Transcript has been lightly edited for clarity and readability.
Kerry Whittemore: Welcome to M.ED, Medical Education for the Practicing Clinician. I'm your host, Dr. Kerry Whittemore, a pediatrician with the University of Utah Health. This podcast is brought to you by The University of Utah School of Medicine. This episode is going to be focused on medical student wellness. With me today is Dr. Michelle Vo, who is an Assistant Professor at the University of Utah School of Medicine. Dr. Vo received her medical degree at Case Western Reserve University, and then came to Utah to train in the Triple Board Residency Program in Pediatrics, Psychiatry, and Child and Adolescent Psychiatry, and she is Triple Board certified in those three things. She is the early childhood psychiatry consult for the Utah Psychotropic Oversight Program, where she reviews and consults on evidence-based, trauma-informed mental health treatment for children in state custody ages 0-6 and supervises resident physicians, as well as being the Co-course Director for the Relationship Leadership Initiative since July 2015. Dr. Vo began her appointment as Director of Medical Student Wellness in the School of Medicine, where she's helped build a the Medical Student Wellness Program, a multi-disciplinary mental health and wellness program for medical students. So, welcome, Dr. Vo.
Michelle Vo: Thank you so much for having me and inviting me here.
KW: Tell me about your position at the Medical School as the Director of Medical Student Wellness.
Who does the Medical Student Wellness Program serve and what services are offered?
MV: Happy to. What I find really exciting as a physician about this job is that I get to do evidence-based care in a capitated environment. One of the reasons why we had to build a wellness program is because our students didn't have great access to mental health care. Utah has extraordinarily high rates of depression and anxiety and suicide among youth. Knowing that was super imposed here in Utah upon the national trend of increasing medical provider or trainee burnout and suicide, about five years ago, the School of Medicine decided to invest in building a more integrated mental health team, specifically devoted to the students.
In this case, what we mean by students is undergraduate medical students, so physician students in our MD program. We leverage our university associations to be a clinical training site for a multi-disciplinary team that includes physicians who are MDs and DOs and the general psychiatry program, so they can learn therapy. And then Master's level Social Work students and PhD Psychology students from main campus too. In addition to the trainees, we also have a handful of full and part-time Clinical Social Workers that do therapy. If that sounds like a big team here, it's because it is. I think just the number of people devoted to the student wellness at the School of Medicine probably tells you a lot about how many students we serve.
KW: I was just going to ask you how about how many of the students do you see of the whole medical student class?
MV: We're still trying to collect accurate data about this past year, but I would say about this past year is that nothing was normal, and whatever data we're able to couple together about academic year 2019, 2020 needs to be looked at with that lens of it was not a normal year. It was an aberrant year characterized by a lot of distress, but most recent data trends, we served over half the student body, approximately 56% of students, in individual services in academic year 2018, 2019. A student body is about 420, 450-ish. You also have to recognize that here in Utah we have a unique population of students, many of them are married and have families of their own, and those families also don't have great access to mental health care, so we try to prioritize those individuals as well.
KW: Is that individual therapy or did you see them as a medical provider?
MV: We do a lot of different interventions or preventive programming, but the individual counseling is by far our most engaging and in-demand service. The students really appreciate having somebody to speak with and get counseling from, that understands the structure of medical education and is devoted to their population. And then it's either a counseling appointment or an appointment with me for medication management. Sometimes they'll meet with me for treatment planning. As you know, I always joke and say that I'm a pediatrician that was sort of socialized to become a psychiatrist, but at my very heart I really am a primary care doctor, and so a lot of times I'll see students for general well-being questions because it's fairly easy to get in to see me, which is ironic because I'm a fairly specialized physician.
This is the type of care I always wanted to provide, and so over the years, I have been able to start engaging with students on some really interesting pathology. I have one student that I sent for a sleep study that ended up being diagnosed with narcolepsy. That tells you a lot about how strong our physicians and physicians in training are. That student was a clinical student. She made it all the way through most of her medical education falling asleep on rounds, practically. Looking at it from that lens of resilience is really important to me because I know the stories of so many of these students, the things that they deal with are really human important things.
KW: Do you have a limit to the number of times you can see them? Do you refer out to the community or do you just keep it within the wellness program?
What is the treatment process like?
MV: No, we really try to be very evidence-based about what we do. We are very fortunate that we don't have any limits imposed upon us, like some other structures might impose upon mental health systems. You really can go through the processes as I think it was meant to run, which is that you would go through a diagnostic process, you engage in multidisciplinary treatment planning that's integrated into your community. It's not about a set limit because not one size fits all. No treatment or intervention is one size fits all. We're just very aware of when we don't have the expertise. So, for example, if somebody needs very specialized therapy, we're lucky that we have a network that we can coordinate to get somebody habit reversal therapy for tics or dialectical behavior therapy for self-harm. And goodness forbid, but it often happens if somebody requires hospitalization, we can facilitate and coordinate that as well. That means we do refer it to some place that can take care of a student that is dealing with that type of acuity.
KW: Right, and this is all free for the students, right?
MV: Well, I mean, they do pay tuition.
KW: That is true. And that is a lot of money.
MV: I think of it as it's an investment that's like capitated and built into their medical education. Because I think that's something that not even our generation of physicians really benefited from—this idea that you care for yourself so you can care for others. That's something that I think is really important, and we are constantly striving to integrate that mindset into medical education at the University of Utah.
KW: You mentioned preventative programming. Tell me a little bit more about what you do.
What preventative programming does the program offer?
MV: Preventative programming used to be more robust when we could gather in person. In Zoom, it is a little bit challenging. And this has sort of evolved over the years, as I think our program has become more and more high profile within the School of Medicine and the student body. But in the beginning, it was lunch and learn lectures, the same types of ones that a lot of student interest groups would sponsor. We would sponsor meditation, we would sponsor lectures from our medical experts on sleep or test anxiety. We were trying to be very intentional about when we would do these things and how. There are these developmental milestones for the students, to use medical jargon, highest yield developmental milestones. Where the first years come in, there's inevitably a transitional period. They often all experience a little bit of that transitional anxiety that they recognize as Imposter Syndrome. So there have been a couple of years I've done Imposter Syndrome lectures in the fall.
And then we try to pay attention. Right now, our preventive programming does not look like lunch lectures because it's not safe to have lunches. It's about working with our partners and curriculum and Student Affairs about some of the common reasons why students experience distress. So things like professionalism, building out the interventions for professional growth. And right now, because of the high-profile anti-racism commission that was created, we are working with those interventions to ensure that equity and inclusion are values that we explicitly teach and exhibit as medical professionals. It's exciting and feels really meaningful, but it's constantly evolving, just like medicine does. I think that's what I always tell the students; we have a great job.
KW: I read that the rates of depression and anxiety are about four times the national average in medical students. Do you find that it's the same at the University of Utah, or do you think that the rates have changed with all your programming? Or is that impossible to calculate?
What impact has the program had on depression, anxiety, and burnout rates?
MV: It's really hard to track because we use so many trainees in our treatment and evaluation of the students, and also the students are a protected population when it comes to the dean's office collecting data and doing research on them, and so I can't really speak to hard data and objective information in a way that I find scientifically useful. But I think that what we have tracked is general rates of burnout in the student body, just as a quality improvement initiative. And so, again, COVID derailed a lot of our collection of data this year, but the four years prior to that, we were consistently measuring burnout data in December of the last four years previous to this last academic year, and they were trending significantly below the generally accepted national average for students. And so that comes from a 2008 study by Dr. Dyrbye and her team at Mayo Clinic, and that most cited statistic is approximately 49% of students reported burnout in 2008 across several medical schools.
That's my benchmark when I'm thinking about how does our program compare our burnout rate. From 2014–2018, every December ranged between 22% and 33%, our highest burnout rate, which I think is pretty good. It approximates the faculty and staff burnout rate and the Resiliency Center measures. The Resiliency Center is tasked with the well-being of staff and faculty, and then the Graduate Medical Education (GME) Wellness Program also exists, and we work pretty closely together when we're trying to characterize our population at the University of Utah Health Sciences.
KW: And for those who don't know, how do you define burnout?
MV: Burnout in this case is from the validated measure, the Maslach Burnout Inventory or the MBI, it measures three different domains in personal achievement, emotional exhaustion and depersonalization. Now, for any psychiatrists that are listening depersonalization means something different to us in psychiatry than it does on this inventory. On this inventory, it means kind of what I would call as a psychiatrist, dehumanization. The tendency to see your patients as having fewer characteristics instead of like an individual person or human being. In the medical profession it's really important to recognize that we don't really measure or promote personal achievement, because personal achievement is often one of the last things that go for medical students, physicians, physicians in training, that is not a valid thing that we can measure on this inventory. We only look at either emotional exhaustion or depersonalization data on this inventory as being high, that's generally the validated measure that people use in the literature to assess for burnout.
KW: The national average is almost 50%—that's so high.
MV: Yeah, of students. It's also really important to acknowledge that they've done this a lot more in residents because the residents are employees, and so they're not considered a protected class for research as much as the students. And so the resident published data has a wider range and a more alarming range, up to 70% in some studies. It's really important to acknowledge burnout is an epidemic of its own, and it's also really important because it's linked to, as you said, depression and suicide.
KW: How do you find that COVID has affected the students? Everyone seems to be burnt out and having a hard time.
How has Covid-19 affected student well-being?
MV: In the beginning, I think you're right, everybody was really struggling. Then there was this interesting phenomenon in which I think the virtual environment has impacted. This is my tendency, as you know, to always try and look for the silver lining, and the silver lining for this particular situation is that our introverted students or our students that may be more susceptible to some of the effects of classroom microaggressions or the stress contagion of being thrown in your pre-clinical years with a bunch of other high performing, high-achieving, sometimes gunner people. That stress contagion for some of our students seems to be mitigated because they're better able to set boundaries, and then the introverted students have a wider variety of ways that they can shine and engage, and then they can disengage if they don't want to. And so some of my introverted students were telling me, "I'm living my best life in social isolation, this is great."
KW: But that's good there's a silver lining for some folks.
MV: I know that's what I said and so that's I think a really important reflection, is that as therapists or physicians, it's really important not to impose our own personal experiences on the people that we serve, because you can't make the assumption that everybody is struggling when we are.
KW: You mentioned earlier, diversity and inclusion. I was reading something about how the rates of mental health struggles amongst marginalized medical students is even more challenging. Have you found that at the University of Utah?
How does the program support diversity and inclusion?
MV: There is definitely an over-representation of students who feel marginalized from the majority who come and seek us out in the wellness room. I don't think it's just the wellness program, just student services in general. That is certainly a trend that has always been part of addressing student wellness at the University of Utah. I think that's why when I have talked about preventive programming and the evolution, that's something that, as I got my legs under me and I started asking the question, "Why do so many students feel like they need to have therapy?" I really don't think that there's anything wrong with a lot of them, but it's obviously very distressing. I'm so glad that they trust us with their care and helping manage that distress.
There were some trends when I first started in the wellness program. For example, we used to have a well-intentioned attendance policy that required every student to be in class. They would take attendance electronically, and you would be in class and they would announce the attendance board and then you had to put it in the log on your iPad. We had students that recently had babies and needed a pump and couldn't take a break to do that. We had students that needed to pray during class because they are a very devout Muslim and they didn't feel like they could do that. I actually saw several students for headaches and I was like, "Why aren't you drinking water?"
KW: Because then they'd have to use the restroom and miss the attendance.
MV: We noticed that trend, we reported it back in a way that people could hear it, and then that policy ended up changing. When I think about preventive programming, that's where I really do feel like partnering with our leadership and those who are tasked with diversity, equity, and inclusion at the University of Utah is super critical because so much of it is intersectional. It's really important to be inclusive. That's kind of a fine line that we have to walk, and especially in a charged divisive climate is that how do you do that and address things so that everybody, even our majority students, as well as our students that feel marginalized, everybody feels like the Wellness Program is a program for everyone.
KW: Right. Do you think just your presence has helped to de-stigmatize the issue of mental health in trainees?
How has the program made an impact on the destigmatization of mental health?
MV: I can't take credit for all of that. I think building a program that is an open-door program with a welcome mat, metaphorically speaking, where all are welcome and everybody is aware of how many people seek out wellness. Wellness is spoken of in the dean's office and among the students and among the faculty in the school of medicine in same breath as the other student services are, which I think is not directly my responsibility. It just has made it okay to speak of this distress and speak of the need to care for yourself and to speak of the vulnerability associated with it. The vulnerability is the stickiest part. Nobody wants to feel like they're weak, least of all our high-performing people. That's always something that we're always trying to address and it would be great if we could run a lot of group therapy where everybody would realize like, "Oh, we all suffer from Impostor Syndrome in September first year of medical school. This is a shared humanity thing." But the stigma of vulnerability keeps them from doing that, and so hence we have this huge therapist team.
KW: Are you able to do any group therapy or is that not possible?
MV: We are trying it out in the time of COVID. In the past, we would run four to six-ish groups, depending on the themes that people were interested in every semester. But group therapy and couple's therapy are really hard to do on Zoom. And it's hard to ensure confidentiality of the space because it really is a treatment space for group therapy. So we're testing it out with some of the things that our students really, really want us to do, like diversity and inclusion groups. I just am hesitating because I just don't know exactly how engaging we are or how effective they are in comparison to the gold standard of being in person.
KW: I think a lot of the listeners of this podcast are attending physicians who have medical students that work with them. I remember from my own time in medical school, having some scary experiences where attendings would pimp you for certain things and that being very anxiety-provoking. Do you feel like the culture of pimping has shifted at all since we were medical students?
MV: You and I both went to medical school outside of Utah.
KW: This is true. And I went in Canada, which has its own cultural difference.
MV: I think at Utah it's maybe not quite as bad as it was where you and I went to medical school. It's more of a collaborative environment here in Utah, I think. I think the School of Medicine has really made it a priority to value our teachers and give them resources. I think there are a lot of conversations about intergenerational differences. I think that's something that I've noticed about our students. That they're that generation. Julie Lythcott-Haims, former Dean of Freshmen at Stanford University wrote this wonderful book, "How to Raise an Adult," about the phenomenon of helicopter or over-parenting because she observed that in a lot of her students. Those students tend to be the same types of students that go to medical school and they're very accustomed to very close guidance.
I find this myself as somebody that doesn't necessarily teach students because that's a conflict of interest, but I teach all of our child psychiatry residents and many of our triple board residents, as well as the general psychiatry residents that do therapy on our team. I find that where other people or other generations maybe like autonomy like I do, that sometimes makes our students really anxious. And so it's really important for our students and our teachers to model and practice open and direct communication. That is something that I coach our students, faculty, and residents about. We're so busy that sometimes one of the things that we take for granted is that we're on the same page.
I'll give you an example and de-identify it. This Labor Day weekend, one of our attendings texted me because she had told the student on her team to take Labor Day off, but then that student showed up anyway. The attending didn't feel listened to and she was very frustrated with her student, and he called the fellow on the TMF. I think because it's like a missed connection.
KW: The student was probably just thinking that he or she was working hard and making an example of, "Look how I'm coming on a holiday and I should get points."
MV: That was part of my response. I think the student probably internalized the old adage that I myself had as a student, which is that you show up, you don't necessarily have any expertise to offer, but you have your enthusiasm and your willingness to learn and work hard. And the way that you show you work hard is you show up earlier than everybody else and you stay later than the rest of the team.
KW: You don't want to be thought of as lazy, as the one who takes the day off when everyone else is there.
MV: This particular student I think also told the resident he wanted more time with this attending. He was a very smart attending, so he wanted a letter. And part of that too is that anxiety that happens. This class of students was pulled from rotation in the middle of March when we were worried we didn't have enough personal protective equipment. They feel short changed and there are concerns at every level that they have shorter clinical experiences. You can see how in a very stressful environment, it becomes this really big deal and creates a lot of distressing or uncomfortable feelings.
KW: Is there anything else that our attending physicians other than direct and open communication should know when they're working with medical students in terms of helping to look out for their well-being of the medical students?
What are some tips for attending physicians to help improve the well-being of their medical students?
MV: The students are searching for models of humanity. Many of them still went to medical school because they're extraordinarily altruistic people who are very values driven. I think in this time to choose to go to medical school when there are so many other options to be a caregiver and provide care for others with less debt and less training time, they're looking for the apprenticeship model that medicine was built upon and they really appreciate the modeling. What I would say to attendings and residents who are interested in education and how to address well-being is that you don't have to take on the responsibility of doing therapy for somebody. The students may look to you with their distress and you may feel a pull to care in that way, but your job is to teach and model for them what to do with difficult situations. And so taking time or a pause during difficult times and acknowledging goes a long way. Because we are so busy, we sometimes forget to do that. Say there was a death overnight—take a 20 second pause to honor that life before rounds. It makes a big difference.
You don't have to share details of your own life, but I think that selective acknowledgement of our shared humanity goes a long way with our students. The other thing I want to drive home is that, you already have your own patients—don't turn the students into your patients. Instead, you can share resources with them. If you're at the University of Utah, you know that we have this robust wellness program. You don't even have to remember my name, you can tell the students to Google "University of Utah School of Medicine Wellness Program" or if you're at a different School of Medicine you likely have some sort of resource and student affairs program. One of the only reasons we exist in the School of Medicine is that there is LCME potentially. Accreditation requires that there's somebody on the team in the School of Medicine that is responsible for your students well-being. It doesn't have to be you directly, but you can connect them just the same way you connect them with other resources in their learning. I really do think this is an important piece of learning for our young physicians. It's hard to be a doctor right now and they have to learn how to self-manage.
KW: Awesome. Thanks so much for joining me today. I think this is really interesting and people can learn a lot from you and from your program at the University of Utah.
MV: It's my pleasure, thanks for having me.