Student Wellness: Addressing Mental Health in Medical School

In this episode of MedEd Thread, we talk with Dr. Stacey Jolly, Associate Professor of Medicine and Director of Career Advising, who discusses the prevalence of mental health issues among medical students and strategies for managing stress and avoiding burnout. She also addresses the impact of COVID-19 on mental health, the importance of seeking help and the role of support systems in maintaining student well-being.

Transcript

Dr. James K. Stoller:

Hello, and welcome to MedEd Thread, a Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano:

Hello. Welcome to today's episode of MedEd Thread, an Education Institute podcast exploring mental health aspects of student wellness at Cleveland Clinic's Lerner College of Medical of Case Western Reserve University. I am your host, Dr. Tony Tizzano, Director of Student and Lerner Health here at Cleveland Clinic in Cleveland, Ohio.

Today, I'm very pleased to have Dr. Stacey Jolly, Associate Professor of Medicine and Director of Career Advising at the Clinic's Lerner College of Medicine here to join us. Stacey, welcome to the podcast.

Dr. Stacey Jolly:

Thank you, Tony.

Dr. Tony Tizzano:

To get us started, could you tell us a little bit about yourself, your educational background, what brought you to Cleveland, and your role here at the clinic?

Dr. Stacey Jolly:

Yeah. So, thank you. It's great to be here. I am a general internal medicine physician, a primary care physician. I've been at Cleveland Clinic since 2009, did my medical training at Stanford University School of Medicine and my residency training at University of California San Francisco in a primary care track, internal medicine residency. And we moved here to Cleveland for my husband's job at Case Western Reserve, and my role is Director of Career Advising. I've been doing that since 2019.

Dr. Tony Tizzano:

Excellent. Primary care track of, of internal medicine. I, I like hearing that, because I get the sense that, when you get into the ivory tower and you're in internal medicine program, and you thought you'd stay primary care, all of a sudden you drank the Kool-Aid of super subspecialties. And, and it's so hard to find a general internist that can help navigate all the others. So kudos to you.

So in today's segment, we'll focus on the importance of mental health in the second of a three-part series exploring the topic of student wellness for medical students at Cleveland Clinic's Lerner College of Medicine. Help us frame this topic. You know, what is the importance of mental health, mental wellness, as a front-of-mind consideration related to students?

Dr. Stacey Jolly:

So, thank you. This is a great timing of the topic. May was actually Mental Health Awareness Month, and I think this is important because, really, health encompasses our mental health and our physical wellbeing health. And so, trying to, as you allude to, de-stigmatize, that perhaps maybe one is separate from the other.

I think the other thing that's important for, uh, students in our audience to know tha- is that it's common. You know, one in five adults will have a mental health illness or issue. Each year, one in 20 will experience a serious mental health issue, perhaps s- serious enough that, in the hospital. And then, one in six youth have, you know, also experienced mental health issue or a problem. And then, many of our listeners, as well as students, are well aware that our COVID-19 pandemic, you know, certainly exacerbated this as well.

Dr. Tony Tizzano:

Boy, that is for sure. Is it more prevalent within the medical profession, or within medical students, than in the general population?

Dr. Stacey Jolly:

To my knowledge, as far as I know, it would be a similar prevalence. Certainly, there is that around the times given the stress of our training, the high sense of pressure that we might internally put on ourselves, but as compared to the general population, there is higher thoughts around suicidality or suicide among physicians than the general population.

But I think the point is, as you allude to, is more that it's common, as well as something that the AAMC is taking notice of. You know, nearly a third, or 30% of the US medical students, you know, have either experienced depression or anxiety, and that our schools and our systems, where we, you know, bring individuals in for training, how can we help support their health that may happen? Things may come up over time that they didn't anticipate, and, and how can we really help them know that it's okay to seek help?

Tony Tizzano:

Sure. And I sure hope we do that, because if you're saying 30%, we're talking beyond prevalent. We're talking common. So we need to look at it as, like, this is part of the norm-

Dr. Stacey Jolly:

Absolutely.

Dr. Tony Tizzano:

... and not... You're not an outlier. If we had any other condition that 30% of us had, we would say it that way. I would guess that most of us are surprised by what you're saying. What does it say for us as a profession, and what sorts of things should we be putting into place that might help us remedy that?

Dr. Stacey Jolly:

Yes. So, I think that one of the things I've been impressed with with our Lerner College program is the sheer amount of just kind of support that we have for our students. And by support, I'm meaning that kind of personal connection.

Our students have physician advisors, our students have academic advisors, our students have myself and Dr. Bryson as career advisors. Our students are working with faculty in the clinic, they have their peers. So there are a lot of individuals that are there for our students and that, you know, should something come up that might be attuned to perhaps seeing a difference or change in a student, or that the student would hopefully feel like they had a trusted, you know, peer, colleague or faculty member to confide in.

I think the other part is that, similarly of, like, walking the walk and talking the talk. And I think that students see their faculty members, their programming, the messaging, amongst a health system that, you know, wellbeing is important and that there are resources to access.

Dr. Tony Tizzano:

Yeah, that's perfect. And I, I know that we do have a lot for physicians. I am impressed that we allow our students to engage the same services. So, what do we do to train our faculty in recognizing some of these warning signs?

And I, I gotta feeling, since there was very little consideration for this when I was in training, that, that the longer a- ago you've trained, perhaps the more you need to, to hear some of this. Do we do something for faculty to kind of make them aware of the problem and be able to recognize it?

Dr. Stacey Jolly:

Yes, and many times this comes up with... Many faculty work with Lerner's, not only students but also trainees, so this is a problem that crosses from our UME, our undergraduate medical education, to our graduate medical education. So things like if somebody's noticing that they're a little bit more short, uh, or curt in tone, perhaps had always been, you know, very much on time and, and doing tasks and now there's been a, a slip or a change. 

So having that, you know, curiosity of, you know, what may be going on, are things okay? Something new changed within their, you know, life or family or friends that, again, we're not aware of, that maybe even they d- aren't aware of, is now manifesting, and, you know, how they're being perceived.

Dr. Tony Tizzano:

So enhancing awareness, like so many other things. Uh, you mentioned in, in previous conversation that there are some tips for managing stress. And, uh, what are some things that students might, along with their reflection, say, "Here are some things I can do to keep myself on the right track?"

Dr. Stacey Jolly:

Yeah, I think this is something that, our students really come in with a lot of g- skills that they'd used in their undergrad and their work, and certainly things that, you know, they also share with their colleagues, with their faculty.

Things like adequate sleep, proper nutrition, hydration, the calming, just kind of knowing what is gonna be that person's, like, way to kind of ground them, their happy medium. Is it- for some, is it a run? Is it, you know, a good book? Is it listening to calming music, is it listening to, like, really hoppin' dancing music? It's going to vary for, you know, each student and each person. But I think also just realizing that sometimes we just need that re-centering and that re-grounding.

Dr. Tony Tizzano:

Yeah, and perhaps it's even easier now. You know, we have all this electronic apparatus. We can be wearing our earphones and no one even really knows, and all of a sudden you can flip over and listen to the MedEd Thread podcast for 15 minutes, and- or listen to some music that you like to listen to. That would've been very hard... I would have had no way to do that during my work day. That perhaps, you know, we have things afoot that will help us do that.

And I also look at these students, and I'm so impressed a- at how different they can be, and do they revel in the fact that they are who they are? And what they bring to the table, you know, collectively, makes for a really interesting cocktail and is to the benefit of our patients. So, we talk about stigma. And certainly, I think, if someone has a sore throat, they wouldn't hesitate to say, "Hey look, uh, maybe I better get a throat culture, make sure it's not strep."

But again, if it's something that, we're feeling blue, we just can't seem to pull ourselves out of it, or there's anxiety and we're having palpitations, you know, how can we help make that more acceptable to come forward and popularize the idea that it's, it's a good thing to do and we're looking forward to you doing it?

Dr. Stacey Jolly:

Yeah. I think this is where... Well, there were certainly many things out of the COVID-19 pandemic that were very difficult. This is probably one thing that certainly helped bring a lot more awareness around mental health and how it is just an integral part of health. Also, our students have the chance to work in-clinic, with either internal medicine or family physician, and I think this is a great system for them to then see.

At least here at Cleveland Clinic, that there's the concept around universal screening. We can't know exactly what's going on in every person's mind, and we can't really say, "This person's more likely than that person to not." It is a common problem, as we said, and if it's up to, you know, 20 to 30% of the US population, and maybe even higher at any time in life. Doing that universal screening of- around, you know, mood and anxiety, I think is, is helpful. It's something for me, as a practicing physician, where I've certainly, through this, caught things that I probably would not have been attuned to.

And then also, for patients to feel like it's okay, it's a normal part of, you know, going to the doctor as well. And our students get to see that. So one, that's helpful. And then two, then hearing from their faculty and their various support groups, interest groups, the action groups around diversity, equity and inclusion, and those personal stories of where- that it is okay to seek help when needed.

I know for myself, personally, I share with students and with residents that, you know, everybody has access to our Caring for Caregivers, and that it is a resource that's confidential, that's helpful. And I've utilized it before when there's been times of, you know, high stress and maybe not-so-good outcome taking place. And so, realizing that it's a wonderful service, I spoke with the Care for Caregivers counselor. It was 10 years into me being here at the clinic before I utilized them, and that I probably could've and should've utilized them a lot sooner.

Dr. Tony Tizzano:

Yeah. I also had an opportunity. It was fabulous. You don't think about it, but, uh, it, it did me a great deal of good. So, you know, there are so many avenues available to these students, and I think... And our students come from so many different places, that I think inherent to that is perhaps some social isolation, for lack of a better word.

But yet, we have these teams. Do you think that's a big step towards helping students overcome the sense that they're alone, and having things like art in practice of medicine, where there's a section done on joy, finding joy in your career, which people might poo-poo to begin with, but listening to how other people revel in what they do sometimes is contagious.

Dr. Stacey Jolly:

Absolutely. It is a huge adjustment when our students are starting medical school, as well as you said, they might be coming from many states, other countries. And so, just getting adjusted to, to Cleveland and its geography and, you know, where, perhaps, is the grocery store that maybe sells your favorite food that's gonna bring you comfort, are all gonna be things that are important for finding that sense of community, feeling that sense of belonging.

And so, I think that there are the s- formal and informal social events that take place, and then, as you said, it's part of the, you know, curriculum that we want to have everybody have that sense of belonging, that we all bring, you know, experiences to the table to share.

Dr. Tony Tizzano:

For certain. Well, I'm glad you mentioned food, because that's my go-to for comfort, and, uh, and now you've legitimized it by saying it. So, I appreciate that on a personal note.

We talk about self-love, and, you know, how you, even when you're feeling down, can have that occur. Or, in the most probably poignant thing that can happen, is when you have a patient that finds themselves in harm's way or maybe passes away. What can we do to help students cope with that? 'Cause that's gotta be a tough one, when you're... Even though you're not ultimately responsible as the student, you're still there.

And you may be spending a lot of time with them, more than perhaps their attending physician or resident might be able to, because, you know, you have the time available. How do we help 'em through that?

Dr. Stacey Jolly:

Yeah. I think this is something that many of our hospital colleagues, our, uh, bioethicists, our palliative medicine physicians and others have helped taken to the forefront around that we, you know, again, we're all human beings, we s- feel that sense of loss, and how can we support one another?

One of the practices that I enjoyed seeing when I did more inpatient medicine and would also partake in, in terms of that reflection, is a pause, you know, allowing people to acknowledge that, you know, something has happened. Perhaps it's a passing, perhaps it's an unexpected outcome, as you alluded to. And then, that debrief, that allowing for all members of the team to have a debrief and share if they felt comfortable in group, or maybe it's individual as well.

I think one of the things that I've found joy in, being a primary care physician and following people for a long period of time, that making incredible connections with them and their families. And when a patient has passed, then I like to get a card and, and write a little something. Oftentimes, they are well-known to my nurses and medical assistants as well, and so we will kinda share the card and write little notes and mail it to the family.

Dr. Tony Tizzano:

Boy, that means so much. I, I know that means a lot.

So, we talk about all these various pressures, and we talk about burnout. Where does burnout come into the mental wellness arena, and, and what steps do we take to combat this problem, for probably all career choices?

Dr. Stacey Jolly:

Yes. So, burnout certainly comes in as a thing that we know physicians will have. We know it's at extraordinary rates. The way it gets defined is thinking where we are maybe feeling less excitement about our work, we might be feeling much more emotionally exhausted, a little more irritable, as well as that kind of depersonalization, where s- perhaps we maybe always enjoy taking care of a patient, we're feeling like it's a little bit more difficult.

So, that may then affect how we feel, how we act with our families. That may affect how we are thinking about the care for our patients, and just not being at the top of our game. On the flip side, I wish I had an answer, (laughs) an antidote to burnout. I think for each individual, it's gonna be different.

The other part that I really have appreciated is, as it's become more aware, and I think aware in the general public, is to your point, that it's not probably unique to medicine, but maybe to a lot of our excessive work in general and many high professions, that it's not just an individual thing, that there are definitely systems, factors, that could and should help us to try and mitigate the burnout.

Dr. Tony Tizzano:

Yeah. I think that latter comment is so key. You had pointed me in the direction of some comments made by the American Medical Association. The vice president, professional satisfaction, said, "While burnout manifests in individuals, it originates in the systems. Burnout is not the result of a deficiency in resiliency among physicians. Rather, it is due to the system in which physicians work." How are we doing?

Dr. Stacey Jolly:

I will say that Cleveland Clinic is working on it, and I think particularly in primary care, I'm in the Primary Care Institute; we have, you know, some of the highest levels of burnout. But also, I think, some of the highest levels of individuals that are highly resistant- resilient, highly compassionate, really there for wanting to take care of people and building those relationships, that we're also creative and coming up with ways to- how to help one another, suggesting systems changes, particularly around in-basket, in-basket burden, piloting AI, giving each other a break on vacation, you know?

We piloted, and now it's pretty much standard of care, if I go on vacation, somebody else is attached to my in-basket and they're taking care of the work for my patients. My patients know that we work in a group practice; when I come back, I can kinda jump right back in, I don't have another extra day of work to do before coming back.

Dr. Tony Tizzano:

Where you're coming in the night before. That is huge. Our group, I just went back into clinical practice, I needed some help. And they do that for each other, which we didn't used to do.

And now, I've learned how to do it for them as well. And you know, it feels good. When you've got a spare moment, looking at your colleagues' in-basket and knocking out some of the ones that are least straightforward, for me, because they're doing more complicated things, and I... It really feels good. It makes you feel good, and it makes them feel good as well.

Dr. Stacey Jolly:

Absolutely.

Dr. Tony Tizzano:

Oh, and I have to mention. I know, just even recently I looked at something on the Cleveland Clinic page that talked about wanting to get feedback. The CEO, Dr. Mihaljevic, is reaching out, wants to hear feedback, ideas, around this sort of thing that make a difference. And hearing that from your CEO, and from our chief of staff, we've certainly heard it in medical staff meetings: "Take your vacations. Do this." When it comes from those levels, I think it makes a difference to all of us and makes us feel like, "Oh, it's okay."

The other thing is related, perhaps, to burnout, is this idea of imposter phenomenon, that these racehorse students have very high expectations. And you get here and you're now in an environment where everyone has those sorts of expectations, and you have the sense that, "Maybe I'm not good enough," or, "How did I get here?" You know, "Did someone miss the boat, w- (laughs) when I went through the interview process and I slipped in?" Do you see that? Do you see that as an issue?

Dr. Stacey Jolly:

I think that the imposter syndrome is something that is a, a feeling, or will creep up on probably all of us at some point in our lives, in our careers. I think where it comes to is, how much does it stay, and how much does it then really start to impact upon us and, and where we're going, versus also, perhaps, realizing that some of it is normal. Each of us has high expectations for ourselves, but perhaps maybe don't understand that we won't know it all, we can't know it all and that's okay.

I will say that I am incredibly impressed and appreciative and learn so much from our students and all that they have achieved, and all that they do while they're here with us, that if anybody's having imposter syndrome at times, it's me, going, "Hmm. Could I have gotten into (laughs) medical school?" Because I can tell you (laughs), it is just phenomenal what they're doing.

Dr. Tony Tizzano:

Yeah. I would second that. And I have that same feeling working with students. There's no two ways about it.

You know, when you were priming me for these conversations, one of the things that you had said that really resonated with me is that failure is an integral part of the learning. You know, if you're not pushing the limits and never failing, like, what are we actually doing? And concealed failure welcomes shame and hopelessness. To speak about it and share it with others builds coping skills. That is so important.

And we're always so hesitant. But if we can feel psychologically safe, that we can have these conversations, and that's where I think the close relationships between faculty and students at Lerner is a real plus, because I'm not so sure I had that.

Dr. Stacey Jolly:

Absolutely.

Dr. Tony Tizzano:

And perhaps it was actually the opposite. So Stacey, what's on the horizon? Given the Dr. Stoller magic wand, if you could create something, what would it be?

Dr. Stacey Jolly:

I think that there's a definite movement around the US to have mental health be, again, an integral part of health. And one of the things that I've been impressed with, uh, students, residents and faculty, is around the taking that to the next level of de-stigmatizing health, of which mental health is part of, in the licensing processor- and the credentialing process, to not have that be a barrier to perhaps a physician or a student or resident seeking the care they need.

Dr. Tony Tizzano:

Boy, I sure hope that's the case. So, again, you know so much about these areas. It's so important. I perhaps missed something that you would like our audience to know; is there anything that you would like to add?

Dr. Stacey Jolly:

Just continue to do that self-grounding, that refocusing, that wellness sharing amongst each other. That is what's gonna be important for our mental health, and I definitely appreciate all that I learn from students.

Dr. Tony Tizzano:

Yeah, ditto. Well, Stacey, thank you so much.

Dr. Stacey Jolly:

Thank you, Tony.

Dr. Tony Tizzano:

This has been an enlightening, thought-provoking episode of MedEd Thread. To our listeners, thank you very much for joining and we look forward to seeing you on our next podcast. Have a wonderful day.

Dr. James K. Stoller

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, SoundCloud, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread and please join us again soon.