DocsWithDisabilities Podcast Ep 17: Justin Bullock

Justin Bullock

Justin Bullock, MD, MPH is a first-year resident in the Department of Internal Medicine at the University of California, San Francisco (UCSF). Originally from Detroit, Michigan, he completed his undergraduate studies in Chemical-Biological Engineering at the Massachusetts Institute of Technology. Justin completed medical school at UCSF where he was a member of the Program in Medical Education for the Urban Underserved. Justin brings a wide range of experience in medical education: he has led over 25 small-group problem-based learning sessions and also was member of UCSF’s peer teaching program. At UCSF, he has helped to evaluate and redesign pre-clinical curriculum around team learning and communication skills. His research interests in medical education focus on clinical assessment, student perceptions of the clinical learning environment and equity in medical student assessment. He recently published a commentary in the NEJM titled, “Suicide—Rewriting My Story”

Dr. Justin Bullock is a current Internal Medicine Resident in San Francisco, California. Justin is passionate about medical education, and diversity in medicine. His article in the New England Journal of Medicine titled “Suicide—Rewriting my story” tells the story of his battle with Bipolar Disorder and suicidality during undergraduate and graduate medical education. In this podcast, Dr. Bullock and Dr. Meeks discuss the critical nature of disability inclusion and a supportive culture for mental health in medical education and training. They touch upon medical student mental health and the reality that many learners share feelings and experiences of depression and suicidality—yet never discuss these feelings, failing to engage in help-seeking behavior—especially once they transition to residency.

Episode 17, Transcript 

DocsWithDisabilities Podcast #17

Dr. Justin Bullock

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 researchers and policy makers that ensure medicine remains an equal opportunity profession.

Joe Murray:

Welcome to the DocsWithDisabilities podcast. I am Dr. Joe Murray, a practicing psychiatrist and an associate professor of clinical psychiatry at Weill Cornell Medical College. I will be guest narrating this podcast.

May is Mental Health Awareness Month and during this challenging time of the coronavirus pandemic, an awareness about the mental health of our learners is more essential than ever.

We wish to offer the listener and the reader a warning before beginning this podcast. Content in this podcast contains information and discussions of mental illness, mental health crises, and suicidal thoughts and action, which some listeners may find triggering. If you or your loved ones are experiencing thoughts of suicide please reach out to the National Suicide Prevention Hotline at 1-800-273-TALK. 

Our interviewee, Dr. Justin Bullock, recently published an article in the New England Journal of Medicine about his experience with suicidality. Today, Dr. Meeks reconnects with him to talk about mental health in the bigger context of medical education and about how learners with psychological disabilities navigate the transition from undergraduate to graduate medical education.

Lisa Meeks:

It has been a while since we talked last and I know it's really early in the morning for you out in California and I'm just so glad to have you joining us today and congratulations on your recent article in the New England Journal of Medicine. And thank you for joining us this morning.

Justin Bullock:

Thank you very much for having me. I'm extremely excited to speak with you. I love your podcast. It’s something that's been very meaningful to me, so very, very excited to talk to you.

Lisa Meeks:

Thank you. That means a lot. …..Tell us a little bit about yourself.

Justin Bullock:

My name is Justin Bullock. Um, I am currently an intern in internal medicine at UCSF. Originally from Detroit actually. So pretty close to where you are now, Lisa. 

Lisa Meeks:

You mean De-toi?

Justin Bullock:

Yes, De-toi, but this is pre Midtown days so it's a little bit different. And I went to MIT for undergrad, studied chemical engineering there. Then went straight through to UCSF for medical school. Stayed there for residency. And UCSF is where you and I first met.

I've struggled with bipolar disorder throughout my life, bipolar II, primarily pretty significant depression episodes. High school, in college, in medical school and now again in residency.

Lisa Meeks:

Do you want to talk about how you engaged in help seeking behaviors at the undergraduate medical education level?

Justin Bullock:

Yes, so I want to start an undergrad. I have sort of the unfortunate experience or slash fortunate experience of attending a lot of high power academic institutions where there are a lot of mental health issues, specifically suicides. As a result, I've been in a lot of places that have really tried to push for students to seek mental health care, and seeing institutions try to change the culture, but kind of continued to struggle too. And so at MIT is the first time that I had a really kind of very significant depression episode that really kind of destroyed my life. And it was there that I first began to access resources. And when I first started to take meds. So when I went to UCSF, I knew kind of with my history that I was going to have some issues. Being the bipolar person that I am, when I'm hypomanic and slightly elevated and function really well, sometimes it's really hard to try and set up care for yourself. But, I kind of knew that things would get bad at some point. So I tried very early to get connected with a psychiatrist and therapist. I think I didn't come to meet you in the disabilities office until maybe a little bit later on during the first or second year when I was trying to get accommodations to attend my therapy appointments. I think that's one thing that in med school, a lot of people stopped doing because you don't want to miss things and you don't want to sort of appear imperfect because everyone's always trying to play the game of appearing like they have everything together. 

Lisa Meeks:

You bring up a really good point. One of my big concerns remains that, when you make release from clinic a disability accommodation, you still have to go through this formalized process, right? You have to disclose your disability to someone at the institution, and UCSF is absolutely wonderful with privacy. So they really respected privacy and never asked to know why a student was leaving. But nevertheless, you still had to go through a process. So disclosure in and of itself is a problem because it may dissuade some people from accessing that service or accessing that resource.

Even though UCSF did a good job, I would say that medical education needs to go a step further and normalize this. And there are schools like Hopkins who allow all students to leave for any reason, for a certain number of hours each week. De-stigmatizing the idea that people are leaving for any set reason because even if you have an accommodation that's release from clinic, there are a lot of assumptions that will be made, especially if you don't have an apparent disability.

The ability to leave clinic is mandated by the LCME.[1] So schools that are saying that it's not appropriate or reasonable for students to leave the clinical instruction time are actually not following guidelines. And that's problematic. I think schools have not paid attention to that and/or tethered that to this idea of mental health and release for services. But I really like the idea of having all students have that time for whatever self-care is to them. And it may be ongoing therapy, it may be something else.

One of the lines in your New England Journal of Medicine article said, is the two hours of release per week worth our lives? And Justin, I have to tell you, that really resonated with me and thinking about the number of students who had come to us for that release from clinic accommodation. And I think it very much resonates with everyone who's in UME or GME now. It may even resonate with physicians that are struggling with the same things. Needing to practice self care in a way that doesn't infringe on their privacy or stigmatize them for doing so.

Justin Bullock:

It's interesting that line. I think this entire piece actually I tried to write to different audiences. I think it's both something that I write for myself and for other people who are kind of suffering, that like, it's okay to leave for two hours each week. It's much better for you to be gone for that time than for you to be dead. There are some differences, which I'm sure we're going to get into between the UME world and the GME world. And sometimes, you know, you feel much more like a worker and less like a learner, even though you're still learning in GME. And for some reason that creates this tension that sometimes makes it harder, at least for me, to feel comfortable leaving.

Lisa Meeks:

Absolutely. You know, I think we've made a lot of progress with UME, and honestly, I give props to UCSF for that. But when you transition into GME, it's very different. The ACGME requires GME programs, as an institution, to have a disability policy and then within the program to afford reasonable accommodations to learners.

But we don't see this happening. We actually don't see this in practice. What we do see are program directors who may not be aware of these requirements or may not be aware of the Americans with Disabilities Act requirements and making unilateral, uninformed decisions about who can and cannot leave.

There is this unspoken, unwritten rule that if you leave you will be viewed differently. You will be assessed differently. This may impact your chances of getting the right fellowship, that there are consequences, right, to leaving.

Justin Bullock:

This is a constant struggle for me personally. And one of the things that I do to try and convince myself that it's okay to leave is that I always think if I was a senior resident and I had an intern who told me that they wanted to go to therapy, or needed to go to therapy or whatever... had to leave, I would very happily cover them for whatever time was needed. I think one of the things that weighs on me very heavily is I always feel bad about making more work for other people, many of whom are already very overwhelmed. And so, I think that is an internal check that I'll do that, I think once I think about that and I say, I would happily do this for someone else, then it makes it okay for me personally.

I spend a lot of time having guilt about leaving and have all these reasons for why it's a bad idea to leave.  But then I just think about the fact that I'm fortunate to be in a residency where I feel like we're very team oriented and try to support each other. Attendings, residents have always been very helpful in getting me out on time. So we have a senior resident who is basically floating during the day who will force me to leave when it's getting close to my therapy time. So, that's been very nice.

Lisa Meeks:

I think it does make a difference. For the leaders that get it, knowing that if your people are taking care of themselves, then they're better equipped to take care of others. And that's better for everyone involved.

Joe Murray:

In the transition from medical school to residency, the process for requesting accommodations is often complicated, with little to no direction for incoming residents. Indeed, residents are often asked to disclose directly to their supervisors--a potential disincentive.

In this section of the podcast, Dr. Bullock discusses how one residency program went above and beyond to ensure that potential residents felt supported and protected when considering disclosing a disability and shares his own experiences with  transitioning to residency.

Lisa Meeks:

I wonder if you can speak to kind of navigating this request in GME, and what were the differences between requesting this accommodation in UME and requesting it in GME? Were there different types of barriers and if so, what would you recommend to improve the process for residents who are looking to request accommodations?

Justin Bullock:

So I would say it starts when you're applying for residency actually. You know, I ultimately stayed at UCSF, but I actually very strongly considered leaving for one program who, in their welcome packet, basically had very explicitly around disability, a statement that said, we want trainees who are amazing with or without reasonable accommodations. If you have any questions about our accommodations process, here is a person who you can contact confidentially, that's completely unrelated to the entire residency application process. And for me that was an amazing statement. It was just on the bottom of a page on one of the handouts. Itt was very subtle, but for me it was extremely meaningful. And I think if I had not been at UCSF and known that UCSF was good around accommodations, I think I would have actually probably gone or tried to go to that other institution, because it really stood out for me. So I think it's really important for people to ask those questions. Oftentimes I wouldn't feel comfortable asking anyone in program leadership, but asking different residents. I think even that's sometimes challenging for people to self-disclose. But I think that's one thing that's had a huge impact on me, and so it's a question that is worth asking I think.

Actually starting residency for us, the process was, we have an associate program director for wellness. And so she was the first person who I reached out to. And for our program, it actually turns out that our program director is the one who is sort of the central hub for accommodations, which again, I think it's something that would make a lot of people feel uncomfortable. I was fortunate to have sort of interacted with her a few times, and so I felt comfortable emailing her.

For my program, it's a little bit of a convoluted process. I first talked with my program director, then the disabilities office, then my providers with the disabilities office who then talked to my program director. And then they set up the accommodations. That was one thing that definitely I felt like I did not get very much guidance on. It was kind of like emailing people and semi disclosing and then like going forward and then like semi disclosing. Not as easy of a process as it was for medical school.

Lisa Meeks:

With regard to disclosure, I really have a problem with the program director being in the first point of contact because, and this isn't rocket science, right? If your boss who decides the rest of your trajectory is the person that you have to disclose to, and you've either never disclosed or you've, you know, you haven't had a positive experience… So you had a positive experience in undergrad, but a lot of people don't have a positive experience. You know, who's going to choose to disclose. A lot of people will not disclose. And that's really difficult. And then what winds up happening is people don't disclose until they're absolutely forced to, right? When you're about to be dismissed from a program, or your mental health has taken such a bad turn that you are in a situation where you have no choice. Empowering people, especially around mental health is important. I think it's really important to empower people that have a history of mental health challenges to say, okay, you know yourself best. You know your triggers, you know what you need in order to maintain wellness should your symptoms become exacerbated.

One in four people will struggle with a mental health issue in their life. And I actually think it's probably bigger than that in medicine, right? And that this is something we should be proactively talking about.

Joe Murray:

In Dr. Bullock’s recent paper, he writes the following detail about his own plan. To offer the listener (and reader) some insight into his thoughts, we share his words: 

 “Jump. I knew the first time it drifted through my mind that my suicide would be by jumping. I would bike to the Golden Gate Bridge and put a “free” sign on my bike. The jump would have to be quick; I would not want anyone to talk me down. I planned what to do with my money and belongings.”

Dr. Bullock’s honesty opens us up to the thoughts and feelings one might experience in a suicidal moment. We might even believe that this is the extreme case, and that most people never reach the point of planning. On the contrary, Dr. Meeks discusses how these feelings may not be as rare as one might think.

Lisa Meeks:

I know the topic we're discussing is really hard. But I think it's really important. There's a part in your paper where you talk about the bridge. And you do it in such a poignant way. For the medical educator reading this paper, and I think every medical educator, Dean, administrator, student should read what you wrote. Your honesty, it's beautiful. It's very difficult to make yourself that vulnerable, especially to essentially the world. It's a beautiful contribution to medical education, so I want to thank you for it.

I also found your writing to be very consistent with self-reports from other students, other learners, other healthcare professionals that are struggling now, that continue to struggle. I think that many people, whether we know it or not, whether we can tell or not, have a plan. I think that you captured something when you talked about coming from a high achieving, high performance background and being in these high achieving, high-performance environments, right? Like MIT and UCSF. And with that particular population comes additional stressors. And some, you know, some may say that people are perfectionistic, but part of struggling with mental health, whether it's bipolar disorder or depression or anxiety, when you struggle with a mental health issue, you feel a loss of control. And one way to regain control is to have a plan in which you can be in control.

And so what better than to have a plan to, if everything gets out of control to the point where it can no longer be mitigated, or at least the perception is it can no longer be mitigated or the pain gets to be too much, that people would have a plan to, to complete suicide. And I think medical educators would be surprised to find out how many people have a plan, how many people on a daily basis that they pass in the halls have a plan. And your honesty, I hope hits home with them. Um, your honesty about, you know, when you're asked about whether you have a plan, you said point blank, I lied. I've been privy to many conversations with different levels of learners and physicians where people have a plan and if asked about it, they lie. But I wonder if you can talk about the reasons, even with all the supports in place that you've had, why you might lie about it?

Justin Bullock:

This is such an amazing question that I love. So I'm going to answer that. It's going to take me a little while to answer. Have a few things I want to say. So I think the first thing is that as I am getting sicker and have these episodes, I'm now at the point where I'm fully aware of what is happening. Like, I know I'm getting depressed. I can see the progression of my suicidality. I think one thing that's very challenging for a lot of people who don't struggle with suicidality is it doesn’t make sense to them. And that's one of the reasons why I try really hard. Whenever I'd have any sort of disclosure events, I try very hard to give my thoughts very clearly so that people who haven't been there can at least try to imagine what it's like to be there. One of my favorite quotes that I once said in kind of a talk was a quote by someone named David Foster Wallace who basically compares suicide to jumping from the window of a burning high rise. And the quote goes something like, make no mistake about those who leap from burning buildings. Their fear of falling from a great height is just as terrible as it would be for you or me standing speculatively at the same window, just checking out the view. The variable here is the fire’s flames, the other terror.[2] Basically there’s, you know, at some point, fear of the flames becomes worse than fear of the fall. It’s not desiring the fall. That was a quote that I think was very helpful for a lot of people when I said it, because it's very true, and that, that's often how I feel is when you're really at that point.

Lisa Meeks:

I think that quote is beautiful and makes a ton of sense to people who may not get it.

Justin Bullock:

Thinking about the lying, I am a, I guess in training, doctor, like I know what things will get me hospitalized and I know what things will not get me hospitalized. And sometimes I want to be able to tell people stuff and them not hospitalize me. And in this piece, you know, I have a conversation with my sister, where I'm basically talking about the fact that I'm very suicidal and she just like accepts it. And, you know, I told her, I was like, I'm sad that my two year old niece won't remember me. She said, do you think I would ever let her forget you? And she kind of has interestingly recently transitioned to a point where she just doesn't want me to suffer.

When I'm talking to her and having a hard time, that's really what she tries to express instead of always trying to like immediately hospitalize me. Cause I think there are sometimes where you do need to be hospitalized, but my fear is always like, I don't want one of my friends… and it's such a tricky, it's such a tricky situation, right? Cause like, you know, your friend, everyone's afraid this, what ultimately ends up happening is no one wants you to kill yourself. But for me it's like I don't want to ruin a relationship with my friend who's going to hospitalize me because I'm suicidal very frequently in my life. And so if I got hospitalized every single time that happened and I would never live. I understand it from both sides completely. It's such a challenging nuanced topic.

Lisa Meeks:

So a couple of things. I think that's the fear, right? That all power will be taken away. That you will be hospitalized. And then there's a chain of events that occur with regard to even licensure that keep people from disclosing. And I think that's what everybody goes to, but you've hit on something else that's highly nuanced and I really appreciate it.

There's this belief for people who have never struggled with a mental health issue, that you're either suicidal or you're not. This idea that you could have thoughts of suicide for the rest of your life, and you learn to manage those thoughts and how you respond to those thoughts. It's a very different thing, right? So to say, are you suicidal? What do you do if your reality is every day you have a plan? And it doesn't mean that you're actively seeking that plan and what you're doing is you arm up every day and you go to battle, right? And you do all the things that you need to do to not enact that plan, but to ask you the questions of are you suicidal or have you had suicidal thoughts? To some degree, I think that's the wrong question. And I think we need to start asking better questions. I think we need to start putting some protections in for people who do have thoughts of suicide. I think that it's not as rare as one might think.

You know, you bring up your sister, that's a very different reaction than what would happen if you told your PD that you were having thoughts of suicide. Right? So one goes to, you get admitted to the hospital, you're observed, you're on suicide watch. You have to miss two to three weeks of your residency. It may push you out. You may have your meds adjusted even if they don't need to be adjusted, even if this is just part of your normal. Right?

The other scenario where you reach out to your sister is somebody validates that, yes, I know you're struggling and I know this has been really hard for you and how can I best support you right now? And it sounds like she supported you by saying, I will never let your niece forget you no matter what happens. And to some degree, that's a very calming thing to say to somebody, right? That's a very supportive statement. That's somebody that you can reach out and say, okay, I'm really struggling this week and I need a plan. Here's my plan. But you can't do that if you answer your PHQ 9, it becomes quantitative and not qualitative.

Justin Bullock:

And especially when, you know, when you're doing a PHQ 9 and you're a doctor, you’re like, I know exactly like how to make my score be high or low, you know, like what questions I should not check. It gets very tricky.

This is where you highlight the importance of having a clinician that you work with over a long period of time before you have an emergency because you know, there are some people who have mental issues for the first time during residency, but I think the vast majority of people have had them before as well. If you develop a good relationship with a provider, I certainly have been very sort of explicit about my suicidal ideation with my therapist and my psychiatrist. And it's often a conversation where, you know, as things are starting to heat up, those sort of asks like, do you need to go to the team to go to hospital? Is it time? And I think, you know, there's definitely some like push and pull that kind of happens with that. But those are people who have dealt with this many times before and um, if you have a sort of good relationship with them, then you're talking to them before you're in a crisis and so they can actually get a good sense of what your baseline is and where you really are.

Lisa Meeks:

I agree. And they're not doing that through a nine question review. They’re doing it through talking to you. And I think a trust gets built and they trust you. At some point, like you said, with each episode, you understand what triggers it better. You understand yourself best. And that's one of the things I think in the disability realm where, you know, we know that the expert is the person with the disability. They're the ones that have lived this for however long and know what they need. Physicians, you know, want to solve problems, right? They're little detectives, they want to figure everything out and fix it. And that may not be the biggest job of the physician when working with a patient who is experiencing an exacerbation of mental health issues. It may be listening is the biggest job in that situation.

Justin Bullock:

And there definitely is such a palpable fear from programs, and I think a lot of people end up having their autonomy like ripped from them. People who struggle with mental health. Um, and that feels very, both angering, kind of enraging it feels like you lose your agency and your ability to sort of manage your own disease. And that can definitely discourage people from getting help and like, and the thing, and I'm going to stress this again, again, again, this is such a complex, nuanced topic that what works for one person is not the thing that works for someone else. And so sometimes having these blanket statements, um, where you treat all people the same actually doesn't work out very well for people who have mental illness.

Lisa Meeks:

That’s such a good point, Justin. I think absolutely. And with regard to accommodations, of course it is mandated to be case by case under the law. So any learner listening who is in residency right now who thinks they might need an accommodation, just know that release from clinic may not be what you need. There may be something else. It may be that lack of sleep disrupts or is triggering to the mental health exacerbation. And so there are lots of different things that are possible and one size definitely does not fit all. And that's such a good point. I'm glad you brought that up. It's important for the audience to hear that. And it's important for programs to hear that too because I don't know if you've ever experienced this, but I've talked to program directors who will say, Oh, well we had, you know, a learner with that once and this is what we did. And it worked. I hear that a lot actually. Every category of disability. And I'm like, Well, good for you. But individuals respond differently. And then when you say something like that, you're also excluding all of the noise that's in a person's life, right? Just because you're a person with a new diagnosis or, you know, a historical diagnosis that's now exacerbated, you are also a person that has life happening at the same time and that life could have multiple variables that are interacting to contribute to what's happening with your mental health. So, one of the things I get concerned about, especially with learners, I call it the default to leave of absence. And that happens a lot in medical education where if somebody presents with an exacerbation, especially of a mental health issue, it is “take a leave of absence, go get help, come back when you're better.” And you know, for so many people, that just, that assumes a ton of privilege that infuriates me because people of different intersectionalities, people with different socioeconomic means, people of different life situations, being outside of school or being outside of the residency program may be the absolute worst thing and may be the thing that puts them over the edge. And this is where we can make the argument against the quantitative measurement and towards the qualitative interview, which is what do you need? What would be helpful for you in this moment? How can we support you? I actually think that's one of the most powerful questions that a program can ask. How can we support you?

Justin Bullock:

That statement spoke to my soul so deeply. I think that it is one of the most, most frustrating things, the loss of agency that people have when they have exacerbation of their mental illness because basically what people say is, you know, X was stressful for me, therefore I'm going to not allow you to do X because X is stressful. Um, but you know, so for instance for me, I can give, I can give two examples actually. So when I was in medical school, as this piece that you spoke of, I attempted suicide and there were a lot of questions about whether or not I should or could return to medical school, um, or I need to take a year off. And I was told by many people that, um, taking a year off, um, like it's just like, you kinda can't bounce back that quickly from, from a suicide attempt. And it was a pretty serious one. And I recognize that everyone was telling me what they thought was the best thing for me. And I actually genuinely believe that. Um, but I also knew that med school for me personally was not a stressor in my life. It was actually a grounding thing in my life. And you know, I think this, it took a lot of personal reflection. Um, and I continued in med school, and for me it ended up being something that was very healing and actually really like my rotations were actually, I attribute a lot of my improvement to them.

One of the big mistakes that I made that I wish I, if I could go back, I would do again is, I wish I would have more aggressively continued to do like other types of therapy after. I think I got better and then just assumed that I was better. Um, and then when I got depressed again, I realized that I was not. There are so many layers to every single decision that you make. And so what works for one person does not work for another.

Lisa Meeks:

Your paper came out. Many people are saying things to you like this is very inspiring, you're very brave. And I think all of those things are true, but I wonder how you are perceiving this because you have opened yourself up to the world and your story and as we discussed, there are consequences for answering questions on licensure exams, and I wonder how you view yourself. I'm seeing all these other adjectives, but how you view yourself in sharing the story with the world.

Justin Bullock:

Yeah, I've gotten a lot of, you know, all very positive responses. Um, you know, some of the ones that are, have been interesting for me, I'll say is there are some people will say, I'm glad you're doing better and all this stuff. And it's very interesting because never in that piece did I say that I was doing better. And I feel like for those people, the point that I wish I could've made a little bit more clearly is that this is a lifetime thing that, um, many people and definitely myself like will continue to struggle with. And you know, you develop skills to deal with it, but it doesn't kind of just like go away. Um, I think that as far as the courage that it took to write this piece, I think, it's interesting. In a lot of ways for me it doesn't feel necessarily that courageous. I think one of the biggest sort of regrets I have about this piece is I had a friend who committed suicide in January of this year, um, who I kind of, I changed the ending of the piece, um, to talk about. And I had wanted to write this piece for a long time and I actually had previously submitted something to another journal and, um, a different piece and they hadn't accepted it. And so I kind of made me disappointed for a while and so I sort of held off. In that sense, I definitely, I recognize for sure that suicide's a very complex topic and you know, who knows if this like one little piece would have done any made any difference. But I think the courage to put out this piece has been building as I've sort of spoken at different events and seeing other people speak.

I remember when I was a first year medical student, UCSF in the fall has a day that they call Suffering in Silence where upperclassmen come and share their sort of experience with mental illness with the first year class. And then in the Spring they have an event called Mental Illness Among Us where first years share with their own class. And I remember there's one person in particular, um, I remember very profoundly, you know, what she said and she talked about having depression and having been hospitalized multiple times in her life and all the different medicines she was on and having to take some time away from school and many other, and I just was really so profoundly moved by her openness and it just made me feel safe and not alone.

And, and it made me happy. Um, and from there I spoke, um, at our class’ Mental Illness Among Us Day, and that was the first time that I ever really went very deep into kind of the darkness that I go through sometimes. And, um, I had such a positive response after that of so many people who came up to me. You know, first there are people who suffered, who came up to me and said, like, you know, your words are very meaningful. There are people who don't suffer and said, your words are very educational. Um, and you know, like I had one person who came up to me three years after I spoke and basically thanked me for what I said. And I've basically spoken at these events, I guess every year that I was in medical school and each time I would have people come up to me. And so I'm now at the point where I have no, there is no uncertainty in my mind about how many people suffer, you know, because people have literally come up and told me. So in that sense, I don't feel alone. I don't feel like I'm the only one. And when I started residency, you know, I was thinking about whether or not to write this piece before or after residency. And I think I was kind of afraid, so I didn't write it before I started residency. And because I stayed at UCSF, I feel like I was very fortunate in that, you know, a lot of people sort of knew me and just kind of like, people have sort of formed their opinions about Justin, so if they're positive or negative, they're already formed. So it kind of, uh, like I didn't feel like I was sort of still had to prove myself. 

I, um, spoke at a few of our like residency recruitment days for applicants and got kind of positive responses. So basically the whole time I'm getting like more and more positive responses from people in leadership positions, from peers, et cetera. Um, and one of the things I do when I'm sad is I write. So this piece kind of came out of that. What I really try to do is I want people to feel uncomfortable. I think for people who suffer, it feels comforting. And for people who don't suffer, it feels uncomfortable. And that's a very interesting, um, sort of commentary I think.

Lisa Meeks:

I think it's important to make people feel uncomfortable because when you're uncomfortable and you have this dissonance between what you think you know and what reality may be, you have to work. That's the space where you have to do the work to align, right? Unfortunately, many of us will lean on our biases and do things to align with whatever we believed or, you know, ground in just the DSM facts. But for others, I think they will explore the uncomfortableness and they'll be more aware of how prevalent it is that people around them that you would never know, that there isn't one sign, right? That someone's struggling with a mental health issue. There's not one tell. There's not one thing that will define somebody with depression or anxiety or bipolar disorder.

And you made a point earlier that I don't want to lose. And that is that this is lifelong. And I think that's the other thing that gets kind of swept under the rug in medical education with this, you know, go away, get better, come back. Or through the wellness initiatives through schools, that any kind of weekly intervention is going to be a magic bullet. There isn't a magic bullet. It's everything, and that it is okay to both simultaneously have something that's disabling to you and to be functioning at the same time. And that's where  accommodations or reasonable adjustments come into place.

I want to thank you because I didn't tell you that I was going to ask you that question and I was really curious how you would define yourself. And when I see people doing kind of what I think is the kind of person on the street definition, right? And they use the word overcome. And of course that's the wrong terminology, right? You haven't, there's nothing to overcome. This is a daily thing and that's pretty consistent with all category of disability.

But I feel like knowing you, what I see in you and what I saw in the article is strength and a healer. And of course that's, you know, what brings you to medicine. But you care so much about other people, you care for other people. You are a very strong individual. And I think that this was a show of that strength to say this is more than just about me. You saw how it helped people on a micro level and now you'll see how it helps on the macro level with of course, this being in the New England Journal of Medicine.

We were kind of laughing before we started recording that I'll never forget the week after you talked in Mental Illness Among Us. My office was inundated and it was like, what is going? I found out, it was, oh, Justin talked. But the wellness team and myself, with disability and accommodation, we didn't have the power in what we said, right? Because we were associated with the institution. We weren't near peers. We could say, these are the resources we have for you. And we had such a great team and I think everybody did a wonderful job in normalizing this. All the way up to the chancellor, you know, the chancellor, the Dean, the Vice Dean, the Dean of Students, the wellness team, everyone did a good job of normalizing this.

And I think, you know, from what I can tell, that continues, which is wonderful, but there's a power in the near peer that none of us have because we're still the institution. You had a power that we didn't have in speaking to your class. And your endorsement of help seeking behavior was enough to move, I can't tell you how many people, to seek mental health services, whether that was psychiatry, psychology, disability services, to get the help that they needed.

Justin, I believe, I truly believe that you being honest with your classmates and sharing your story, and not sharing it in a watercolor version, but in a very true and raw way that made you vulnerable. I think you saved lives. I really do think that you did that and I think you will continue to do that as a physician because as we discussed, like you're going to be an internist and many people will not go see a psychiatrist because of the barrier to having that stigma or the fear. It's the unknown. But they'll go into their primary care person or their internist and they will say something-- not quite disclosing-- but something on the cusp. And you will be the person that picks up on what they're saying and that will draw it out. And you will be the person that knows that handing that person a PHQ9 in that moment is the absolute worst thing that could possibly happen because that person will sit there and they will think, I don't want to answer these questions and I don't want to say anything else. The person is seeking help and understanding and empathy, as we all are from our physicians in a time when we feel exposed or fearful or weak.

And when somebody is calling out to you and they don't quite know how to articulate it, I believe you will be the person that picks up on that. And I believe because of your experience, you will be very comfortable having a conversation with that patient that could potentially save their lives.

Justin Bullock:

One of the questions I often ask myself is if I could go back in time and never have bipolar, would I do it? And it's a question that I don't think I can answer. Um, because in some ways it's obviously made me suffer, but in a lot of ways it's like enriched my life so profoundly. And you know, I think what you're talking about is something that I've already begun to see happen is I've had patients who like, we can communicate without words. It's interesting. It's very sad, but it's very beautiful at the same time. And I 100% agree that I think it makes me a better physician and makes me more empathetic and more caring and it makes me more understanding of things that I don't understand. And um, one other reason why I try really hard to speak out about my mental illness is I 100% see the ways in which it has benefited my life. When I'm like very productive, I can sleep a little bit less. I did it all the classic like, you know, slightly elevated things. Um, and sometimes people sort of mistake my like super productivity for like being a super person, but it's actually just pathology. Um, and so it’s something that I actually want to like, I want to like openly say that, yes, I realize that I am like submitting papers during intern year, but that's maybe not necessarily a great thing. I always feel very self conscious about creating negative like pressure environments for other people. And in some ways I view my disclosure as my attempt to like help with that.

Joe Murray:

As they wrap up their conversation, Drs. Meeks and Bullock discuss what learners should know about disclosing disability and navigating the need for accommodation.

Lisa Meeks:

Are there things that you want to say to the person that's listening to this? An especially vulnerable population right now is the person that's transitioning to GME. And of course, I mean, we are in the middle of a pandemic. So what could be possibly worse than you could be going from UME to GME and you know, so you're going into the wild West anyway. There's no policy, as I've discovered about disability disclosure. You have to disclose to your new boss, and by the way, a pandemic is happening. That's a lot of pressure on somebody with a disability. And I've always been a proponent of disclosing early. I think I still have to be because, in so many ways, I think it can be the thing that makes or breaks a situation. But, you know, you're the one in the trenches that's gone through this, the learner. What advice would you give?

Justin Bullock:

First, I completely agree. I think that your accommodation should be set up before you begin residency. I mean for me that meant emailing my program director and sort of doing all those things because once you get into residency, you're just really busy and it's so easy to get super busy and then you basically don't look up until you're three months into residency and then stuff starts to get stressful, et cetera, et cetera. Um, I think it's very important to set everything up very early and that way there's just like no question.

Um, I think the second thing is to be very thoughtful about the things that trigger you. Um, one of the warnings that I was given like 50 times before I started residency is that for people who have bipolar disorder, nights can be very destabilizing. Um, but I, of course, am like, someone who I'm like, I want to do nights. I don't want to like not do nights, you know, that sounds like, the nights seem like they're fun. And I think what I did not do well is, I was a little bit not intelligent with how I did my medicine. And so I basically would like schedule meetings knowing that I’ll only get three hours of sleep, but knowing that my brain kinda can for like periods of time. So I took a risk and then I was not thoughtful.  So I don't regret in any way taking the risk. Um, but I think I should have been very, very disciplined about like, I have to like make myself sleep seven hours. We will like pharmacologically do this if we have to.

And then I think the third thing I'd say is that intern year is hard. It's like very hard. I'm someone who loves medicine, who loves being in the hospital. And it's really hard to be very bad at something, to have to work all the time and have few days off. Um, and sometimes it's really hard to recover, like if you have a setback in your life when you're working so much. Um, and so just to kind of say that out loud and you know, there was a point in the year where basically you realize that like everyone is doing terribly. That is clearly a systemic issue. Like there is no way that every single intern, you know, when you say, how are you doing? And the interns say, you know, and it was like, yeah, I know that's like, that's a problem. Um, so, it's not you, you're not weak, like, there's nothing wrong with you. It is the system. And, you know, this is where I like take it upon myself, everyone listening that we have to like actively fight to change it because the system is like trying to do everything it can to keep being terrible and toxic, and we have to not stand for that.

Lisa Meeks:

It's hard when you go into a situation that there will be something that gets destabilized. So it's almost like going into war. I think that the quantitative things that we're looking at are not telling us what we think are telling us. I thank you for just who you are and for sharing everything that you've shared and I feel lucky to have had the opportunity to, to be part of your journey. I know that your paper will absolutely make waves in medical education, important ones. And it lets us not forget because even though we're in hard times right now, even though a pandemic is happening, physician and learner and student mental health has to remain at the forefront of our concern, especially in things like this. If we're taxing these individuals on the continuum in normative times, think of what's happening right now.

Justin Bullock:

I actually want to say thank you to you. UCSF definitely misses you. You made a massive, massive, massive change in the time that you were here. And so much of why it was like easy for me as a medical student was because of you. And I think many, many people feel that way. And you know, for me, it's amazing to see you doing all this amazing stuff. I'm sad it's not at UCSF, but you know, you're doing so much, all these amazing articles, the podcast. I'm sure you're making a huge difference at Michigan. So, yeah, I really appreciate you and what you do.

Lisa Meeks:

Thank you. I feel I need to say a big Go Blue before I say this, but I miss UCSF. I miss the student interaction and it was such a positive experience for me to work with so many incredibly creative individuals. It's just such a unique place to work and learn, and my son lives in San Francisco now. I definitely miss city living and miss all of you guys and was really blessed to get to do what I did there and was really blessed to get to know all of the incredible students.

Joe Murray:

As our conversation with Dr. Bullock comes to an end, we hope this episode opens up some honest conversations about mental health for medical students and trainees. Throughout the MedEd community, we must continue to create compassionate training programs that foster self-care and holistic growth for our learners. 

Kate Panzer: 

To Dr. Bullock, thank you again for your honesty and openness with readers and listeners alike. By coming forward, you and your colleagues are changing the culture of medicine and mental health in very meaningful ways. 

And to everyone in the audience, thank you for joining us. We can all help prevent suicide. If you are experiencing thoughts of suicide, The Lifeline provides 24/7, free and confidential support. Please call 1-800-273-8255.

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, nonderivative license. This podcast was produced by Lisa Meeks and Kate Panzer.


*This podcast was created using excerpts from the actual interview and is representative of the entire conversation. Interviewees are given the transcript prior to airing. Some edits may reflect grammatical and syntax adjustments for transcription purposes only.


[1] LCME requirements for UME relative to counseling:


12.3     Personal Counseling/Well-Being Programs

A medical school has in place an effective system of personal counseling for its medical students that includes programs to promote their well-being and to facilitate their adjustment to the physical and emotional demands of medical education.


12.4     Student Access to Health Care Services 

A medical school provides its medical students with timely access to needed diagnostic, preventive, and therapeutic health services at sites in reasonable proximity to the locations of their required educational experiences and has policies and procedures in place that permit students to be excused from these experiences to seek needed care.


12.5     Non-Involvement of Providers of Student Health Services in Student Assessment/Location of Student Health Records 

The health professionals who provide health services, including psychiatric/psychological counseling, to a medical student have no involvement in the academic assessment or promotion of the medical student receiving those services, excluding exceptional circumstances. A medical school ensures that medical student health records are maintained in accordance with legal requirements for security, privacy, confidentiality, and accessibility.

[2] Full Quote: The person in whom Its invisible agony reaches a certain unendurable level will kill herself the same way a trapped person will eventually jump from the window of a burning high-rise. Make no mistake about people who leap from burning windows. Their terror of falling from a great height is still just as great as it would be for you or me standing speculatively at the same window just checking out the view; i.e. the fear of falling remains a constant. The variable here is the other terror, the fire’s flames: when the flames get close enough, falling to death becomes the slightly less terrible of two terrors. It’s not desiring the fall; it’s terror of the flames. And yet nobody down on the sidewalk, looking up and yelling ‘Don’t!’ and ‘Hang on!’, can understand the jump. Not really. You’d have to have personally been trapped and felt flames to really understand a terror way beyond falling.”