There is clearly an appetite for and recognition of the need for self-care training to improve student/doctor health and wellbeing as well as being able to inspire patients to self-care. The majority of medical schools who responded to this survey have implemented some form of self-care training, albeit widely disparate in nature and in nearly all cases only available to 1–10% of students through student selected modules. Whilst recognising the potential for self-care training to turn around the current rates of burnout in the profession and to enhance personal health and wellbeing it is perhaps surprising that only 67% of respondent medical schools agreed that self-responsibility through daily life choices is the key to true health and wellbeing. The influence of lifestyle on health and wellbeing is an area that just keeps expanding with more and more conditions being added to the list [10–12]. The major causes of death in the western world through non-communicable diseases like cardiovascular disease, stroke, diabetes, chronic lung disease and cancer are mostly related to lifestyle factors  – showing that we are more responsible for the state of our health and wellbeing than we have previously acknowledged or considered or perhaps even wish to consider as we may not want or feel able to give up or change our ways of living. Indeed, it is often only when illness and disease strike that people will reconsider and change their lifestyle but perhaps it would make more sense to do this before we get sick? If the doctors of tomorrow are to inspire their patients to self-care and adjust their lifestyle, then the doctors of today need to be living that themselves so it is taught and reflected to medical students. This was acknowledged by the desire to bring in training for staff who are to teach the students in self-care and to have people who live and apply self-care in their own lives and don’t just regurgitate knowledge regarding what is considered to be healthy. This is crucially important as self-care is, unlike many subjects taught at medical school, not reliant on knowledge acquisition, information and recall. It is very much a lived science and only someone who lives it can present it with the true authority and power of the lived experience and knowing of what is truly self-caring and what is not. As a simple example, there is no integrity in a teacher who drinks alcohol advising students not to drink alcohol as it does not come from a body that lives and knows the benefits of such a choice. What is offered in this paper regarding self-care comes from a body (EM) that has lived both a self-destructive way of life and a self-caring way of life and thus it is not mere opinion but lived experience and embodied knowing of what is truly self-caring and what is not, combined with a deep philosophical understanding that is lived and applied. Everyone is free to accept what is offered for consideration or to reject it as they wish.
Self-care training is not just important for the wellbeing of the students and future doctors but also so that they have the skills to be able to advise their patients of the same and become true role models for health and wellbeing. Given the vast number of NHS consultations on a daily basis, a self-caring medical profession has a great opportunity to inspire patients to do likewise and to improve patient outcomes .
Steve Boorman has stated that our ‘own individual health is our own responsibility’ and that this should be taught to medical students and trainees including surgeons [5, 9]. The more we take and accept personal responsibility for health and wellbeing, the more empowered we are as we realise we have the power to live differently, to make different choices and thus not be a victim of things happening to us over which we have no control. The latter is a feature of the biomedical model but as we shift from the biomedical to the biopsychosocial and to the holistic model of illness and disease manifestation, the level of personal responsibility increases and so too does the level of empowerment. We come to realise that our daily life choices which constitute our lifestyle, are a form of medicine and can be good medicine or bad medicine depending on the choices we make. Our bodies experience all that we live and are impacted by our choices and the more we accept and live this the more power we have over our own health and wellbeing. This is being confirmed by the research showing the role of lifestyle on illness and disease manifestation [10–13]. Likewise it follows that making different lifestyle choices can contribute to health and wellbeing  and can be borne out by personal experience and experimentation with those choices.
Hence, the emphasis on personal responsibility for health and wellbeing is intended and is important as it is the key to true health and wellbeing – a fact that as human beings we don’t like to hear as it is always easier to blame something outside of ourselves. This may account for some of the contradictory results that place an emphasis on personal responsibility for if agreed to it then asks us to consider to what degree we are taking responsibility for our health through our daily choices and consider changing them, whereas disagreeing with it allows us to continue as we are in the belief that other factors may be more important than the way we live every day. Therefore, whilst we fully acknowledge and definitely agree with the need to address toxic systems and environments as part of creating safe, nurturing and healthy workplaces , our ability as human beings to both recognise such toxic systems and to address them in an effective way is increased and facilitated when we are more caring for ourselves as we are more aware, present and willing to call out that which is abusive, bullying, harassing or harmful. In addition, even in the most supportive environment a doctor who is not self-caring will be compromising their own health and the quality of care they can give to another.
Self-care training is NOT about producing doctors who tolerate abusive and bullying practices – it is the opposite. It provides them with the skills to both be able to recognise what is abusive and toxic and how to call it out and address it directly. Toxic systems are not stand alone entities – they are systems created by people but where the systems have not been created for people. The people who create or perpetuate the toxic system themselves are not self-caring, for if they were they would not be able to behave in such a way or to create systems that were devoid of true care for people. Toxic systems prioritise quantity over quality; targets, numbers, and throughputs at the expense of the quality of the service and of the employees delivering those outcomes and their quality of health and wellbeing.
Thus whilst both personal and systemic factors need to be addressed, the latter will only be truly addressed when the former is, such that we engender people coming through the system who will be able to change the systems, change the culture, by reflecting a different way and bringing that to all areas of their work.
Despite the support for self-care training only 60% felt it should be a mandatory part of medical education. This is a surprisingly low percentage given that most recognise the benefits of self-care training both for the wellbeing of the trainee, their future role as doctor and adviser to patients regarding self-care choices and its potential to prevent or turn around rates of burnout. A medical trainee is an expensive commodity and it seems somewhat ludicrous to spend hundreds of thousands training doctors  only to have them end up leaving the profession or having significant periods of absence or under performance and presenteeism [17, 18] due to burnout or maladaptive coping strategies.
Whilst the medical curriculum is always under pressure with many people wanting a slice of the pie for their subject, we feel it is imperative that self-care training is a standard part of every medical curriculum. It could be argued that due to the onerous and demanding nature of a medical career that self-care training is even more important to enhance personal awareness and provide skills that enable a doctor to work hard, play healthy and not get so detrimentally affected by the work they do.
One of the weaknesses of this survey is that we did not go into more depth and detail regarding the exact nature of the self-care training strategies that are offered across the different medical schools. So whilst 93% offer some form of training we do not know if that is one or multiple tutorials, workshops, courses or lectures and in the majority of schools it is only available to 1-10% students. It is clear that there is a wide range of strategies available and that each school is in charge of the range of approaches it can offer. Whilst this allows autonomy and making best use of local resources it also means there is no uniformity or consistency in the type of self-care training that is being offered, making it more difficult to assess the long term impact and outcomes of the different strategies utilized. Whilst we appreciate there is little appetite for a standardized curriculum on this subject and most prefer to establish their own programs guided by local expertise and interests, this could potentially hamper the progress of self-care training if it is not undertaken from a place that understands the whole person and how the different aspects interact and interrelate to know what is truly self-caring and what is not. The body is the key instrument for knowing what is truly self-caring and what is not and self-care training needs to focus on enhancing body awareness and techniques that help people to discern what is truly healthy and what is not by the effects on the body. Simple experiments with daily life choices regarding food, sleep, exercise, emotions etc. can empower people to know through their own body what is healthy and what is not.
We had a good response rate of 44%, aided by sending the follow-up email, an approach that has been affirmed elsewhere as increasing the yield . Bias could occur if those responding were the medical schools with an interest in self-care. Non-responders could occur because the email did not reach the correct person, time constraints/busyness precluding the filling in of the questionnaire, a lack of interest in the subject or a dislike/disagreement with the questionnaire itself.