Problem
Distress, depression, and burnout are common during medical training. Rates of depression among resident physicians are higher than in the general population, with nearly half of trainees experiencing depression or depressive symptoms at some point during their training. 1 Distress and depression are associated with increased medical errors, decreased quality of life, unprofessional conduct, and suicidal ideation. 2 In the United States, up to 75% of individuals with mental health disorders do not receive treatment. 3 This percentage is similar to what is seen in medical trainees, with only 25% of depressed medical students seeking mental health care. 4 Lack of appropriate mental health care has the potential to lead to grave consequences, including suicide, among trainees.
There is a strong stigma surrounding mental illness with an associated decrease in help-seeking behavior in trainees. This stigma involves how one feels about being mentally ill and receiving treatment, how others judge those with mental illness or those who seek mental health treatment, and how one anticipates being treated by others after getting a diagnosis or receiving treatment. 5 Barriers related to stigma that prevent medical trainees from seeking help include lack of time, concern about documentation in their academic record, concerns about privacy and confidentiality, and fear of jeopardizing future career opportunities. 6 Concern about potential career consequences is ingrained early in medical training, with more than 50% of burned out medical students reporting that disclosing a mental health issue would cause residency directors to pass over their application. 7 These concerns affect physicians later in their careers as well, as perceived potential repercussions to medical licensure prevent nearly 40% of U.S. physicians from seeking formal medical care for treatment of a mental health condition. 8
Supervising faculty physicians are important role models for trainees in both personal and professional matters. Medical students value humanistic and professional characteristics in role models and studies have shown that exposure to negative role modeling is independently associated with increase in depression in medical students. Due to the stigma in medical culture that suggests help-seeking is a marker of weakness rather than empowerment, it is important for faculty to role model this important behavior. A recent study of medical students demonstrated improved attitudes regarding mental health after 2 physicians self-disclosed their personal histories of mental illness as part of a “lived experience panel.” 5 This type of structure is similar to Schwartz Center Rounds, which are 1-hour, case-based, interactive discussions led by a physician and/or a professional facilitator. Topics covered are rarely discussed outside these sessions, whose main goal is to increase participants’ sense of personal support. 9 To our knowledge, core faculty disclosure and discussion of personal mental health experiences has not previously been reported as part of a residency training curriculum. We hypothesized that such discussions would reduce stigma toward help-seeking during training, promote self-reflection about mental health, and improve resident physician awareness of mental health resources.
Approach
Aim
The aim of this study was to investigate the impact that a resident teaching conference involving personal reflections by faculty on mental health struggles during their training would have on the knowledge, attitudes, and behaviors of resident physicians surrounding mental health. Specifically, the primary goal of the conference session dedicated to this aim was to reduce the stigma surrounding mental health issues during medical training through faculty disclosure and role modeling. Secondary goals included promoting participant self-reflection on current mental health status as well as awareness of mental health resources available at the institution and in the surrounding community.
Setting and participants
Participants were internal medicine residents in all levels of training at Mayo Clinic Rochester. The session took place during a 1-hour noon conference that was part of the core curriculum in December 2016. The conference topic for each day is listed on the residency’s internal website. Residents are expected to attend at least 50% of noon conferences, but not all, in recognition of clinical duties, days off, vacation, and other unavoidable scheduling conflicts. This study was deemed exempt by the Mayo Clinic Institutional Review Board.
Program description
Core faculty members were recruited through an email by the principal investigator (B.E.V.S.) that disclosed the nature and goals of the conference. Faculty were advised that the goal of the conference was to reduce the stigma surrounding mental health disorders during training. Three individuals volunteered to disclose their personal experiences with depression and other mental health disorders during their training. Each faculty member was allotted 15 minutes to share their story, with 15 minutes of time at the end of the session for informal discussion and fielding questions from those residents in attendance. Faculty were instructed to share how their experiences had affected their training, how they navigated their mental health struggles, the importance of seeking support, and what strategies and resources they found to be helpful. A list of mental health resources both within and outside the training institution was provided to the residents during the session for future reference. Measures were put into place to protect both trainee and faculty confidentiality during the conference. These included not recording or broadcasting the lecture to other locations on campus and not allowing other faculty members or trainees outside of the internal medicine residency program to attend the conference. Ground rules were established to note that meeting content was not to be shared beyond the session itself. Questions and audience participation were voluntary, and residents were not required to share their opinions or ask questions.
Program evaluation
Immediately following the conference, residents in attendance were asked to complete an anonymous 6-question survey that assessed self-reported knowledge, attitudes, and behaviors about mental health during medical training (Table 1). Residents rated their level of agreement for each question using a 5-point Likert scale (strongly disagree to strongly agree). Residents had the option of leaving open-ended comments about the session. Results were aggregated and reported using descriptive statistics.
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Table 1: Postconference Self-Reported Resident Knowledge, Attitudes, and Behaviors Surrounding Mental Health, From a Study of Faculty Disclosure of Mental Health Experiences and Resident Perceptions of Stigma, Mayo Clinic Rochester, 2016
Outcomes
Of 102 residents on site on the date of the conference, 69 (67.6%) attended. Attendees were 40 men (58.0%) and 29 women (42.0%), a similar gender ratio as for the training program as a whole. There were 24 postgraduate year 1 residents (15 categorical, 9 preliminary; 34.8%), 28 postgraduate year 2 residents (40.6%), and 17 postgraduate year 3 residents (24.6%), representing slightly fewer postgraduate year 1 residents and slightly more postgraduate year 2 residents than across the full residency program. Thirty-nine of the 69 resident attendees (56.5%) completed the postintervention survey.
Results are detailed in Table 1. One hundred percent of residents who completed the survey (39/39) either agreed or strongly agreed (hereafter reported as “agreed”) that they enjoyed the conference and 34/39 (87.2%) agreed that they would like to have a similar conference held in the future. Thirty-five of 39 (89.7%) respondents agreed that their knowledge of mental health resources available at Mayo Clinic increased and 33/39 (84.6%) agreed that they were more likely to pursue mental health resources.
Thirty-eight of 39 (97.4%) residents agreed that faculty sharing of personal struggles destigmatizes mental health issues during training. The same percentage reported engaging in postconference self-reflection regarding their own mental health and well-being.
Nineteen respondents provided specific comments and feedback about the sessions. The complete list of comments is provided in Table 2, with prominent themes including an increased comfort with mental health issues, normalization of mental health discussions, and increased sense of support from the residency program.
Table 2: Complete Listing of Open-Ended Comments From All 19 Survey Respondents, Organized by Session Objectives, From a Study of Faculty Disclosure of Mental Health Experiences and Resident Perceptions of Stigma, Mayo Clinic Rochester, 2016
Next Steps
To our knowledge, this is the first report describing a session during which core faculty disclosed their history of mental illness with residents within a structured curricular setting. We found that nearly 100% of residents reported increased knowledge of mental health resources available at the study institution and increased likelihood of using these resources when needed. The session was also successful in promoting trainee mental health self-reflection. Furthermore, residents felt that having faculty members share their personal stories destigmatized mental health issues during training. Individual resident comments indicated that the session was meaningful and powerful to many, helping to normalize mental health disorders and conveying programmatic support of trainees.
Promoting trainee wellness and reducing the stigma of mental illness are a current priority of the Accreditation Council for Graduate Medical Education (ACGME). The latest revision of the ACGME Common Program Requirements (Section VI) focused specifically on resident well-being, with changes to have been implemented in all training programs by July 1, 2017. In addition, the ACGME Council of Review Committee Residents (CRCR), which comprises residents and fellows representing all ACGME-accredited specialties, has discussed strategies to address mental health concerns during training. The CRCR suggested that training programs increase the awareness of depression and other mental health disorders in training, ensure confidential identification and treatment of such illnesses, destigmatize the process of seeking mental health assistance, and foster peer and faculty mentoring. 10 Sessions like ours align well with these suggestions, offering promise as part of the larger well-being initiatives training programs must work toward as required by the ACGME.
Avoidance of help-seeking can be attributed to a medical culture that can sometimes view help-seeking behavior as a marker of weakness rather than empowerment. In medical trainees, concerns regarding stigma associated with mental health illness and potential long-term consequences present significant barriers to reaching out to receive mental health care. Our study demonstrated that faculty disclosure of personal experiences with mental illness reduced the stigma of mental health disorders according to resident physician self-report. Willingness of faculty physicians to share their own experiences with mental health illness during training in similar sessions could be a powerful and effective strategy for reducing stigma among trainees. Such critical role modeling could shift the culture surrounding mental illness in trainees from one of stigma to one of support and help-seeking.
We acknowledge several limitations of this study. Only residents on site were eligible to attend the confidential, protected conference. Although the gender distribution was similar to that of the entire residency and we had representation from all years of training, we were unable to determine whether survey respondents might have systematically differed from the residency class as a whole. Furthermore, the topic may have self-selected for residents who feel strongly about mental health and other wellness behaviors, which may bias our results. In addition, this study involved a single specialty at a single training site. As a cross-sectional postintervention analysis, these descriptive data are also subject to potential biases limiting causal inference. We do not have information regarding longer-term attitudes or actual utilization of institutional mental health resources by residents after the session. Future studies should investigate these outcomes, including the impact these sessions may have on utilization of mental health resources and on objective measures of trainee well-being, self-reflection, and stigma.
A number of additional considerations arising from our initial experience may inform future efforts. First, exploring additional ways to facilitate discussion and interaction would be useful. These might include small-group breakout sessions on specific topics. Second, it may be helpful to have a mental health expert present to help facilitate the conference and field questions. Conversely, however, it is possible that this could raise the perceived intensity of the session for participants, so the optimal composition of session contributors is unknown and merits further study. Third, the optimal length, timing, and frequency of these sessions are unknown. For example, it may be helpful to have a similar conference later in the academic year to reach residents who may have developed symptoms of depression or burnout over the winter months.
Medical training is a stressful time, often leading to distress, anxiety, depression, and burnout. There are many barriers to seeking mental health care for medical trainees. Our medical culture creates an environment where seeking help can be discouraged as it may be perceived as a sign of weakness. Sessions during which faculty discuss their own mental health struggles may help reduce stigma, increase trainee knowledge and utilization of mental health care resources, and decrease the downstream consequences of not seeking assistance. We encourage further study of longer-term outcomes and actual help-seeking behaviors across learner levels and training environments.
References
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2. National Academies of Sciences, Engineering, and Medicine. 2019. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. 2020. Washington, DC: National Academies Press;
https://doi.org/10.17226/25521. Accessed December 22, 2020.
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