong education. Yoga can help transform personalities as well as enhance a sense of wellbeing, and lower initial anxiety, hesitancy. Yoga practice can increase feelings of respected contentment, confidence, and peace. Modern medical advancements require integration of various traditional healing techniques such as yoga, music to promote health healing and longevity. Hence a holistic integration of both Western and Eastern systems may enable provision of the highest quality of patient care.[14]
Undergraduate medical education stress reduction and support programs The U.S. medical schools do offer resources available in support of the health and well-being of the medical students.[14],[19] As an example, Harvard University Medical School “Center for Wellness and Health Promotion” provides optional programs and resources (i.e. acupuncture appointments) with the intent of fostering the emotional, physical, and spiritual well-being of the entire community. It also offers a wellness initiative and task force which consists of student-led initiatives such as an interest group, grant programs, and a speaker series. All are aimed to reduce burnout and strengthen resilience within hospital rotations but are unable to provide assessment on the long-term functionality of such initiatives (https://meded.hms.harvard.edu/wellness).
These programs are laudable, but they do not specifically focus on the use of yoga, and to our knowledge, no data showing that they are working to reduce the impact of stress in UGME.
Outside of the U.S., there are substantial research studies conducted around stress, anxiety, and coping among medical students. In India, the Center for Yoga Therapy, Education, and Yoga research has introduced foundation courses during basic sciences such as physiology, anatomy, and biochemistry. Community medicine and physiotherapy disciplines where yoga therapy benefits can be integrated.[12],[20] First-year medical students received exposure to yoga during the 10-day orientation program. During daily sessions, they receive lectures detailing the foundations of the philosophy and psychology of yoga as well as the science behind the effects of yoga. They received practical training in various techniques aimed at stress management including asanas, pranayamas, and contemplative relaxation practice. Feedback was regularly obtained from medical students showing benefit from improved stress management and enhancing their adaptability to curricular and extracurricular activities. The program was continued throughout the training and offered as 1-h sessions over the weekend and evening sessions. Medical students received serial lectures on yogic aspects of lifestyle as well as physiological aspects of yoga practices in therapeutic potential of yoga. These lectures and lecture demonstrations were conducted during physiology, anatomy, and biochemistry hours in a collaborative manner. All members participated in the research projects to facilitate general awareness about yoga with seminars and workshops.
Vision for yoga theory and practice-based programs Little is known about the contribution of different curricula approaches to perceived stress and coping strategies institutions and students apply to help alleviate stress. Large, prospective, multicenter, and multi-method pilot projects are needed to identify student and curricula features that influence stress, depression, anxiety, and coping strategies among medical students. A curriculum for yoga deserves a prominent place among these efforts. This would require substantial effort from faculty from various disciplines with faculty development programs performed before implementing yoga training in a structured manner. During the planning stages and the testing of pilot programs, we recommend obtaining pre- and postfeedback evaluations from medical students participating in the study with the parameters derived from Spielberger's anxiety scale. Integration and implementation require concerted coordinated effort requiring effective leadership and teamwork from the faculty across various disciplines for curricular changes supported by different councils.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
Correspondence Address:
Sridevi R Pitta
University of Missouri, Springfield, Missouri, 2505, Scripture St. Ste 100 Denton, Tx, 76201-2481
USA
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijoy.ijoy_115_22
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