Ep 12: Arghavan Salles

Headshot of Arghavan Salles

Dr. Salles is an advocate for gender equity, and teaches about how implicit bias can impact true inclusion. In this podcast, she and Dr. Meeks discuss wellness in the context of medicine and how the messages we send to those with marginalized identities, including disability, may impact mental health and a sense of belonging.

Episode 12, Transcript 

DocsWithDisabilities Podcast #12

Dr. Arghavan Salles

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 Docs with Disabilities 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.

Kate Panzer:

Welcome to the 12th episode of the Docs With Disabilities podcast. My name is Kate Panzer, and I am an MDisability research assistant at the University of Michigan Medical School. Today, we will explore the topic of physician wellbeing and its impact on trainees and professionals with various identities. Tune in as Drs. Meeks and Salles discuss the serious concern of physician burnout and how individuals and institutions are implementing change.

Lisa Meeks:                

So, every once in a while you meet someone who is a force for goodness in medical education. And that was my experience this past November at the AAMC meeting. And I was brought together with this person by our mutual friend, Dr. Pete Poullos. Could you introduce yourself for our audience?

Arghavan Salles:        

My name is Arghavan Salles. I am a fellowship-trained minimally invasive and bariatric surgeon. I have a PhD in education and have focused my research mostly on gender equity and challenges for women in the workplace. I also have done a fair amount of work on wellbeing, which is an interest that I had out of my experiences as a surgical resident and helping to create a wellbeing program for our surgical residency.

Lisa Meeks:                

What made you start to advocate for women in medicine and for physician wellbeing?

Arghavan Salles:        

I think probably the wellbeing piece came first because that was just an opportunity that came my way. We had a really devastating experience, which was that when I was a surgical resident one of our graduates from our residency went on to take his own life less than six months after leaving. And that really had a massive impact on the entire program, partially because of course it would anyway, but also the special person that he was made it even harder than I think anyone would have anticipated. To give due credit to the leadership at the program at the time, they recognized that they never, ever, ever wanted to see that happen again to one of their residents and wanted to do something big and meaningful to make a difference.

I was fortunate to be one of the four residents who essentially were tasked with coming up with a plan. What could we do that would be different? How can we arm our residents with the skills that they will need to go into what is a very challenging career. We all know medicine is really, really tough and the burnout rates are high and the suicide rates are high. We were asked to figure out what kind of program we could put together that would help residents have tools for managing adversity in the future.

I had a pretty significant interest in wellbeing, having just been a surgical resident and not feeling that it made a lot of sense for my personal health to live that life and struggling from that perspective. And then I had this opportunity, which was incredible and I married that with the research I was doing, which was mainly focused on gender. But because I already had an interest in wellbeing, I was also looking at things like sense of belonging and grit and self-efficacy and other factors that were associated.

Lisa Meeks:                            

Your voice is a really powerful one on Twitter. And when I see your posts, I'm always in awe of how you're able to call things out in a way that is respectful but powerful and backed up by data that shows systematically differential outcomes for women and men in medicine. Do you think that well being is part of that?

Arghavan Salles:        

Yeah, absolutely. I think those things are married. And it's not just women, obviously. It's also, there are so many other aspects of people's identities that can be marginalized, whether it's race, ethnicity, age, obesity, having a disability, sexual orientation, gender identity. In all of those cases, you're facing challenges in the workplace and in the world at large. I think for most people, there's no way to experience that everyday without having some impact on our personal wellbeing.

Lisa Meeks:                

I do a little exercise when I'm doing a training where I have everyone shut their eyes and think about a physician. What does the physician look like? And it is never an individual with a disability that comes to mind when we think of a physician, which is kind of fighting that same expectation. We don't expect people with disabilities to become healthcare providers.

Are you aware of the campaign that Julie Silver is doing with the pictures kind of remapping the walls of medical education? I love that campaign so much. It really is kind of the same concept that we used with our Docs With Disabilities campaign, which was the idea of bringing attention to these other identities that are in medicine.

Arghavan Salles:        

The campaign is called “Walls Do Talk.” And, I agree with you completely. I mean, it's about showing really truly who can be a doctor and who can be a leader in medicine and trying to erase old stereotypes. I don’t know if you saw this, but a while back, one of the former deans of Harvard had posted that he was upset that they had changed out the pictures in an auditorium, and they had made the change for this exact reason, like you're saying, that people realized that they were sending a message about what kind of person could succeed in medicine, and it was not an inclusive message. So they took down all the pictures of people who were all looking the same as each other. And this former Dean was lamenting that, saying that we were erasing history. But to me, we weren't erasing history. We were erasing a specific aspect of history. We know that women's contributions for example, but also those of people of color, those of people with disabilities and those who have any other marginalized identity are often erased. So while this person was saying that we were erasing history, I think that we were actually acknowledging that maybe that wasn't a complete history.

Lisa Meeks:                

Absolutely. And creating a new history saying this is the future. You're trying to connect these communities and these learners to medicine. So what is drawing them away from medicine? And I think it's partially the lack of mentors available and partially microaggressions that are so strong.

Arghavan Salles:        

I think medicine is very ablest. I mean, look at the things that we ask medical students to do, the things that we ask residents to do. It's super human. We're asking for people to go without sleep and food for extended periods of time and to work an inhumane number of hours. And if you can't do that, then you're out. Right? That's the messaging that's out there.

Lisa Meeks:                

I think that we are losing a lot of talent because of the situation, because of the environments that we're putting people into. And I think that's a perfect transition back to the focus on physician wellness and to your original story of loss. You are one of these four residents that were tasked with building a program.

You know, 2011, we didn't have all of these wellness groups that we see now are popping up in residency. So you were probably one of the first programs to address this in kind of a structured fashion. What did you create? And was it impactful?

Arghavan Salles:        

I was lucky that I was working with three other really insightful, thoughtful people. And we just sat down and thought about what we felt were the biggest challenges in residency, and were there things that we could do to change that. You know, some of the things were easier to accomplish than others. But, some of the main things that we did were, one, we installed a refrigerator that was stocked with food and drink very close to the OR and close to the wards where our patients typically were so that when people were on call or very busy, they could still grab something with protein and something that wasn't fried and wasn't going to cost them a lot of money. At that point in time, our hospital had really almost no healthy food options, especially overnight and late in the day on weekends. So those residents whenever they were on a week of nights would have very limited options.

We also wanted people to have tools that they could use moving forward. So we hired a psychologist to meet with our residents. And she met with residents every week, but it was a different group on a rotating basis. Each class would meet with her every six to seven weeks and either talk about specific challenges. Part of the reason that we felt that was important was one, for people to be able to gain skills for stress management and dealing with what comes up in a very challenging work environment. But also, that helped to build bonds among the people in each class so that they could have a stronger network with each other and also realize that a lot of their struggles were very similar.

Having these residents meet regularly with each other we thought would help minimize that feeling because then they would see, oh, you too, struggle to get enough sleep or to see your family. And then we implemented a more formalized social program. Basically having events with more regularity to try to people bring people together outside of the work setting. And we also created a mentoring program within the residency for senior residents to be paired with junior residents.

The other part of your question was about the impact, which is very common. Even a few years back when I would talk about this program, people would ask, “Okay, but did you change the rates of burnout in your program?” And you know, it's very hard to know. Some people obviously join when their interns and other people graduate, and then other people go on research and so on. It's very hard to actually track any one individual over time. So we weren't really able to do that.

When you look at gross levels of burnout or general psychological well-being, there really aren't differences over time. I don't think that's surprising. I think the bulk of the stress and pressure on residents is all the hours that they're spending working in the hospital. I don't think that having a refrigerator or a psychologist or a guide to where you can find a local physician, any of that is going to impact what they're doing the remaining hours of their time. I think hospitals are very stressful work environment and the hierarchy in medicine is toxic and none of the things that we did change that fundamental truth.

Lisa Meeks:                

Yeah, I appreciate your perspective on that, and I love the idea of the psychologist, perhaps for a different reason than what the intention was. And that was to normalize the idea, right? I know a student who recently went into a surgical residency and two things happened that she actually tweeted out about. One was that they gave you time off and made you get established with a primary care physician because we know that residents don't take care of themselves and will defer their own health for their work.

And two, that they all had to meet with a psychologist, not once, but at least three times because anybody can do something once and say, okay, check that box. I've done that. But then they need to meet with somebody three times. What this does is it exposes everyone to a psychologist, right? There is a normalization in it. It's not, oh, so-and-so is going to seek help. There's time allotted carved out in the program for it. And the chances are, while you could check a box for one, over the course of three appointments, you can't just sit there and not talk. I mean, you can actually establish some rapport with this person such that if you start to feel like your wellness is in jeopardy, you would be more likely to reach out to them. Residents do have health insurance, so they didn't require a lot of financial investment. What it was, was time. And what I heard you say was, you know, really the amount of time that you have to spend in a hospital is almost inhumane. And the amount of deprivation that you expose your body to, whether that's sleep or food or human contact is damaging to our systems. And I think until we come up with a better structure for training, we're going to continue to see these no matter what interventions we put in place.

Arghavan Salles:

Residents, and physicians broadly I think we could say, do not take good care of ourselves. I don't think that's because we don't want to or that we prefer to take care of other people. It is that the culture does not make space for caring about ourselves. There are likely microenvironments here and there that are much more supportive, but most of us feel that we can't start clinic late or leave the OR early or whatever it is to go see a doctor. It is not a thing that is commonly done or if it's done, it's not spoken about. And so even as practicing faculty, it just seems like you have to move the earth to be able to go see a doctor.

I do think that the number of hours residents and physicians broadly are required to work is not appropriate, but I also think that our focus on hours is misplaced.  Because if you look at startups, for example, when people are really passionate about the work that they’re doing, especially if they're working with a good team and they believe in their product, people can work for a lot of hours a week and still be pretty happy. But when you're working in a system that doesn't allow you to express any human emotion, doesn't allow you time to go take care of yourself, doesn't allow you to eat properly, doesn't allow you to exercise. People are not valued for their intelligence and their dedication and all the insight that they bring to the job. It's about doing more RVU’s or getting that consult done quickly. That to me is much more toxic than the sheer number of hours that people are asked to work.

Lisa Meeks:                

Absolutely. And for a direct comparison, if you're in one of those startups, you are at times being brought to and from work. You're being given healthy lunches and dinners. You’re able to go and see a physician sometimes right on the campus of your workspace. You're encouraged to take a break and go play ping pong or basketball or go to the gym that's right there. So the work environment is completely different. There's a lot of flexibility with something like a startup. It does not come with medicine. That flexibility is not available. If you got five hours of sleep, some people are wearing that as a banner.

Arghavan Salles:        

Right. This honor and the martyrdom that people value in medicine I think is really damaging. I don't think we should be proud of not having slept. I don't think we should be proud of having worked 21 of the last 23 days or having taken whatever, however many calls or having seen so many consults in such a short period of time. I mean, all these things that you hear people talk about, I think we should, when we hear those things say, “Oh wow, we need to change your schedule. We need to back things up.” And that's for all levels. That's not just for trainees. The big difference is that trainees don't have any control over what they're asked to do, but faculty still face a lot of those same pressures. That culture permeates, and I don't think that it's healthy.

As physicians we see really challenging, tough situations every day and some hit us harder than others. But nowhere is there a regular place to process that and you're expected to just move on. Like if you just coded someone who passed away in the ICU, you just gotta keep going. I think that's really toxic. We are all human and we all have emotions and it is hard to watch somebody die.

Lisa Meeks:

I hear residents talk about the stairwells.

Arghavan Salles:

Mmhh.

Lisa Meeks:

The top stairwell of a hospital or a bathroom that's kind of in a corridor that's a little bit, you know, to the side as this place that they can go to cry. And they have their five minutes of crying and then it's back to business. And you might get actually taken to task on that five minutes if you kind of disappear.

Arghavan Salles:

Right, where were you?

Lisa Meeks:

Right. It is a difficult thing. They're not doing that in startups. So people are working multiple hours, but they're not facing death and dying. And you and I both know that despite all of the suicides that are talked about or covered in the media, there are hundreds that are not.

Arghavan Salles:

Right.

Lisa Meeks:

And so I don't think people understand the extent of which this is kind of ravaging medicine, and you know, no one has a solution and every solution comes with a set of new issues. Right? How do you train a physician? Do we do we extend training and reduce the amount of time that's there?

Arghavan Salles:        

Well, nobody knows how many hours it takes to become a competent surgeon. And it's not one set of hours. It's not a certain number. It's different for every person. People learn at different rates, people have different challenges. And yet we're saying, okay, if you spend five years in a hospital as a general surgery resident, you're done. And then when people talk about, like, this comes up a lot when I talk about parental leave, people say, well, what the American board of surgery says we have to have this many weeks of training every year. And if you take more than that, then you have to take an extra year. And again, that's completely arbitrary. We don't know how many weeks a year is what you need to become a competent surgeon. And if it's 40 versus 45 versus 36, we have no idea. Like even the length of the training itself is pretty arbitrary. So why do some people feel like, oh well all of a sudden if you take one fewer week or you work one fewer week, then you have to repeat a year. Nobody knows.

Lisa Meeks:                

What are your thoughts on making everything competency-based and you move through the competencies?

Arghavan Salles:        

I think it makes a lot of sense, but our system is not set up for that. It would require a huge shift because right now a large part of what the residents do is service, and this would be a shift to having almost everything they do, be education. I think it would be fantastic. I don't know how we could get the system to shift that way.

It's just so many hits to take when you're a trainee that you don't get treated with respect, you have no time to take care of yourself and you don't get compensated for your time the way that you deserve to based on your skills, knowledge, and expertise.

Lisa Meeks:                

Well, and I think the debt, the crushing debt really, and the inability to see a way out as part of what's contributing to the lack of wellness and the completed suicides is just, there is no way out. Once you're in that amount of debt, you have to generate a pretty high income.

Arghavan Salles:                    

Right.

Lisa Meeks:                            

Right? So you have to stay on that hamster wheel. And of course we know that one of the most critical times and times where people are at the most risk is that transition from UME to GME.

Arghavan Salles:        

Like every transition. GME to fellowship and fellowship to practice. And nobody talks about that last one. But that's a big one.

Lisa Meeks:                

It's the realization that it's not going to get better, I think. I think that people get out of one system. I used to have students say, “If I can just get through this, if I can just get through this.” And that would be a red flag for me because if they're just getting through... I would literally have students who would go home, crash, cry themselves to sleep, get up in the morning, do it all over again. If that's what's happening in medical school, residency is not going to be better. It's going to be worse.

Arghavan Salles: That’s correct.

Lisa Meeks:

And I think once they get there and they realize after the first month, this is going to be far more work with far less sleep and far less money. And to some extent the training wheels are off. And depending on where you went to medical school, I mean, some medical schools really take really good care of their students with a lot of wraparound support.

Arghavan Salles:

Right.

Lisa Meeks:

You know, once you see that that's off, the gloves are off, it's a wake-up call and some people just cannot see that light at the end of the tunnel.

Arghavan Salles:        

I think it's really hard, and I think that you're absolutely right that there's this narrative in medicine that it gets better. And that's true at every stage. I remember when I was a resident and I mean, quite frankly, I was miserable, and people say, “Oh, it gets better. It gets so much better when you're done and you're practicing. It gets better.” And my experience was not that. And you know, my experience is only my experience, but I think it gets different. Every stage is a little bit different than the previous one. And the challenges are different, and the benefits are different.

When I took my first faculty job, I didn't feel that it was better. I had more responsibility. I did have higher compensation, but when you are making money and have no time to spend it anyway because you're always working, it helps with the debt, but it doesn't really help with your overall sense of wellbeing. I just felt more responsibility and more pressure without really more support.

Lisa Meeks:                

It's just a different hamster wheel. You get on it and then it's, you know, what are you going to do to get promoted?

Arghavan Salles:

Right.

Lisa Meeks:

What's the next thing? There's always something else. There's always a next thing. Right?

I want to bring this back to disability, and I think everything that we have discussed, all of the barriers that we've discussed really and truly are there for everyone. But for so many with a disability, it's a layer on top of the already very fraught system of getting through medicine, especially if you are in another marginalized population, so you're coming at this from an intersectional perspective. Many people choose not to disclose their disability out of fear. And then those who do have to navigate a system where they're trying to decide at every point, are the reactions to things or my lack of progression or any assessment really. Is it through the lens of someone believing that I am not able to do this because of my disability or is this true feedback absent any bias.

Arghavan Salles:        

I think that's very challenging, no matter what kind of identity you carry, whether it's a disability or it's your racial identity or your gender identity or sexuality or whatever, it is really challenging to navigate because there will be things people say to you and you find yourself going, “Hmm, are they saying that because I'm a woman? Are they saying that because of my disability?” And you have to kind of unravel all of these conversations to try to figure out, okay, what's the grain of truth that I need to take with me and incorporate and maybe changes that I need to make versus what of this is inappropriate and not relevant. It's very, very challenging to navigate and it's exhausting.

Lisa Meeks:                

You don't know how to respond to it because you're doing so much gut checking, and you're in your head about it. It wasn't so blatant that you can say something or report something, wasn't a kind of this outward bias or discrimination. So you find yourself in a constant state, I would call it like sub-level anxiety that you're navigating the world through because you know that at any moment, especially if your disability as apparent, that you might be getting viewed differently because of your disability. And that makes it really hard for people.

I had a good friend who was a woman of color and a woman with a disability and you know, we would have these conversations about disclosure. But for her, what she would say to me is, I'm too busy being a woman of color and navigating that landscape. I don't have the privilege of putting disability on top of that because I'm already knee deep and trying to just get through medicine and not have people judge me because I'm a woman or because I'm a woman of color. I can't afford that disability tax, if you will.

Arghavan Salles:        

Yeah. And I think that is great insight that she has. I don't know if you saw the Women in the Workplace report that came out this fall that's put together by McKinsey and Lean In, but this year they looked at, people with disabilities in addition to looking at racial identities and gender identities. And they found that women with disabilities have fewer opportunities and less managerial support than do other women and also are most likely to experience microaggressions. They also are more likely to experience sexual harassment. Some people say that these intersectional identities are additive. I actually think that they're exponential. I don't have data behind that, but I just think once you add a second identity that people aren't used to, that you're far, far more likely to have to face these obstacles in the workplace. We are not inhabiting a meritocracy. And that I think is the biggest, most damaging myth that is out there in academics. That if you just put your head down and do good work, you'll get ahead and it is just not true.

Lisa Meeks:                

If you are a person with a disability, the very little extra time that you have in your day is usually spent taking care of your disability-related needs. So for someone with a reading disability, getting through an article may take twice as long as someone else and to digest that material. So when everyone else comes home and they say, okay, I've got to catch up on these three articles for this patient tomorrow, that may require six hours versus three hours. So there's nothing to give, there's no time to borrow from. You know, so you are in a deficit from day one. I call it the horrible, terrible deficit cycle. Like you can never catch up because every bit of extra time that you have is spent managing personal care or personal needs. A person that requires physical therapy once a week, when do you find that time?

Arghavan Salles:

Right.

Lisa Meeks:

And when you take that time, you may be held accountable to a higher standard of something else when you come back because you took two hours, as if you were going to the beach for two hours.

Arghavan Salles:        

That’s exactly right.

Lisa Meeks:

The individual that's trying to navigate this with a disability is also I think, not as protected by the policies. So we talked earlier about there's no policy to guide this and in residency actually the ACGME requires a certain level of policy for disability, but we find that there isn't any. When someone who needs to disclose a disability and seek accommodations to ensure that they have full access goes looking for that information, they can't find it. You're forced to kind of live in this space of, well, since there is nothing there to guide me, that must mean that there isn't any guidance or that people with disabilities don't work in this space or are not trained in this space. 

Arghavan Salles:        

It’s totally invalidating. Whatever you're experiencing is so uncommon that we don't have a policy around it. And it's basically a big glaring message of you don't belong here.

Lisa Meeks:                

Right. But I'm glad that there are people like you, agents of change that are bringing these issues into the literature and into the media. I see more and more people being willing to voice their opinion and actually demand change. I know that it is driving change. I'm cautiously optimistic that the landscape will improve for individuals with disabilities. But it has to improve in the bigger context that you’re driving, this bigger force of equity and wellness and change that keeps people in medicine rather than driving them out. All of this, being a person with a disability, it can only go so far if the bigger system’s problems are not addressed.

Arghavan Salles:        

Yeah, I agree completely. And I think we need, like you said, more and more people to talk about basically being in medicine and being a human. There's so much suppression of that, just that we're supposed to show up and be perfect workers and just see a bunch of patients and have no thoughts or feelings or emotions and then go home. But literally not a single one of us is living that life. We are all having so many different experiences and feelings and emotions and we're just suppressing the vast majority of it, which is totally unhealthy and not sustainable. And so the more, in my mind, the more that we can all openly talk about that, the better off we'll be.

Lisa Meeks:                

And we have to fill our buckets. It's like your bucket gets depleted every day to different degrees and you have to replenish it. And the worst situation is when you've drained that last bucket and there's no reserve whatsoever.

I had residents tell me that they stopped asking their peers because if they asked, they didn't have time to address an answer that wasn't, “Yeah, I'm fine.”  You talk about us not being human. That is very dehumanizing when you don't even have time to care about the person next to you because it may mean sacrificing yourself. We need change. I'd love to end on a happy note.

Arghavan Salles:        

For me, the happy note is that as much as we often feel disenfranchised as physicians, regardless of your other identities, the fact of the matter is that we do have agency. We choose every day whether we're going to go into the hospital, whether we're going to go into the clinic, whether we're going to go into the operating room, whether we want to live the life that we're living. We can choose that we want to do something different and we can choose that we want to change our path, and we all have the power to make that choice. No one is forcing us to get up and go to that hospital, to get up and go to that job if it's not what's bringing us joy and allowing us to live the life that we want to live.

Lisa Meeks:                

I think we also have the agency to band together and stand up against something that brought us joy at one point and that joy was depleted. And to say, “Enough, we've had enough, and this is a new wave of trainees and a new wave of physicians and we're going to start implementing change.”

I know a lot of people in leadership that are working really hard to improve the conditions for medical school and residency and practice for physicians. I think that we're at a critical juncture and I do see the tide changing. My hope is that with people like you and the multiple voices that we have, not only in the Twitter universe, but actually writing and changing policy, that we will force this change, that we will be part of this change. And, I'll remain optimistic because that's my happy place.

Arghavan Salles:        

I think that's the only way we can be, right? Because otherwise you would stop doing the work. So we have to believe that something is going to make a change and that hopefully we're part of that change, right? I think I'm trying very hard to push for change. At least within surgery and definitely for me within medicine, I feel like we are really making it hard for people from different backgrounds to contribute and be valued. And that is to the detriment of the care that we provide our patients. So I think there's a real obligation and a compelling call to our profession to say, we've got to take another look at how we're valuing people and how we're supporting people who have different backgrounds and different abilities to succeed and contribute in meaningful ways.

Lisa Meeks:                

I think that's a perfect sentiment to end on. And I am so grateful to Pete Poulllos for connecting us.

Arghavan Salles:

Me too.

Lisa Meeks:

And so grateful for you taking the time to connect in Phoenix and for talking with our audience today. And I am absolutely grateful that you're one of the warriors out there doing the hard work. So thank you so much.

Arghavan Salles:        

Thank you. Thank you for all you do.

Kate Panzer:

Thank you to Dr. Salles for sharing her insight on physician wellbeing and to all of you for following along. Join us next time as we sit down with Dr. Monica Wood to learn about her experience with disability as an orthopedic surgeon.

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.