DocsWithDisabilities Podcast Ep 26: Special Edition

DocsWithDisabilities Podcast #26

Introduction:

Lisa Meeks:

Doctors with disabilities exist in small but measurable numbers. How did they navigate their journey? What were the challenges? What are the benefits to patients and to their peers? What can we learn from their experiences? My name is Lisa Meeks, and I am thrilled to bring you the DocsWithDisabilities podcast.

Join me as I interview Docs, Nurses, Psychologists, OT’s, PT’s, Pharmacists, Dentists, and the list goes on. I’ll also be interviewing the researchers and policy makers that ensure medicine remains an equal opportunity profession.

Sofia Schlozman:

Hello everyone, and welcome back to the Docs with Disabilities podcast. This is Sofia Schlozman, one of the show’s co-producers. Today, we bring you Part 1 of a three-part series on psychological disability and wellness in medical education. I learned so much from this conversation, and I am honored to have the opportunity to share the insights of our host, Dr. Meeks, and our three incredible guests with our audience. Before we begin, I’d like to make a brief statement; This episode is dedicated to Karen Headrick, the mother of our host, Dr. Meeks, who died November 16th after battling COVID. We encourage our listeners to continue vigilant safety practices, wear a mask, wash your hands, and continue to practice social distancing. And now let’s begin by hearing from Dr. Meeks.

Lisa Meeks:

Welcome back listeners, as you know I have a deep commitment to learner wellness and access to medical education for individuals with a psychological disability. Unfortunately, my research suggests that despite a high prevalence of depression in learners, a mere .03% disclose depression as a disability. This, coupled with research showing that only 15% engage in forms of help-seeking like therapy or counseling suggests that something is amiss. 

In addition to my work, I also keep connected to the heart of this topic by reading first-person stories shared in commentaries. Today’s show will be informed by the authors of two such commentaries that stand out as bookends. They showcase the varying levels of disclosure of psychological disability across the medical education continuum. 

On the one hand, we have a commentary in Academic Medicine titled: In My Experience: How Educators Can Support a Medical Student with Mental Illness. The author is known only as anonymous--on the polar opposite rests Dr. Bullock, a 2nd year medicine intern at UCSF and a fierce advocate for mental health and systems change. He is the author of the New England Journal of Medicine article, titled Suicide: Rewriting my story.

Salient to these two articles is the fear and stigma associated with disclosing a mental illness and engaging in help-seeking behavior. Yet very real downstream consequences of disclosure are ever-present concern, and one that may tip the scales between silent suffering and engaging with program or community resources. That’s where my other guests come in.

Dr. Jessi Gold, is an assistant Professor and the Director of Wellness, Engagement, and Outreach in the Department of Psychiatry at Washington University School of Medicine. She is an “it’ girl on social media, advocating for topics related to physician wellness. She is refreshingly honest in her approach, and says what most people are thinking. She is joining the conversation today to discuss these downstream consequences.

Erene Stergiopoulos, 2nd-year psychiatry resident in Toronto Canada, is an up and coming change agent who straddles research and advocacy for the inclusion of disabled learners in medicine and her work is informing and shaping policy on disability inclusion and wellness. She is going to talk to us today about her work and what we can do to radically reboot how we address mental health in medical education. 

Welcome to the show everyone, it’s certainly a powerhouse episode.

Let’s begin with anonymous….

Lisa Meeks

anonymous writes, “a couple of weeks before I started medical school, I admitted to a trusted mentor that I was worried about my post-traumatic stress disorder and how it would affect my education. He looked me in the eyes and he said, don't let anyone find out that place will eat you alive.”

Now I'm going to stop there for a second and open this up for kind of our first question for the panel. And my question is: Do we perpetuate the silence that is ever present in medical education by this encouragement that students hide any kind of mental health related disability? Is this still a problem in 2020?

Justin Bullock:

I'll start. Yes, it is certainly a problem in 2020. In medicine we're so often taught that we have to have this be completely sort of perfect, um, and have no flaws. And that, for some reason, we, as physicians wouldn't suffer from the same conditions that our patients suffer from. To me, what this mentor is saying is like, basically you can't have any weaknesses if anyone knows you have any weaknesses, like you won't be allowed to like succeed in medicine. And I actually think that's a narrative that is that I definitely feel like I got, and it's something that I've been very actively trying to like fight even within myself.

Jessi Gold:

it's a horrible problem. I think it starts early and it starts probably as a pre-med frankly, we weed out people who would be amazing doctors, if you can't fit this specific mold and you struggle, you are not for lack of a better word worthy of entering this hallowed profession. And if you can't check these specific boxes and meet these perfect criteria, you can't either. and we, you know, have attempted to change that narrative by being somewhat open, to taking people who come from different backgrounds and have different experiences then you go to medical school and it's not much better. You can very easily struggle and people will say, you know, why are you struggling? That should be easy. You can deal with this. Why is this hard? This culture is a culture where you don't complain and this is the way that it is. I even remember that when I was on my surgery rotation, somebody made fun of me for, um, my dad being a psychiatrist. They were like, what, what are you going to do? Like go into the same field as your dad and be a psychiatrist? And I think we in, you know, making fun of mental health as an option of a career and belittling psychiatry as a field, and saying things about patients that have mental health issues or saying “that's just another mental health patient” or “that person's got a personality thing” or whatever we do that perpetuates that within our own culture, it makes it additionally hard to then say, well, I fit that, that's me, like, why would you ever want to say that you are someone who struggles when we're repeatedly, disparaging that mold in a patient. We have many ways that we make it impossible to feel comfortable and safe being someone that struggles or someone that is even like stable and fine with a mental illness because that narrative isn't taught or shown or encouraged because people don't think it's safe. You should be allowed to talk about whatever you want to talk about in your own history. It's your story.

Lisa Meeks 

Well, you make so many good points. And the reality is- if this were any other type of medical condition, people would not hesitate to talk about it and they might even seek counsel being that they're surrounded by physicians, it wouldn't necessarily be as big of a secret or something to hide. And I know Erene, we've discussed this for hours on end at various points, the reality of, of being in the field of medicine and would we even disclose, like I said, and I, I readily say all the time, which I think is a terrible sign of what is out there that I don't think that I would disclose a mental health concern, if I were experiencing one, I would be very fearful. And there are lots of reasons for that and that's bad, that's terrible, because if somebody that has the privilege that I have in, in that space is afraid then what does it feel like to be a learner who has far less power to bring their authentic selves into this space.

Erene Stergiopoulos:

Yeah. I think that the thing that's so unique about psychological disability is that institutions question someone and their ability to make decisions and their ability to provide “quality or unsafe care”. The second that there's any kind of psychological disability, whether that's depression or addictions or trauma or personality disorders and it's fundamental to the way that our culture, our society frames, mental illness, the way they view, what happens to you, to your judgment, to your insight. That's so  tragic to me because the  second someone has a diagnostic label, those labels are chronic and they stick onto someone's file for a really long time and so the second someone discloses, they know that they're entering into that realm where they can't take that label off and they will always be looked at with that eye of  “Oh, well, we have to keep an eye on that person to make sure that they're okay to practice.” And so, it's so understandable when people decide not to disclose for that reason.

Lisa Meeks:

Anonymous goes on to write in the article.

 "I have run into a number of problems related to misplaced good intentions. There are not many of us with visible yet well-managed mental illnesses. And my advocates have had to learn how to offer guidance and flexibility without compromising my autonomy or the high technical standards of the program. Though, my experiences have largely been positive that is far from universal friends and classmates have experienced discrimination or even been forced to leave their programs. I write anonymously in acknowledgment of that implicit threat, but also with the hope that the individual support I have received may become standard throughout the larger medical education system." 

First of all, let's just talk about how beautiful this writing is and I think within a few sentences, the author has really encapsulated a feeling. I know from being in meded, you all know from being in meded, this is absolutely true. And I think that so often there are well intentioned individuals. I know Justin, you and I have talked about how that works in real life. And I think, you know, this student, despite the positive experiences still felt compelled to write anonymously, even though this person was well supported in their program, there's so many things in our system that keep people in a fearful place. Because of the way that you've disclosed, looking at anonymous writing and their words. What does that feel like for, for you as someone who has been so forthcoming?

Justin Bullock:

Yeah so, the first thing it's looking back now with the experience of the last, um, eight months or so I think anonymous is, um, smart. I understand where they're coming from and, you know, one of the things that I, this my favorite line actually is “there are not many of us with visible yet well-managed mental illnesses.” And I think, I think that medical education does not understand that you can have active disease and be well-managed and, and well-managed does not mean that you don't suffer or you're not disabled in some way at some times. I assume that anonymous wrote this as anonymous, both in some ways of self-protection, but also to really say that like, you kind of have to do this anonymously, right? Like you can't really be super visible, otherwise you're just like susceptible, anytime you falter at some point in the future, because humans inevitably falter, you know, whenever you falter, people attribute it to this one thing. I totally understand why someone would write this as anonymous.

But it's still not safe. I think it's still incredibly vulnerable to submit this piece to a journal because someone sees this person's identity, even if they write it as anonymous, you know, and it still takes so much strength from my eyes to write all the things that they wrote. I definitely do not view it as an act of cowardliness at all.

Lisa Meeks:

No, absolutely not.  In having talked to anonymous several times over the course of the last two weeks, I can tell you that they wrote this with the genuine hope for a different future for the cohorts that come after them. And I think wrote it as well to push an agenda, to push a conversation, to occur that wasn't happening quick enough to be able to create a space that was safe for them.  

 

MUSIC

 

Lisa Meeks:

So, Jessi, I'm actually curious because you see in, and in clinic, you see providers, you see learners, you see students and you more than anyone would have firsthand knowledge of the fear of repercussion, uh, professionally.  Maybe you could give us some insight. Is this an anomaly where people are afraid of disclosing or is this pretty standard across all of the health professions?

Jessi Gold:

It's pretty standard. What happens too, is people delay care because of it. And they don't come until way too late. I mean, we have lots of other reasons for that, like we have completely normalized illness. Like, you know, we look across and we're like, that guy looks like they're not sleeping and that guy's not sleeping, so we must all not sleep, that must be the way we are. And actually, that's our baseline is completely often unhealthy for the most part. So, it takes a really long time for people to notice that they need help, because we've normalized what is probably already not good behavior. A lot of people struggle and they wait a long time to get care because of it. And they worry what it means to get care because of it. And don't want to get care in their institution because of it. 

I work, in a facility where I could technically bump into people that I see quite regularly see, or students, I shouldn't, I never see people that I grade or anything like that, but I could teach a seminar or something where there's a lot of people and I could recognize a face of a faculty member or something, and I think that makes people nervous for mental health a lot more than it does for any sort of physical health.

I have a lot of friends that are OB-GYNs and we make a joke a lot about how people are very comfortable having babies in, in the system that they work in and are totally fine with people seeing that happen and witnessing that, which is beautiful, but also very intimate, um, and have no problem with that person, seeing them around but are completely uncomfortable with ever possibly bumping into me. And so, we, we do a lot of things to overly protect people in these scenarios and try really hard to do that. And I think we do a really good job and sometimes I think we do a little bit of a disservice to people to do so, so much because it just continues honestly, to perpetuate mental health stigma, to be like, okay, we have completely segregated mental health as a field, and now we're all the way over here.

And we are the field that nobody talks about and now you're good.

People are so uncomfortable talking about it by the time they talk about it it's a lot of like, what if people notice, what if it affects my work? What if it becomes a reason why I can't go to work? And I have to tell someone if I file for disability from work and they see the reason, what does that mean? Can I file for disability for the fact that I have hip pain from five years ago, instead of the fact that I'm depressed right now, do you think that I can go ask my primary care doctor to do that instead? And you're sort of like, no, you can't, you know, but it comes up a lot because people are so uncomfortable with mental health being the reason. And I hope someday we get past that. I think it's a societal thing, only worsened in all fields of medicine, but we're not there yet at all.

 

MUSIC

 

Lisa Meeks:

I think it's even stigmatizing to seek the service and, in some respects, that it may be slightly different for counseling. I'm curious, Erene, what you hear from your peers. I know we had talked, uh, earlier about what was happening really in your kind of near peer group.

Erene Stergiopoulos:

Yeah, it's really interesting because ever since I started residency, I think at least 50% of the medical students that I've worked with have disclosed to me, like, uh, specifically like a mental illness. And it was, I think part of it is because I always disclosed that I had accommodations in medical school so they feel like, oh my God, okay. I'm actually in a safe place to talk about, you know, what I've been going through because a lot of them haven't, uh, access to accommodations, oftentimes because they're afraid to, um, they're afraid of the downstream consequences. They don't have any idea how it's going to affect the match. They have no idea what accommodations are available.

In Canada, if you are a medical student or a resident or a physician, um, we have these things called physician health programs. I think there's something very similar in the States. they're moderated by the medical regulatory authorities. So, like we have our Royal college of physicians in Canada. And those basically when a physician is in distress or they need a psychiatric assessment, especially there are psychiatrists who can see any kind of medical trainee or staff physician urgently for an assessment, and it's not supposed to be this punitive duty of fitness to practice assessment, but actually just if someone needs the assessment, they can get it quickly. But then I also have talked to people who've had those assessments before, but it turned out that this person, like the person who was assessing them was also a psychiatrist involved in teaching in the program.

These were psychiatry residents who told me that they went to an assessment and one of the docs who assessed them also supervises residents. So, it gets really tricky. I think that there is a lot of fear that if  the second you see a specialist, especially if you live in an academic center, which if you're a learner, you do that, you will run into a specialist who will then become your teacher or your supervisor, or who you'll run into in the hospital at some point, no matter what specialty you go into.

Jessi Gold:

I would add one of the things that makes that fear, such an issue is like, if you have an emergency and I'm sure Justin can speak to this too, the fear of not running into people, you know, can make you not want to get hospitalized in the place where you work, and then you cannot get help. I've seen, and even when I was a resident, worked on a ward where we had multiple medical students and undergraduates, but multiple medical students that were admitted on the psychiatric unit and had complete extra precautions, there were no medical students assigned to their cases. We didn't let them be in the room when their cases were discussed, we tried really hard to do as best as we could to preserve their identities. But of course, if you are on the unit and you saw them, you knew they were there, right. So, there's only so much you can do. And I think that makes it hard because if you're in an acute situation and something happens in you're really in need and the closest place that is to you is the place that you work. They're going to take you there. And that has a lot of issues because you don't want to not go there because it also could be the best place in the whole area by far, there's a lot of issues, a lot of compounding factors there.

Justin Bullock:

So recently, I had kind of a mental health meltdown. Basically, I ingested a large number of pills and I called 911 and they came, they asked me where I wanted to go. I told them to take me to my institution and actually ended up, causing a lot of problems for me with a fitness for duty evaluation, um, before that information was later kind of disproven. So, I mean, exactly what you're saying, Jessi.  It's really like what I'd rather die or protect my confidentiality was really the decision that I was trying to make in my head in that moment. And that's really sad. Um, and I think it's because I knew that once that information was in the wrong hands, it would be used against me.

Lisa Meeks:

I don't know what the solution is for that, because I think that with any intervention it's always designed to be helpful. And then we find, you know, a year or two down the road, what portions of it are actually harmful. And then once those things are, squarely situated, um, people are really opposed to change, I think, especially in more rural areas where you don't have access to perhaps the amount of care such that you could find a provider that would be outside of your academic network. And so, it gets tougher and tougher for some residents versus others.

At UCSF, if a learner presented with a history of psychological disability and hospitalization was part of that history one of the things that we would do is say, “in the event that, you have an acute flare of your symptoms or your condition is exacerbated, where would you like to go?” You know, how can we support you in and not having to go to a specific site?

On the flip side, if a student was seen at our emergency room, um, or they were admitted to one of our hospitals one of the things that we would do is offer them the opportunity to complete their psychiatric rotation at another hospital, so that they're not rotating under the same attendings who may have been on their case.

 

MUSIC

 

Lisa Meeks:

Hearing about the experience from undergrads versus graduate medical students has been very different strikingly different with regard to the consequences and the level of protection and the level of support and that's very sad. So, it seems that even when you're in an environment where it's extraordinarily supportive, you're encouraged to seek help at the undergraduate medical education level. And, perhaps you are seen for an acute presentation of symptoms, that you are almost enveloped in this little safety nest. But even sometimes within the same institution, the consequences or the experiences or the support system looks very different once you become a physician.

Justin Bullock:

I think that the argument that when people say, at least what I've been told is essentially, this is because of state licensing. learners are sort of protected because they're not yet physicians, but once you're actually treating patients, then there's this sort of specter of the state medical boards, which, tend to be very, very patient centric and not provider centric. I think there's a sort of disproportionately strong response, um, because of this sort of fear of the state medical board, it's like sort of punishing institutions, or sort of removing licenses from physicians.

Jessi Gold:

I don't really know why there's a huge difference between medical students and residents? I mean, I do think there's a different level of coddling, um, for lack of a better word. Like there's just like a different level of support that we give in general. Right. I feel like we don't wrap people around with our arms as much. Like we'd have a lot less resources I feel like for mental health for residents. I've always felt like that. I think we're catching up, but I feel like the medical school was thinking about it before residencies were thinking about it, and way before faculty's been thinking about it. I feel like that's kind of the order of things. I don't know why that is.

Lisa Meeks:

The biggest risk, the biggest group that is at risk are the interns

Jessi Gold: Uh-huh 

Lisa Meeks: statistically speaking. So, you would think that there would be concentrated focus and resources in that group more so than others.

Erene Stergiopoulos:

I almost wonder if the interns are the highest risk group, because they go from that environment where there is still a lot of coddling to an environment where they're literally just thrown in and it's like, “Oh my God, where are my secure attachments?” I'm just lost, like in terms of the coddling. I certainly saw that during COVID where, I mean, the second COVID was announced as like a crisis, a global crisis, all the medical students were pulled off service. And thenthe very same day that happened all of the residents in Canada got an email saying that it was our duty to continue working and that we would have to make personal sacrifices to continue working. And there was no mention of course, of having a preexisting condition or being immunocompromised. It was sort of just expected that like, okay, we're, we're physicians now we have to, we have to sacrifice ourselves. And so, there's this immediate switch and, and shift in the discourse as soon as you get that MD after your name.

Lisa Meeks:

Yeah. And you think about the biggest life stressors that can occur, right? Moving, which many interns are moving across country, the lack of a support system, immediate support system, there’re financial stressors, right? And so, and, and lack of control over your time, which I think is a huge contributor. Um, and then of course, lack of sleep.

 

MUSIC

 

Lisa Meeks:

We've talked about the fear. We've talked about the barriers, um, a little bit to help seeking, but you know, Justin, you get into that a lot more. You're on the complete opposite side of the bookends from anonymous and, you know, you're unapologetic in your public facing approach to your mental health. And I think this is no more evident than when you were going through the fitness for duty and it felt like a play-by-play to some extent.

I know we talked about it a little, there's this fear too, when you have a specific diagnosis that any behavior, and so even this public facing behavior and transparency about what was happening, could be perceived as a symptom of your diagnosis. And so that had to be extraordinarily difficult, but in your article, you write, “despite my fear, I frequently speak out about mental illness. I'm not afraid of others knowing that I have bipolar disorder. I fear instead that I may encourage others to get help, but will ultimately kill myself.” 

It's just such a juxtaposition of where anonymous is coming from and where you're coming from and I wonder if you can speak to why you have been so boldly and unapologetically public about your disability, perhaps even speaking to some of the system issues, why you felt like you could disclose this at the institution where you're training.

Justin Bullock:

Yeah. Um, this is such a good question. There’re so many things I want to say. The first thing that I will say is I, you know, reflecting back on me sort of writing and then, you know, trying to get this piece published. I think I was very fortunate because I was in a very solid place with respect to my position in my institution. I'm very fortunate that there are many people who are very high up, who I know very personally and who have sort of been around through various parts of my journey. Um, and so anything that I was writing, they were sort of already well aware of.

I was talking with someone very, very powerful within UCSF and a very good person who I really look up to. And, um, basically, they said to me, Justin, if I were to find out tomorrow that you died by suicide, um, I would be very, very sad, but I wouldn't be shocked. Initially that statement can sound a little bit, like, I think it makes some people sort of like, like take a step back, but I actually think it shows a true understanding of mental illness. You know, if someone has really bad heart failure, you know, that they could die tomorrow, like they could have an arrhythmia and they could have a heartfelt exacerbation and up in the ICU and, and pass. He wasn't saying it in a way that was like, “Oh, like, there's nothing we can do about it.” But he was just saying like, I understand that you are suffering and that you have a serious mental illness. 

The reason why I fought so sort of vocally against my institution is because I will, like, I will never, ever, ever deny that I have a serious mental illness. Um, but I very, very, very strongly believe that I'm a good doctor and I do not believe that I have done anything which has ever indicated that I am anything less than an average physician at my institution.

So, for me that it was so dramatically clear that what everyone was doing was solely based on my mental illness and had nothing to do with my performance. I really felt like people are very afraid of mental illness. That fear causes them and to harm people. And I really wanted people to know, like, I am not ashamed at all.

Actually, writing that piece was super liberating. I was like, well, the whole world already knows I'm bipolar. I literally said in the piece like everyone already knew, I tried to commit suicide and was in the ICU, you know? So, like, anything that happens sort of within my realm of normal. And so, I don't think that that makes one, not a good doctor. I actually think it makes me a better doctor. I know that I understand some of my patient’s way more than other people do because of my experiences as a patient.

Lisa Meeks:

You went on to say that there are these structural challenges, really for learners that are in medical education. And, and one of the things that I know we've talked about this before, and I think this line and your commentary has been repeated, I can't even say how many times, but you said: 

"It should be easy for all trainees to go to therapy. But I have friends at other programs for whom it is challenging or even frowned upon our lives are worth more than the two hours we are gone each week."

You would think that this two hours to go to therapy on a weekly basis is some sort of egregious action on the part of the student that they would be willing to miss two hours. And I'm with you and saying, you know, what is a life worth? Is it worth two hours? And, and so that point, and to our point up to now, we've been talking about mental illness versus some other sort of physical illness is that if the same student were going, because they had had an accident and had to go to physical therapy, no one would be questioning the need to go. And no one would be causing an uproar over the loss of time, we would figure it out. And some, some schools have gone as far as to say, everyone can leave for two hours a week and we're not going to police what you're doing, we're going to call it a wellness white space, and everyone can use it however they need to use it.

And so, we have these vastly different approaches to “wellness” or “mental health or physical health” and, and varying levels of support, as well. And you talk about the barriers that are presented for learners, the logistical challenges of coordinating if you need to go, we’ve talked about jeopardy. If you need to call in. And I know for my learners, the thought that one of their peers would have to jump in was enough to keep them from accessing healthcare that was so desperately needed because they knew that everyone needed it. And I think these are structural barriers that we have that we've known about for a very long time. And this is where Erene, I'm going to tap you in, we've identified the barriers. When are we going to fix them? When are we going to start doing something that's actually meaningful? And that reduces the stigma and gets people access, quick access to what they need.

Erene Stergiopoulos:

I think one of the things that this conversation has been circling around is, um, professionalism, which is sort of the unspoken word in all of this. And it's such a double standard because wellness has been lumped into the competencies around professionalism in so many different ways. It's in the official, like I think it's in the ACGME ones. It's definitely in the CanMEDS competencies. Um, but at the same time, the second you show any kind of mental health distress, you become unprofessional. The second you're missing time on the wards to go to therapy. It becomes unprofessional. They're like, Oh, well, why are you missing so much time? So, it's this incredible double standard, which is, I think, why it's so hard to actually find the solutions because the second you actually stand up for yourself and say, Oh, I need this accommodation. Or I do need this time to focus on, you know, actually staying alive, you get all this pushback. And it's like, Oh, well, you're not being professional.

Circling back to your question how soon can we get this done? What needs to get done? What are some solutions, um, you already pointed to the universal design principles of why don't give everyone flex time, like two hours a week and have them do whatever they need to do to stay well? Other things would be things like, um, opt-out counseling. So that's been done.  The University of Indiana had first and second year residents in internal medicine. they gave them all this sort of wellness day where they could participate in an opt-out mental health assessment. They called it a wellness assessment. and they also offered them protected time for follow up. and their participation rate was huge, it was in the nineties and the people who did participate were much more likely to use mental health services down the line if they needed them, because it completely broke that stigma barrier of like, Oh God, if I get this, if I get an assessment, I'll be seen as weak, I'll be, I'll be judged as someone who isn't cut out for medicine, because the fact was that everyone got the assessment. 

Another barrier is, you know, where does funding go? What gets prioritized in the institution? That's like the whole hidden curriculum of, you know, what is actually valued, um, which comes back to Justin's point of, you know, what are we valuing here? Are we valuing a resident's ability to provide service or are we valuing their quality of life,there's so many contradictions in medicine, so many mixed messages?

Sofia Schlozman:

That concludes episode 1 of our three-part series.

Thank you to our three fantastic guests, for their openness and thoughtfulness in discussing these important topics.  And thank you to you, our audience, for listening or reading along.

We hope you will join us for Part 2, available now, for a discussion on the importance of supporting learners and a discussion of why it is so difficult, yet so important, to normalize discussions of mental health in medicine.

This podcast is a production of the University of Michigan Medical School, Department of Family Medicine, MDisability initiative. The opinions expressed in this podcast do not necessarily reflect those of the University of Michigan Medical School. It is released under a creative commons, attribution noncommercial, non-derivative license. This podcast was produced by Lisa Meeks and Sofia Schlozman.

 

Music:

-       “Aspire” by Scott Holmes

-       “Donnalee” by Blue Dot Sessions

-       “An Oddly Formal Dance” by Blue Dot Sessions

-       “Li Fonte” by Blue Dot Sessions

-       “The Poplar Grove” by Blue Dot Sessions

-       “True Blue Sky” by Blue Dot Sessions

-       “Positive and Fun” by Scott Holmes

 

Resources and References Mentioned in this podcast:

 

Anonymous. In My Experience: How Educators Can Support a Medical Student With Mental Illness, Academic Medicine: November 2019 - Volume 94 - Issue 11 - p 1638-1639 doi: 10.1097/ACM.0000000000002953

 

Mata  DA, Ramos  MA, Bansal  N,  et al.  Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis.  JAMA. 2015;314(22):2373-2383. doi:10.1001/jama.2015.15845

 

Meeks LM, Plegue M, Case B, Swenor BK, Sen S. Assessment of Disclosure of Psychological Disability Among US Medical Students. JAMA Netw Open. 2020;3(7):e2011165. doi:10.1001/jamanetworkopen.2020.11165

Stergiopoulos, Erene MD, MA; Hodges, Brian MD, PhD, FRCPC; Martimianakis, Maria Athina (Tina) MA, MEd, PhD Should Wellness Be a Core Competency for Physicians?, Academic Medicine: September 2020 - Volume 95 - Issue 9 - p 1350-1353

doi: 10.1097/ACM.0000000000003280

 

Martin A, Chilton J, Gothelf D, Amsalem D. Physician self-disclosure of lived experience improves mental health attitudes among medical students: a randomized study.JMed Educ Curric Dev. 2020;7:2382120519889352. doi:10.1177/2382120519889352

 

Additional Articles by Participants:

 

Erene Stergiopoulos, MD, MA

 

Stergiopoulos, Erene MD, MA; Hodges, Brian MD, PhD, FRCPC; Martimianakis, Maria Athina (Tina) MA, MEd, PhD Should Wellness Be a Core Competency for Physicians?, Academic Medicine: September 2020 - Volume 95 - Issue 9 - p 1350-1353

doi: 10.1097/ACM.0000000000003280

 

Stergiopoulos, Erene MA; Fernando, Oshan PhD; Martimianakis, Maria Athina MA, MEd, PhD “Being on Both Sides”: Canadian Medical Students’ Experiences With Disability, the Hidden Curriculum, and Professional Identity Construction, Academic Medicine: October 2018 - Volume 93 - Issue 10 - p 1550-1559 doi: 10.1097/ACM.0000000000002300

 

Stergiopoulos E, Fragso L, Meeks LM. Cultural Barriers to help seeking in medical education. JAMA Int Med, 2020, Dec. 28. [Epub ahead of print]

 

Dr. Stergiopoulos was a previous guest on this podcast see: https://medicine.umich.edu/dept/family-medicine/programs/mdisability/transforming-medical-education/docswithdisabilities-podcast-ep-2-erene-stergiopoulos

 

Justin Bullock, MD

 

He was previously a guest on this podcast see: https://medicine.umich.edu/dept/family-medicine/programs/mdisability/transforming-medical-education/docswithdisabilities-podcast-ep-17-justin-bullock

 

Bullock JL. Suicide—rewriting my story. New England Journal of Medicine. 2020 Mar 26;382(13):1196-7.

 

 

Jessi Gold, MD,

Calhoun AJ, Gold JA. "I Feel Like I Know Them": the Positive Effect of Celebrity Self-disclosure of Mental Illness. Acad Psychiatry. 2020 Apr;44(2):237-241. doi: 10.1007/s40596-020-01200-5. Epub 2020 Feb 25. PMID: 32100256.

 

Gold JA, Johnson B, Leydon G, Rohrbaugh RM, Wilkins KM. Mental health self-care in medical students: a comprehensive look at help-seeking. Acad Psychiatry. 2015 Feb;39(1):37-46. doi: 10.1007/s40596-014-0202-z. Epub 2014 Aug 1. PMID: 25082721.

 

https://www.forbes.com/sites/jessicagold/2020/07/13/it-is-time-to-stop-s...

 

Anonymous:

 

 Anonymous In My Experience: How Educators Can Support a Medical Student With Mental Illness, Academic Medicine: November 2019 - Volume 94 - Issue 11 - p 1638-1639

doi: 10.1097/ACM.0000000000002953

 

Lisa Meeks, PhD

 

Meeks LM, Plegue M, Case B, Swenor BK, Sen S. Assessment of Disclosure of Psychological Disability Among US Medical Students. JAMA Network Open. 2020 Jul 1;3(7):e2011165-.

 

Meeks LM, Ramsey J, Lyons M, Spencer AL, Lee WW. Wellness and work: mixed messages in residency training. Journal of general internal medicine. 2019 Jul 15;34(7):1352-5.

 

Meeks LM, Murray JF. Mental Health and Medical Education. In Medical Student Well-Being 2019 (pp. 17-58). Springer, Cham.

 

Lee WW, Guillett S, Murray JF, Meeks LM. Wellness and Disability. In Disability as Diversity 2020 (pp. 83-102). Springer, Cham.

 

Lapedis CJ, Meeks LM. Burnout Contagion. Annals of internal medicine. 2019 Jun 4;170(11):816.

 

Murray JF, Meeks LM. Support medical students with psychological disabilities. Disability Compliance for Higher Education. 2016 Jul;21(12):7-.

 

Taylor NL, Miller M, Meeks LM. Physician Licensing, Career, and Practice. In Disability as Diversity 2020 (pp. 279-295). Springer, Cham.

DocsWithDisabilities Podcast #26

Introduction:

Lisa Meeks:

Doctors with disabilities exist in small but measurable numbers. How did they navigate their journey? What were the challenges? What are the benefits to patients and to their peers? What can we learn from their experiences? My name is Lisa Meeks, and I am thrilled to bring you the DocsWithDisabilities podcast.

Join me as I interview Docs, Nurses, Psychologists, OT’s, PT’s, Pharmacists, Dentists, and the list goes on. I’ll also be interviewing the researchers and policy makers that ensure medicine remains an equal opportunity profession.

Sofia Schlozman:

Hello everyone!  Welcome back to the Docs with Disabilities podcast.  This is Part 2 of our three-part series on wellness and psychological disability in medical education. In Part 1, Dr. Meeks and guests Dr. Bullock, Dr. Gold, and Dr. Stergiopoulos discussed the stigma that surrounds disclosing a mental illness and the challenges of seeking care for one’s mental health while in medical education.  If you have not yet listened to that episode, we strongly encourage you to do so.

We begin now with a discussion of why it is so important for medical education institutions to support student wellness.

Lisa Meeks:

What happens when you don't support learners? and I'm talking about all learners? not just learners that are presenting with acute mental health concerns, but those that are in States of burnout as well, when you take a learner to the edge of what they're able to handle and by virtue of not having accommodations or not having protected time or not doing what you're supposed to be doing under the ACGME regulations, which is to allow them to, you know, go and engage in and health related and necessary appointments. you risk that learner needing to take a leave of absence or having an exacerbation that is so acute that, something tragic happens or they leave the program. You know, if we're going to talk about learners as a function of resources, then you've lost that resource for good, right. losing a resident is extraordinarily costly to the program. And it's not only costly to the program in terms of resources and finances, it's costly for morale. Think about the learners that remain and the additional pressure that's put on them while the program works to figure out a solution.

Erene Stergiopoulos:

Absolutely. I mean, leave of absence has such a high cost to everyone. a resident on call overnight in Ontario where I work makes like $130. If the resident had to drop out of the call pool, for any reason, they had to get a staff to cover that shift. The staff would bill like probably a thousand dollars. so, we're a very cheap workforce. And so, maintaining our ability to continue working is actually in the interest of the employer, in the interest of the system. But in terms of leave of absence, the cost, like you said is so high because it's so much lost productivity, it takes the resident away from their sense of being able to have a sense of control. it takes them away from their support system, it takes them away from being able to function and find themselves in a place where I was like, you know, I have an illness I'm making my way through it. I'm using accommodations and I'm still participating. when we're on the provider side, when someone, when a patient comes to you and says, you know, I have an illness, I need time off work. 

We very rarely say, Oh yeah, here's six months off. Like you have no ability to do your work at all given your current illness. We very, very rarely do that because we don't want to take away someone's locus of control. We don't want to take away their sense of self-efficacy because that's actually more damaging in the long run, especially for mental health. So many of the strategies that we give to patients are graduated return to work things that allow them to have a sense of control and mastery over their environment while still managing their illness. So, you can actually have both at once, like Justin was saying, you can have a mental illness and be an amazing doctor, but we don't live in a model that really acknowledges that at all.

Lisa Meeks:

Justin, what do you think about Erene suggestions with the opt-out counseling? Where everyone goes to see someone and get connected in the beginning, is that feasible? Would your colleagues engage in and therapy more readily if that structure was in place? And do you think it would reduce the stigma?

Justin Bullock:

I definitely do. My program actually started doing this this year with all the interns. So, they have three scheduled therapy appointments that are opt-out with protected time for them. I think it's an amazing idea. The thing that kind of remains to be seen, as I believe pretty strongly that like fit matters a lot with therapists. So, one, you got to have good therapists. I think a lot of people who haven't done therapy before and who haven't had a good match with like a therapist or any mental health provider, they don't know that like they're like, Oh, I tried therapy once it didn't work. And for me it's like, no, that's not how it works. Um, and so, but so people have to know that they can like try someone else. Um, and so if there could be more than one person, who's an option, you know, people of varying genders and like race, ethnicities and sexual orientation, because what different people need, you know, is different. Um, but that being said, I think having something is definitely much better than having nothing. also, just to circle back way earlier too, I think it was your point, Lisa, my biggest obstacle to leaving the hospital is putting more work on other people. Um, cause cause you, cause I'm sure I've said this to you before is like, everyone's so close to breaking that you're just like, I cannot put one of my sticks onto someone else's basket cause their basket is about to pop. so, it's nice when you have this protected time, that's scheduled to be a way, so then you're not adding anything extra.

Lisa Meeks:

Right, right. And you know, you talked about, and you've talked before about this, you know, the need to protect the people that are kind of in your pod, if you will, knowing that if you leave, it's, it's going to be rough on them. Um, we've talked about the stigma, Jessi, you brought upan important point, which is there's such an abnormal sense of what is normal in residency. I 100% agree with you. even if it's absolutely destructive, when you've normalized it, everybody looks around and says, okay, well this must just be how it is. and they don't see themselves as impaired. They don't see themselves as depressed. They see themselves as looking like an intern, like every other intern.

Jessi Gold:

The only study I've seen on that is the study of the surgeons at Mayo. And they'd had them do the mayo wellbeing index and they asked like the bottom third of them, where they thought they were compared to other surgeons. And 70% of them were like we're average or above average, but they were all in the bottom third. So, we just can’t calibrate at all. So, I think, you know, there haven't been a lot of studies on that, that you can look around and you can see that we don't know anything about that. We think just because we went to school in this that we should be able to identify signs and symptoms and warning signs in ourselves, but we're not very good at that because we don't want to identify them in ourselves. And because we normalize not sleeping and eating and functioning, so why would we have those are just life symptoms So I think it makes it really hard.

We don't stop and think about ourselves very often. I think this happens, especially right now with everything that's going on. But I do think, we're caregivers, why would we think about where we fit into the equation? I have a lot of conversations with people about how just because we take care of people does not mean we aren't human and we're not people ourselves. We don't often stop and think about how we see hard things. And we, you know, as therapists here, some of the hardest darkest things that people have ever experienced in their life and can't just hear that over and over and not have a reaction. And you have to take care of yourself to be a good caregiver, and it is not good medicine to think that you can just go on adrenaline purely forever and it's just not possible.

Mental health fields like social work have done this really well for a long time and normalize getting mental health treatment. Psychiatry does a decent job valuing therapy. It's almost part of the education to understand yourself. I don't know that it's always to help you treatment wise, but it is part of your education. I don't know that everyone else thinks like that, but I do think it helps psychiatry residents start on that path of thinking that way.

For me, I appreciate reading people like Justin and talking about this stuff vocally and always tell him that because I think, you know, it's hard doing my job and not having examples of people that talk out loud about it. I appreciate people that are able to get help at any stage, but I do think we do need some people that are able to break the barrierswith their name attached in the same way that celebrities are doing that in other ways for mental health in general culture, right? To say “hey, I can function. I can exist. I've gotten here and I have survived and I am functioning and I have mental health challenges.” I think that I've become more comfortable talking about going to therapy and what my therapist says for the same reason, because I feel like it's hypocritical not to. I think it makes me a better doctor and I would want my patients to know that somebody was holding me up and making me feel better. People should know that their providers have support.

 

MUSIC

 

Lisa Meeks:

I do think there's this groundswell of support, Jessi for the things that we're talking about, the systems change that needs to occur. And people like Justin certainly are helping push that agenda. And by being so vocal, I think it's moving the needle. And I remember the day, and this is such a weird thing to remember, but I remember the day that Esther Choo, do you know what I'm talking about? All of you probably like, Oh, I know exactly what she's going to say, but Esther Choo tweeted out. I go to therapy.

Jessi Gold:

So, Esther actually tweeted it in regards to Dr. Breen's suicide and said, you know, basically that she was on Lexapro and goes and sees a therapist. And honestly as a medicine prescriber, it is very rare that people talk about being on medicine. I can tell you time and time again, that people will talk about going to therapy. Therapy has been co-opted in a lot of ways by the wellness industry and it is trendy to go to therapy. It is okay to go to therapy. A lot of times it is not common for people to just be like, yeah, I mean, I'm on Lexapro when I was on Lexapro, you know? And I think that when I saw that, I was like, that's amazing. And basically when she did that, I said, I go to therapy and I wouldn't be able to do my job if it weren't for that, a bunch of healthcare providers after that were like, Oh, you know, I see a doctor, I see a psychiatrist for this, I see a psychiatrist for this, and it took off, like, I've never seen that many healthcare providers ever admit that they have mental health difficulties or struggle.

Lisa Meeks:

We talk about the abnormal things that we normalize, right. That not sleeping, not eating, not taking care of yourself. And I thought this is one of those things that is going to be normalized. It was like, oh my God, all of these people, all of the right people are saying all of this stuff. I felt like something opened up on the earth and all of a sudden it became okay. 

It's like this little secret that everybody in medicine knows, but nobody talks about. I remember being somewhere for a grand rounds. They take you out to dinner the night before this is obviously pre-COVID. Um, you know, you get to go out to dinner, hang out with cool people. And I remember I was talking about mental health and medical education, and then somebody laughed and was like, “is there anybody at this table that is not on an antidepressant and seeing a therapist?” And I could not believe pretty much everybody at the table was saying, by virtue of not raising their hand, Hey, like, this is what it is. And, the person who had started that conversation said, “I don't know anyone who can undergo the stress of what we do on a daily basis and not at some point in their lives need to unpack that with a professional.” And I just thought, oh my gosh, this is amazing. And if the students could hear, of course, there's no students sitting there at dinner, right? And I'm thinking, if the students could just hear you guys talking like vulnerable humans that have struggles and are going through things that we don't, they see you as super human. And so, I know Erene you wrote about it in your paper.

Erene Stergiopoulos:

I think, I mean, it has such an incredible impact when a physician role model actually discuss discusses their mental health experiences and their actual like experience getting care because it's one thing to hear it from a peer, but if you're a learner and you actually see one of your mentors or like just someone who's made it, someone who's like in the field practicing, um, and saying, Oh yeah, I'm on an antidepressant. And oh yeah, I see a therapist that just completely takes away that kind of, I don't know, like the mystique of, Oh God, this isn't allowed, or this isn't supposed to be actually happening when you're a doctor. 

So, there was this one study that I really love. It was a smaller study, but it was super promising where it studied medical students' attitudes towards active accessing care. And it found that if students actually knew a physician who had struggled with their mental health who got treatment and for who improved from that treatment, they were much more likely to actually access care. I think 90%, over 90% of students said they were more likely to access care when they actually knew someone like a staff physician who had done, who had accessed care. So that just shows how powerful it is to actually see someone in the field saying, “yeah, I do a hard job, it's rewarding and it's, it's really taxing.” In some of the research that I did like about medical students with chronic illnesses, someone worded it so beautifully, they said, you know, being in medicine, you sacrifice a huge part of yourself. It's not easy to hear people's trauma every day, to see trauma all the time in the hospital and we need someplace to process that. So, like everyone's been saying, I mean, this is not an easy job at all. It makes a lot of sense that we need the extra help.

Lisa Meeks:

And I've seen this in action. I mean, we at UCSF, we had this mental illness among us day, and I swear that on that day, when Justin Bullock would get up and talk to the class or, you know, any of his peers that came after him, in the wellness group, we would be booked solid for a week after that event occurred. And it was such an opportunity for a peer to stand up and say, okay, this is what happens and to normalize using the resources. I think it's super powerful.

Jessi Gold:

I do actually think in a lot of ways, and I will tell you, this is the hope of COVID in my opinion, is that it has affected so many healthcare workers in so many levels that you cannot deny that mental health affects healthcare workers and that we need to talk about it, you just can't get away from this conversation and you cannot be a healthcare system and not talk about this right now. It is absolutely malpractice to not be talking about this as a healthcare system. So, I do think that's a big thing.

Justin Bullock:

Something that I have been fortunate to get to witness is since I wrote that prospective piece in March, um, I've always had people who are sort of like younger than me in training, like the process since writing that piece I've actually had multiple attendings who shared various chronic illnesses. And it's just been really fascinating. I always really appreciate it, but I'm also just like, why didn't you share that with me before now? I say this again, there is no reason for us to believe that we, as physicians would be any different from the patients that we serve.

And the other thing that I've been dying to say, because I've thought you cannot say this enough is like, we cannot have any discussion aboutmental health in trainees without talking about how ridiculous 28-hour, 30-hour, 24-hour shifts are. They were like physiologically, not normal. And they have all these studies and I don't think we need a study, I believe that any reasonable person should be able to see that working for an entire 24 hours plus is not going to be good for the providers. 

Lisa Meeks:

I don't think we're accounting for the nurses and all of the other healthcare professionals that are keeping people from doing harm when they're tired and exhausted and overworked. So, you know, there's a system in place and we have safety precautions in place. So, would we expect patient outcomes to be worse? Well we would hope not. We would hope that the, the system of safety and the kind of peer monitoring, um, would keep that from happening. But we weren't measuring damage to the provider.

Justin Bullock:

Exactly. And, you know, and that's what I always say is like, you know, we narrowly measure a lot of these studies measure things like patient error or like, you know, medical error. And I think, but you don't measure the way that, like the person who sleep deprived just yelled at a nurse or was rude to the intern who came on. And then that, you know, it's basically just like propagation. There’re so many ways that it is beyond just these measurable errors.

Lisa Meeks:

This all leads up to a big elephant in the room that we haven't talked about. And why is everybody so fearful? Like, what's the origin of that fear. And I think stigma is part of it, but there's a major downstream effect to disclosing any type of mental health related disability that especially once you pass that threshold, Justin, as you mentioned, going from UME to GME and all of the sudden there is, there is a watchdog organization, which is there for the good, and I don't want to discount that, but there are some things that are not good, and Jessi that's where you come in and school, all of us and help us understand and help the listener understand what is going on with the state medical boards?

Jessi Gold:

I think what you would hope is that they would follow the Americans with Disabilities Act (ADA), which would mean that they're supposed to either ask nothing or ask about impairment. And impairment would mean, “Is whatever is going on with me, physical or mental illness actively going to harm the patient in front of me?” What does happen instead is that a lot of States, like more than half of states, still ask about historical mental illness, like more than five years. Like, “have you ever in your past ever seen a psychiatrist or therapist?” “Do you have a diagnosis?” And what that means is people get scared to ever get help because it can follow you if you can ask about historical care. Right? Because that means if I get care and I get better, it doesn't matter that I am better, whatever better means, because they can always ask about it. And it doesn't matter because once it's on my “chart”, it can follow me wherever I go, because someone can always look it up or figure it out and I have to report it.

 

Nobody knows what it means to say yes on these applications. So, a lot of states it's really unclear what happens to the applications when you fill them out. So, people get really nervous about answering them. Some people lie. People kind of hope you just, nobody can figure it out because of HIPAA. Right? So, you kind of hope that there are multiple ways that you're protected from that never coming out. And you're probably more likely than not okay, now I'm not encouraging lying, but I will say, I know a lot of patients and I have a lot of patients who have made that decision. And I have a lot of friends who have made that decision. They can choose to interpret the language in a way that they think they could make an argument for.

Lisa Meeks

The learner is reading that and the way that is best for them to interpret, or they're asking their mentors.

Jessi Gold:

I completely agree. And I know lots of people that have then asked a mentor because they're like, I don't know if this counts, like, does this count and I get it. And I think, you know, in a lot of these States, it's like, if I say yes, does it get reported in such a way that patients can then see it? is it in some, you know, system that's searchable? And so, all my patients know my diagnosis is reported in such a way that then I have a provisional license or a restricted license. Does it cause a problem in such a way that then they're like, get a checkup on me or do extra things. Are they going to ask for my doctor's notes? Are they going to try to make sure I'm in treatment when I haven't been in treatment for 10 years because I'm fine?

What you know is there's folklore of people who have had horrible things happen when they've checked the box, right? You've heard from an attending, you've heard from a friend you've heard from someone that getting treatment could affect your ability to practice medicine in the future. That is bottom line, what you have heard. And that is not incorrect, you know, and it's fair to have that opinion because it is true as it stands in a lot of States, and we move right? We, as providers, do not stay in the same state our whole career, we move for residency and fellowship and we move in academics if we get a different job. So, the idea that we could possibly have to answer different questions at a different time in our career is completely logical.

I just had to answer Illinois licenses because of telehealth, because we get patients from Illinois to cross the border and we didn't used to have to care because they just drove here.  But we get them when they're physically in Illinois right now. Illinois asks much different questions then Missouri and the Illinois mental health questions are in this same little section as criminal history and pedophilia. And so, you're reading it and you're like, well, that's really nice that you think if I've ever gone to therapy, that I'm a criminal.

The way that they're phrasing that is ridiculous. Now the Federation of State Medical Boards doesn't think they should be doing that. They have a document that says they shouldn't be doing that. They wrote it, they put it out there. They said, stop doing that. And some States have stopped or made some alterations, but a lot of the States where that has happened has really been like grassroots activism.

Lisa Meeks:

We have students making decisions about the rest of their life and where they live based on this question

Jessi Gold:

Based on fear of the idea of the question, which is so scary. Physician suicide is among the highest of any profession we should. Absolutely never, ever think in a moment of urgency or life or death, is this going to take my job away from me?

Lisa Meeks:

Right.

Jessi Gold:

And there are people where that has happened. There are people who have attempted instead, and there are people who will tell you stories of their partners who are no longer with us or family members who are no longer with us, that this was a very big factor in that decision. There are no simple suicides, right. But this is not something that I would ever say is not a factor.  Ivery adamantly believe it needs to be changed.

Lisa Meeks:

Yeah. And unfortunately, to Justin's point, the States are very fearful of physicians who have had any type of mental health history, and it's because it is automatically equated to criminal behavior. And, you know, that's, that's one of the big driving forces for Stigma and you can't be a competent physician if you have a history of, and, or a current symptoms of psychological disability, which is sad because as we know, many of our physicians do have either a history of, or currently struggle with some sort of mental health concern. So, this is very prominent yet it's treated as if it's some sort of terrible anomaly.

Jessi Gold:

Yeah. I mean, I think that that image in a lot of ways is just further perpetuated in society, right? Because we only talk about mental illness as like a scapegoat when people are violent or when people do something that we don't like, or when people do something that is hateful and then we just try to blame mental illness for it. Right. So, when you go to talk to people who have no relatives that they have ever talked to about their mental health, or have never really had an experience with someone with mental health, and they're running the Federation of State Medical Boards, they say, well, people with mental illness are violent because they read the newspaper and that's what the newspaper told them. Right. And that's what we let the newspaper tell them over and over and over for 50, 60, 70, 80 years, right. We've been doing this forever and we're not, we haven't changed that narrative. people call it out, but they keep doing it. They do it all the time. And so, it makes it really hard because if those people are the ones making the decisions and you have to change hearts and minds on a very prominent narrative.

 

Sofia Schlozman:

Thank you Dr. Bullock, Dr. Gold, and Dr. Stergiopoulos, for sharing your experiences and insights with our audience. Your perspectives have strengthened my understanding of the complexities of discussing mental health among healthcare providers, and I am sure that you have done the same for our listeners.

To our audience, thank you for joining us!  In Part 3 of our series on wellness and medical education, our guests will respond to listener questions.  We hope you tune in.

 

Music:

-       “Aspire” by Scott Holmes

-       “Donnalee” by Blue Dot Sessions

-       “Gambrel” by Blue Dot Sessions

-       “An Oddly Formal Dance” by Blue Dot Sessions

-       “Positive and Fun” by Scott Holmes

 

 

Resources and References Mentioned in this podcast are available on Transcript 1

Some text has been adjusted in this transcript for ease of reading.

DocsWithDisabilities Podcast #26

Introduction:

Lisa Meeks:

Doctors with disabilities exist in small but measurable numbers. How did they navigate their journey? What were the challenges? What are the benefits to patients and to their peers? What can we learn from their experiences? My name is Lisa Meeks, and I am thrilled to bring you the DocsWithDisabilities podcast.

Join me as I interview Docs, Nurses, Psychologists, OT’s, PT’s, Pharmacists, Dentists, and the list goes on. I’ll also be interviewing the researchers and policy makers that ensure medicine remains an equal opportunity profession.

Sofia Schlozman:

Hello, and welcome to the third and final episode in our three-part series on psychological disability and wellness in medical education.  If you have not yet listened to the first two episodes of our series, we strongly encourage you to do so. 

Today, we conclude our conversation with questions for listeners and a final discussion of some of the most impactful changes we can make to improve medical education for learners with mental health challenges.

Let’s begin.

Lisa Meeks:

I have some questions that came in from listeners. And if the three of you will entertain me, I would like to ask each of you a question on behalf of a listener and we'll see where the conversation goes from there.

So, Justin, I'm going to start with you and a listener wrote in and said, “I have been so moved by your story and how you share your experiences. But it's also made me become acutely aware of the potential repercussions for taking a leave of absence and, and having to come back into my residency. What are your ideas for change for the fitness for duty process?”

Justin Bullock:

So, I will acknowledge that it's probably a little bit different at each institution within some States there are the physician health programs that basically run fitness for duty. But, at least at my institution, fitness for duty was just overall very, very harmful to me. It's really interesting. I think my therapist would say I have a lot of trauma in my lifetime and for whatever reason, this experience was particularly traumatic to me and I think a lot of it comes from the frame with which fitness for duty is approached. And it's definitely very, sort of, punitive as if I had done something wrong. Essentially my institution had one pathway for people who had mental illness or substance use disorders and it really came from this punitive substance use discipline mindset where the person has no agency and they can't control themselves. The drug has won and you know, they are not to be trusted with their own decision-making.

Specific things that I think should be changed are 1.. the fitness for duty process had zero mental health providers on it, on the committee, they were all like surgeons, anesthesia, some internal medicine. The one person who was a therapist was actually not a part of the actual decision-making. And so basically when they got recommendations about my mental health and I pushed back on them, they had no one who had any competency, when I said, “oh, this is an unreasonable requirement, and this is because I've done therapy for the last 10 years all these reasons”, there was no one who could even consider that claim. There are a lot of structural things too, there were no black people in the committee, there were like a very, very small number of underrepresented minorities on the committee. They never spoke with me directly they only had secondhand like resource information, so I never got to tell my story and everyone else was sort of framing it in their own way. There were some like HIPAA violations, et cetera, et cetera, et cetera. There are many, many things that I think just made it first, just like the data that they were collecting was flawed. And so, from my perspective, with flawed data, you cannot make an accurate decision. 

So, I think there really needs to be an entire retooling of the process to make sure that there's like fidelity for the information that you're getting, that there's some way to verify its accuracy.  That you have content experts on the committee, as well as, you know, if you're going to like refer to external experts. And then really just stop making the process so shameful, you know, I said this to many people, if this were my first diagnosis with bipolar, or if I had a substance disorder and those are my first diagnosis was like substance disorder, I will live the rest of my life in shame because of the way that they approached the process, and the lack of transparency and the way that they couldn't provide me with any policies or anything. And I think that that really hurts people, you know, and I think fundamentally at the end of the day I actually am much, much, much less likely to ever come forward ever again. And that's very unfortunate because I have an active mental illness, and that to me is what harms patients and that is what harms providers.

Every other time I self-withdrew from work, I always called out of work. I always got myself to the hospital. This was a victory. The fact that I like called nine 911 and, you know, just like comparing over my life from, from like six years ago, my last suicide attempt I actually didn't know if I was going to live and I ended up in the ICU and this suicide attempt, I like ended up in the hospital and I knew I was going to be fine. And so, while people may not see that as progress, I actually see that as momentous. I think that that was so much better. And I didn't hurt any patients, I didn't even come close to hurting any patients. 

And I will say that the institution has really acknowledged the myriad of ways that this process was problematic and are currently in the process of retooling and actually know that they're sort of changing the membership already. And I've been asked to share my experience with this taskforce that's supposed to be fixing things. I think that, um, because I was so vocal and because I did not relent at all--and I think UCSF is a progressive institution--that actually is willing to listen to trainees if you make them listen. So, I think there is progress that is happening is just slow.

Lisa Meeks:

You also had a long history and like you said you were well-respected by all of us. And, there was trust and a relationship. So, I think that, had this been someone else they might not have been able to move the discussion.

Justin Bullock:

And I think that's really, because there were really one or two key, like leaders in the institution who were my allies and I believe that without them, it wouldn't be no one, like no one was listening to me until they got involved.

Lisa Meeks:

Yeah.

Justin Bullock:

Which is unfortunate.

 

MUSIC

 

Lisa Meeks:

So, next up Erene, you wrote a paper on academic medicine. it was 2020, just a few months ago, I believe, September, is that right?

Erene Stergiopoulos:

Yes. September, 2020.

Lisa Meeks:

And the title, I should say, is Should wellness be a core competency for physicians? (https://journals.lww.com/academicmedicine/fulltext/10.1097/ACM.0000000000003280).  And I recommend everybody read this, but I will read you the question from our listener, which I think people with disabilities find anything that has the word disability in it. First of all, if you publish anything. And we were talking about students with learners, with disabilities, every learner with a disability is going to find it because there, cause there's so few resources and kind of roadmaps out there that everybody is, is soaking it all up.

But for this, this listener, their concern came on the heels of this article. And they said, “the technical standards at my institution have a domain called behavioral and social attributes. And it says a candidate must possess the mental and emotional health required for full utilization of his or herintellectual abilities, the exercise of good judgment, the prompt completion of all responsibilities.” And it goes on, but they said “ if I have major depressive disorder, even if it's not active, can I say that I possess the mental and emotional health required for full utilization. Even if at times I may require accommodation?”

Erene Stergiopoulos:

Hearing those statements, like actually reading out official policy and reading out technical standards is so disheartening because it shapes the entire educational environment in which that person is training. It shapes whether they feel like they even belong in medicine in the first place when they have to see that written on a paper and question, whether they're even allowed to be in that space.

The thing about competency and wellness and technical standards around disability is that the wellness world pretends that disability isn't part of it.  They imagine everyone is sort of, kind of cruising along at a 7 out of 10, maybe in terms of their overall general wellness and then med school and residency throw some, some roadblocks and then they might see their wellness dip and so they think, okay, add the ice cream, social, deploy the meditation retreat, or the one hour of meditation at seven 30 in the morning, that's mandatory, um, that will get them back up to their 7 out of 10, and in fact, back to the 10 out of 10 of wellness that they, that they should be at.

The thing about wellness and turning that into a competency and what we talked about in the paper was the problem is that the way that wellness actually gets actualized or operationalized at institutions is that it's, it's sort of this extra add on activity. We all know about the meditation hour or the mandatory seminar on how to manage your burnout. That makes you come in at 6:30 in the morning, instead of actually giving you time to sleep, which would probably be way more beneficial to everyone's wellness. So, the way they define wellness is actually not necessarily a very universal way of defining it and what activities actually help people be well.

But then on the flip side, it's also, “how do they define competency, right?” “How do we actually measure that competency…?” if measuring wellness means, “Oh, how many times can a person engage in very conspicuous Self-care like going to the yoga session, drinking a kale smoothie or whatever” Then a lot of people with disabilities who actually have to do a lot of extra self-care to begin with to manage their condition. they're not judged as well because they're not going to this smoothie making session. So, it puts them at this huge disadvantage where they're actually the biggest experts on wellness because they live it every day. They have to manage themselves and their conditions on a constant basis and they self-monitor their mood, they self-monitor their pain and their physical abilities and their ability to sleep and get regular scheduling. And yet that is not honored. That's not recognized as a form of wellness.

Lisa Meeks:

The reality is that this has to be addressed with, or without accommodation. And so, I think there are actually two issues here, right?

One that we don't view these mandates through the lens of somebody might need an accommodation and might be able to fully do something when that's in play.

And then two, if we're going to start putting wellness or emotional behavioralstability into a competency, like you said, how are we measuring this? And what does it mean to, to know what it takes to manage your own personal health care and to be a good provider? Like Justin said “there has never been a day when I wasn't in control of whether I was going to be near a patient. I'm self-aware, I know exactly what I need to do, even though I'm living with a mental illness” then so does that count, or do you have to absolutely be free of any mental health concern at all times in order to be a qualified student.

Justin Bullock:

I honestly think that because I have all my mental health challenges, I know my emotions. I am much more in touch with my emotions, then I feel like a lot of people around me and I think that's a super skill. So, something on Twitter that I saw, I don't know what the Canadian version of the NRMP, the matches, but that like, in these like standardized letters for family medicine some of the questions that arethe person, basically always show composure was not, it was not like tearful or not like...

Erene Stergiopoulos:

Not defensive and not tearful.

Justin Bullock:

Exactly. And I don't believe that having emotions makes one a bad doctor. Um, I will never believe that because it's not true.

Lisa Meeks:

So, it says that you can't be tearful.

Erene Stergiopoulos:

Yeah, for the match, like it's called CaRMS in Canada, the reference letters have a standardized template now for family medicine matches specifically. And it says please comment if the candidate has shown these unprofessional behaviors and like, I've definitely cried with patients.

Lisa Meeks:

I have definitely cried with patients. Is there anybody on this call that has not cried with a patient or been tearful when you witnessed something that was worthy of tears?

Jessi Gold:

I've cried in between. I've never cried in the room, but that's like my own stuff, but I've definitely cried in between.  I've cried outside the room too, like right outside the room, like ran outside the room, and cried, and had a bunch of nurses be like, “I've never seen a doctor cry.” That was interesting. But definitely not that I can think of like absolutely in front of a patient.

Lisa Meeks:

I give this talk called the benefit of the bathroom stall. That's a place that, especially for learners that have panic attacks, when you're having a panic attack, you’ve got to get somewhere where you can implement whatever your system is, so finding a safe space in a hospital where you can legitimately answer a question of where you have been and somebody probably won't follow up on it. It's, it's literally teaching people where they can go to be human.

Justin Bullock:

For me, it's like, if you could find someone who doesn't cry at this and like, they're not to me, a human. Like my first code, my first like bad code as an intern, we were basically coding someone for like 30 minutes. And eventually we asked the family to come in and the families like crying over the body of their father. I was one of those ones where like, I mean, first I have to be in here because, you know, we still need to give this person medical care, but like there's an emotion and everyone in this room is experiencing it. And I think it was normal.

Lisa Meeks:

Mike Natter does the sketching, he's a famous medical student. We all love Mike Natter (TWITTER: @mikenatter), he's like the most amazing ever. Um, and he's just a good human to like on top of all of that skill and talent, he's just a good human, but he has this pretty widespread sketch that he did that shows residents curled up crying (https://www.acpjournals.org/doi/10.7326/G19-0002) because you can't be seen crying on the wards and it's it, he has some pretty, pretty intense, uh, sketches that really powerfully translate into shared emotions that we've all experienced.

 

BEAT MUSIC

 

Lisa Meeks:

Well, Jessi, I'm saving the last question for you.

This is from one of our listeners and, and this listener was very, very specific, very excited that you would be answering this question and is very wanting to know exactly when it would air. It was like very invested in the end, getting your answer. So, no pressure. “I felt the need to limit where I applied to residency based on one question and the state licensing board. And therefore, I was only even able to consider half of all the residencies that were available while I ultimately found many that I'm looking forward to interviewing with. I still wonder where else I could have gone if it weren't for my health history, what types of advocacy are going on right now for modifying the state licensing applications.

Jessi Gold:

Yeah. Um, that question makes me really sad. I just wish that that wasn't a thing and that people could go wherever they wanted and that they wouldn't have to think like that. And we didn't live in a world like that. And I wish that I could fix that for you, but I can't make things magically better tomorrow, but I appreciate your question. And I guess it's probably good that you thought about it ahead of time. So, it feels like a safer place for you to go.

The best place for advocacy right now on this issue is through the American medical women's association (https://www.amwa-doc.org/our-work/initiatives/physician-mental-health/).  So they're starting in a campaign called humans before heroes and are basically trying to get a bunch of organizations together on the same page to go state by state and change the wording. It is going to be a large undertaking, but they could use support, help if you're in certain States and want to be a champion for it um, they could definitely use anybody who's interested in helping. You can just search, AMWA like humans before heroes and look it up.

Lisa Meeks:

And we'll put a link to it in the transcript too.

Jessi Gold:

Yeah. There's a lot of really good people that are partnering with it, there are a lot of people that are interested in changing this and I'm telling you a lot of it has to do with COVID. Um, but I am hopeful that like with a big coalition of people and moving, you know, state to state with such a big coalition, including American foundation for suicide prevention (https://afsp.org) which has local chapters in every state and so does AMWA (https://www.amwa-doc.org), I think you would maybe see some momentum again, you know, it has to be a state by state thing and it's not going to be easy, but I, I do think if some States change, that maybe other States will change.

Lisa Meeks:

Thank you so much. And I just have one wrap up question for everybody we've identified a lot of barriers tonight and, and things that people are aware of, and I think some perhaps that our listeners may not be aware of, I think especially the downstream consequences of having carried a mental health diagnosis or actively seeking, counseling and what might be waiting for them into residency and, and on into practice. So, this might be new information for students, and I'm going to give a lot of resources at the end of the podcast and a lot of links that, students and learners can utilize to get and find support and answers to more questions that they have.

And we talked just briefly about what interventions and what we would need to do to change the system. And I really do think the system needs a complete overhaul. But if there was one thing, just one intervention that you think could be super impactful and change the status quo, whether that be structural or a resource that could dramatically improve help seeking for learners that experience a mental health challenge, what would it be? 

Erene Stergiopoulos:

So, the one that I will say is the one that I actually completely learned from Lisa which is, getting rid of this defaulting to leave of absence. It's something that's done at so many schools. I've even seen it beyond medicine. Like I've seen it in undergraduate education, but the problem with leave of absence, like we've, we've talked about has been that it takes away so much from the student in terms of their sense of mastery, their connection to their social supports. It might be their financial wellness as well. It relies on them being a student, because what if they have to restart paying their loans, or they don't have access to scholarships anymore or bursaries. And it also signals this ability that this idea that you can't be practicing or learning medicine and have an illness at the same time. And so, I just find that the leave of absence, this default to leave of absence anytime someone signals that they have a mental health issue can be so damaging. And so, that would be the biggest intervention that I would say could really help with this with the barriers to disclosure, because I think that learners know, they hear what their colleagues have been through. They hear, “Oh, this person, um, had to take a leave of absence and now they're gone for a year.” They suddenly are not part of our year anymore. And we never heard about them ever again.

It just adds to the stigma. And it also means that the institution is not actually working towards creative accommodations to help this person actually thrive while also continuing to participate in their program and so, because there's this idea that, oh, well, when you have an illness, you just leave, they don't actually, it becomes a sort of like self-reinforcing, or this, this vicious circle where they don't actually invest in the resources like the specialists who can help determine creative accommodations that would actually help support more learners to continue engaging in the program while also managing a chronic health condition or a chronic mental illness.

Justin Bullock:

I love that. I superstar what you just said Erene.

I think mine would be to recognize that the person with the illness is the expert in their condition and specifically when we think about people who maybe are struggling to actually work with them, you know, in, in internal medicine, in my residency, we talk so much about patient centered care and working with patients to build plans that are like realistic for them. In the fitness for duty, you returned to work, whatever you want to call it world we completely forget that. And I think this relates to theautomatically going to leave of absence.

Jessi Gold:

I think normalizing a culture of vulnerability is the thing that I would most like to see. And that's bottom-up and top-down so faculty modeling it and peer modeling of it. So being able to say like, it's okay not to be okay and asking for help is a strength, not a weakness, from sort of every level is something I'd like to see change and would make a really big difference. And if you saw your leaders doing it, like faculty leaders and team leaders and staff leaders, et cetera, I think people would feel a lot more comfortable doing it moving forward.

Lisa Meeks:

I think one of the other benefits too, to your point about vulnerability is needing to know that somebody that is very successful went through the same stuff that you're going through. And, and is that successful individual. That is powerful. Some of the best female mentors I have, they keep it real. And that is one of, I think the biggest, greatest qualities about these women. They are rock stars, but they are real rock stars. They don't hold anything back and it invites everybody to be authentic and to be true to themselves. What would it feel like if everybody just brought their authentic self to work and no one was afraid of their identity, regardless of what that identity was, or, you know, the, the struggles that they had, that'd be a pretty incredible thing.

Justin Bullock:

One thing that I was thinking about from what you're saying with Jessi saying, thinking about anonymous is in my dream world, people don't have to disclose their entire lives in order to be treated like humans. I think that there are some people who are very open about their lives and other people who are prouder about their lives. And I think you should be able to be however, like makes you happy. But I don't think our medical society allows us to be where we want to be comfortably. 

Jessi Gold:

Right. And then you have a lot of internalized stigma. You don't learn to love yourself that way. And that's a problem.

Lisa Meeks:

Take us full circle back to anonymous. And I personally just want to thank anonymous (https://journals.lww.com/academicmedicine/fulltext/2019/11000/in_my_experience__how_educators_can_support_a.13.aspx)  I was so grateful when I reached out and heard back and I just kept saying, I'm so grateful for your writing. And I feel that way, Justin, about your telling your story as well.

And in the last sentence of that paragraph writing anonymously and in acknowledgement of the implicit threat that is out there, this person also says, 

“I strongly believe that this will foster a generation of clinicians with rich and varied experiences who can be strong advocates for their coworkers and patients in all states of mental health and illness.” 

And so, in that anonymous was talking about becoming a physician and why it's important to have people that have experienced mental illness in medicine and to be part of the larger medical education system.

And anonymous, I think you're absolutely right. I think we have all agreed on that tonight. And I think we have a lot of work to do. and Jessie, I was so glad to hear you bring up pre-meds because we often don't talk about, you know, the messages that people get before they even enter our institutions. along the entire pathway, there are countless barriers to truly and authentically engage in mental health support to being okay with not being okay at times, and to understanding the benefits of being a physician that has the lived experience of psychological disability. So, I want to thank anonymous. I want to thank all three of you for your time and talents and, and coming on and, and speaking to our audience, I'm super appreciative.

And to the audience, I hope that you will engage with the writings of all three of our expert guests who are absolutely lovely people individually and dynamic change agents out there in the universe for medical education. 

Sofia Schlozman:

To our guests, thank you, thank you, thank you. 

As an undergraduate currently considering a career in medicine, this discussion has provided extremely valuable insight into the many changes needed into medical education and has provided hope about how to make the system more inclusive.  I am in awe of your eloquence in discussing these issues and your dedication to confronting these challenges, and I am so glad that we have a platform to share your insights with a wider audience. 

Thank you, also, to our listeners for listening or reading along to this series. We hope you will subscribe to our podcast and join us next time.

 

Music:

-       “Aspire” by Scott Holmes

-       “Donnalee” by Blue Dot Sessions

-       “The Poplar Grove” by Blue Dot Sessions

-       “Dusk Cathedral” by Blue Dot Sessions

-       “Lovers Hollow” by Blue Dot Sessions

-       “An Oddly Formal Dance” by Blue Dot Sessions

-       “Positive and Fun” by Scott Holmes

 

Resources and References available in Transcript Part 1

Some sentences have been altered for ease of reading.