#4 Learner Mental Health with Dr. Chantal Young

January 4, 2022 | By Molly Heublein

Summary

Join us to discuss supporting learner mental health in health professions education.  Dr Chantal Young shares her approach to helping individual students who may be struggling, as well as local and broader systemic approaches to enhancing wellbeing in medical school and beyond. 

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Credits

• Hosts/Producers:  Era Kryzhanovskaya MD; Molly HeubleinMD
• Show notes, infographics: Isabel Valdez PA
• Editor (audio): Clair Morgan of nodderly.com
• Guest: Chantal Young PhD

CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner
• Picks of the Week
• Case from Kashlak
• Student mental health assessments
• How to approach a learner if you have a concern
• Definitions
• Strategies for teaching wellbeing
• Transitions in medical school
• Policy supports in school
• Modeling wellbeing
• Case 2
• How can we get involved to improve medical education and advocate for wellness
• Outro

Learner Mental Health Pearls

1. If you are concerned about a student’s mental health, be careful about your relationship.  Educators bringing up well-being could be seen as either loving and supportive or as intrusive depending on the setting, learner, and faculty member.
2. The most important step to take when addressing a student or learner who may be struggling with their mental health,  is to surrender the desire to fix, diagnose or treat. Instead, Dr. Young recommends being present and listening to the student; listening is the most powerful intervention you can give
3. To support mental health more broadly, look into what is already occurring at your institution and/or joining in a regional or national advocacy group.  Systemic changes are going to be important to really support learner mental health, which will need top leadership support.

Learner Wellbeing in Medical Education

What to do if a learner comes to you with mental health concerns

If a learner (or faculty) comes to you with mental health concerns, Dr. Young suggests listening deeply to the student’s unique story with the intent to understand not only what they are concerned about, but also the emotions behind those concerns.   Next step is validating and normalizing their experiences.  Many learners in health professions education experience mental health concerns. Support the learner by acknowledging and appreciating them for being brave enough to care for himself/herself  to seek advice.  Dr Young tries to highlight other special qualities that the student possesses and demonstrates.

Student Mental Health Assessments 

Some institutions are piloting standardized mental health assessments, such as Dr Young’s program at University of Southern California where students take periodic mental health self assessments (using the Keck Mental Health Survey) with dedicated classroom time and privacy measures.  The assessment covers a broad array of mental health topics such as substance misuse, anxiety, depression, suicidal ideation, trauma and cognitive distortions.  The goals of these longitudinal assessments are to improve self awareness in students as well as to gain information across the spectrum to improve systems (Young, Acad Med 2021).    

The ACGME Internal Medicine Milestones 2.0 has added a professionalism standard around knowledge of systemic and individual factors of well-being.  Dr Young stresses that learners should not be evaluated on their mental health, and institutional mental health surveys should not be involved in grading or competencies.    Specifically the ACGME acknowledges this by stating “This … is not intended to evaluate a resident’s well-being. Rather, the intent is to ensure that each resident has the fundamental knowledge of factors that impact well-being, the mechanism by which those factors impact well-being, and available resources and tools to improve well-being” (ACGME 2020).

What to do if you have concerns about a student’s wellbeing?

If you are concerned about a student’s mental health, be careful about your relationship.  Educators bringing up well-being could be seen as either loving and supportive or as intrusive depending on the setting, learner, and faculty member.  

 We may not know when a learner is suffering in silence, but warning signs for mental health issues, or red flags, are major changes in the student’s behavior or appearance.  The “difficult student”,  who may appear irritable, defensive, or entitled, is actually often experiencing emotional suffering and may need more support.  The student that is withdrawn or does not speak often could likely be experiencing high anxiety.  

The best approach with learners about whom you have concerns is to be gentle but direct, and Dr. Young suggests setting aside time to speak with them privately.  She recommends pointing out the specific  behavior you are noticing, and letting them know that you are worried and that you care.   She reminds us to respect the learner’s boundaries, they may not want to talk with you and that’s ok. 

In meetings with a student, Dr. Young employs the “one eye out and one eye in” method of listening wherein half of her attention is the needs and feelings of the student and the other half of her attention focuses on her personal reactions and feelings.  She tries to be equally invested in caring for herself while also caring for others in contrast to the past practice of being oriented only on the needs of others. 

The balance between being educator vs provider

The hardest thing for educators in medicine to do is to NOT try to fix.  The most important step to take as a mentor or educator is to surrender the desire to fix, diagnose or treat. Instead, Dr. Young recommends being present and listening to the student; listening is the most powerful intervention you can give.    Find the words to suggest mental health care for the students; be direct and avoid violating the privacy of the student.   “It sounds like you might be experiencing depression, do you think that’s right?”  “I’m so glad you’re telling me that today, have you thought about talking to a mental health provider?  Would you mind if I send an email to help connect you?”   

What do you do when you know a student declines help when they truly need it.  

Over encouraging a person to get help when they are not ready can backfire.  The student might not be aware that it is time to address a problem.  In these instances, we should allow the student to walk their own path, even if the path may lead them to a decline, without controlling them and realizing our limits. 

Definitions of Wellness vs Well-being, Burnout, Mental Health 

Dr. Young prefers the term well-being over wellness, feeling that wellness is overused. 

Resiliency is how quickly we bounce back from difficulties.  Dr. Young points out that medical professionals and trainees are resilient people and focusing on resiliency may be not as helpful when the real issue may lie in the environment. 

Burnout occurs when one has experienced persistent, relentless stress and lack of agency that one becomes emotionally “checked  out” in response as an effective coping mechanism (Hopkins 2019).

Dr. Young defines mental health as how the mind and heart are doing; what is the mind’s level of ease and friendliness. 

Strategies to teaching wellness, resilience, wellbeing to faculty and learner

Lead with data, we respond well to positive data.

Faculty being vulnerable and sharing both what has worked for the educator and stories about their struggles can help support learners to normalize mental health concerns and treatment (Vaa Stelling 2021). 

Dr. Young suggests teaching an anti-perfectionist approach.  Perfection is not a natural state humans can reach, but it is one many learners strive for, which can set them up for failure (Hu 2019).

Dr. Young models work-life integration by showing her vulnerability, such as talking about mistakes made, and seriously prioritizing self-care.  She tries to set boundaries (ie no email on the weekends).

Well-being through medical school:

There are specific challenges to each year of medical school (Dyrbye 2005).

First year: “high school all over again”.  Navigate new social and academic pressures.

2nd year:  Stressor of Step 1, research expectations, ongoing academic work.

3rd year: Transition into clerkship much like to starting a new job every four weeks, while trying to learn where they fit in new team dynamics

4th year:  Applications and interviews, rank orders.

All of these share a feeling like you have to prove yourself over and over with no time to rest, which can be a set up for mental health declines.

Changes in the system or policies that encourage wellbeing.

What can learners do 

Interpersonal: Peer mentoring can be a way to participate interpersonally, be mindful about how much this is taking from the learner and giving to the learner (students already have a lot on their plates).

Individual: Self work reflects back on our ability to give back in the health care and the broader society.

Broader system:  Starting a wellness group is challenging, to be successful this really needs to come from the administration if it does not already exist to support the time and money involved.  But starting with small things can make a difference.  Find the small things that are occurring in wellbeing at your institution, and connect with the people who are involved in those.   Using a group voice rather than individual voices and building through small changes within the system can be more effective.  Consider joining an advocacy group/group of allies to discuss needs and options for systemic change or engaging top leadership to review.

Be aware that this is not something an individual can solve alone.  We are at a moment in medicine where the scales are just starting to tip.  It is not the medical student’s responsibility to fix the mental health challenges associated with medical school.

Specific practices to consider to support learner mental health:

• Pass fail grading
• Wellness days off
• Limiting last minute schedule changes 
• Reimagine the whole process of medical education- how long does it really need to be?  What content is really valuable for today’s health professionals?  How can we improve from historical approaches?

(Dyerbye 2019).  The AAMC COSA working group is working on a longer list of recommendations which should be published in early 2022.

In the end, the bigger systemic changes needed will have to come with upper leadership.

Resources:

UME Wellness Programming and Strategies for Evaluating Wellness Programs A National Review from the AAMC
Dr Young runs a listserve around wellness in medicine, specifically around medical student wellbeing, but open to others, with lots of resources that can be helpful if you are interested in this.  Please email chantal.young@med.usc.edu to join.

Links

1. Dr Young’s book recommendations:  What Doctors Feel: How Emotions Affect the Practice of Medicine by Danielle Ofri  and Meditation for Fidgety Skeptics: A 10% Happier How-to Book by Dan Harris, Jeffrey Warren, and Carlye Adler
2. Era’s Pick of the Week the book  Transcendent Kingdom by Yaa Gyasi
3. Molly’s Pick of the Week the podcast Teaching In Medicine with Dr Kathleen Timme

Goals

Listeners will become familiar with approaches to addressing physician wellbeing/wellness as it relates to medical education and the pipeline of future providers. 

Learning objectives

After listening to this episode, listeners will be able to…

1. Distinguish between (and raise awareness for the interplay between) wellbeing/wellness, burnout, resilience, depression, and medical professional mental health
2. Describe the approaches taken systemically, interpersonally, individually to address medical professional wellbeing. 
3. Recognize when the wellbeing in team members or learners is suffering and employ strategies to address it. 
4. List steps educators can take to promote wellness in their learning environments

Disclosures

Dr Young reports no relevant financial disclosures. The Curbsiders Teach report no relevant financial disclosures. 

Citation

Young C, Heublein M, Kryzhanovskaya E. “#4 Learner Wellbeing in Medical Education.. The Curbsiders Teach Podcast. http://thecurbsiders.com/teach  January 4, 2022.