What is it like to be suicidal?

 From the 5/14/2021 newsletter

Perspective/Opinion

 

 

What is it like to be suicidal?  

 

 

By an anonymous medical student

 

 

A medical student shares their personal journey with suicidal thoughts …

 

 

To me, being suicidal is a physical place in my mind. I’ve boarded the wrong train, or maybe it’s the right train going in the wrong direction. It’s a vast transit system: all the stops are underground so I can’t see where the train is going, and the doors are locked so I can’t get off. In addition, my vision is too blurry to read the map posted on the door.  

 

As I ride to The Wrong Place, I only know that’s the destination if I pay close attention to myself. There are telltale signs: my hobbies become boring or arduous, my favorite foods taste like saliva, and I avoid eye contact with the mirror. 

 

As another stop goes by, my arms and ankles become heavy—too heavy to lift. Taking a shower sounds like a luxury that I simply do not deserve. I do not have the energy to hurt myself at this point... until the train reaches its next stop. 

 

This next stop is at the most dangerous neighborhood I can imagine. Here, I have the will to get out of bed, say my goodbyes, and seek out my demise. At this point, one of two things will happen. I either tell a friend my plans (you know, so they aren’t surprised; it’s common courtesy really), or I call my mom. Every single time so far, someone, somehow, has listened to my spiel about why I should leave this world. The person I am speaking to invariably disagrees with me, and I can feel the train slowing down. Slowly, I can sense how absurd the idea sounds as I hear my own voice speak this strange manifesto. 

As I am connecting with this other human, their logic and compassion towards me overpower the force of self-destruction. The train finally stops, the doors unlock, and my vision clears. I choose to walk onto the platform and take the stairs back up to ground level, where the rest of my life is waiting. I am existentially exhausted, having both won and lost an argument that put my life at stake. 

 

Personally, I find the feelings of suicidality are always temporary. They fade away, and I am left to live with myself, knowing that some part of me tried to delete all parts of me. But I am not afraid for the next time I head to The Wrong Place. At this point, I know all the stops and the symptoms that accompany them. I can usually get off the train before I end up at the I-don’t-deserve-to-shower part of the journey. I can’t exactly put that on my resume but, hey, I can still be proud of myself.  

 

It's a skill in self-awareness to know when you’re in trouble and when to get help. When I am faced with an internal struggle, seeking out a third party gives me a perspective I can’t generate on my own. There are wonderfully compassionate people—counselors, therapists—who have dedicated their careers to helping people get un-stuck when they feel stuck. They have given me tools that I can always carry with me; their expertise has been distilled to a few tips and tricks that work for me to navigate stressful situations and life changes. I encourage you to seek inside yourself the will to live, the love of those around you, and most daringly, the point at which to be vulnerable and seek help; for me, it was the most difficult and most rewarding thing I have ever learned. 

 

 

 

Author’s note: After much deliberation, and due to the current climate of resident medical education, this piece will be published anonymously. Special thanks to my campus colleagues for being such an open and supportive community. 

Stigma and Vulnerability: Our Experiences with Struggling in Silence

 From the 5/14/2021 newsletter

Perspective/Opinion

 

Stigma and Vulnerability: Our Experiences with Struggling in Silence

 

Sofie Kjellesvig and Sadie Jackson - MCW-Central Wisconsin medical students

Medical students are high achievers who are often adept at hiding their shortcomings and moments of vulnerability.  We, the authors, hear our peers admitting to some of their struggles: being behind on lectures or not feeling ready for an exam, for example, but these statements are almost always qualified by, “but it’s fine, I’ll be okay,” or something similarly diminishing.  In fact, there are times when we have felt unsure about whether things will truly be okay. We do not openly share these feelings, no matter how many times we’ve considered doing so.  Perhaps this is out of fear of what others may think, a belief that we are suffering alone, and the stigma that surrounds academic performance and mental health. 

We’d like to break the silence by illustrating some of the ways each of us struggled during our first year of medical school:

 

Academic challenges can break down students’ confidence and isolate them as soon as classes start. For anyone who hasn’t had a cadaver lab before, anatomy in medical school can be a rude awakening. Among the class there are seasoned veterans with extensive dissection experience, some students who have taken anatomy and held a scalpel a few times, and then students like me who had never heard of the pisiform bone, let alone picked up a probe. Anatomy scared me and I didn’t feel like I belonged in lab. With time and practice I improved, but I still found it very difficult. No matter how far I progressed, I couldn’t shake the feeling that I was not good enough and was falling behind my peers. Ultimately, I found myself asking if I was cut out to be a doctor and struggled with worsening anxiety about this. I was uncomfortable admitting how much those feelings pained me to classmates who appeared to breeze through the course.

 

Why is this so challenging? Our grading for these courses is pass/fail, so why do we compare ourselves to peers and consider ourselves a failure if we don’t measure up? What I found out when I did make myself a little vulnerable was that friends who were excellent anatomists still had their own issues at times: they had these feelings about a different course, or they were having trouble with school/life balance, or they were just finding life in general to be a lot harder during pandemic times.

 

Other challenges, especially those related to mental illness, are rarely shared by classmates. This is not because medical students suffer from mental illness less than other groups.  Mental health and suicidal ideation, understandably, are heavy topics for most people.  Even though some of us may feel comfortable sharing our experiences with those who ask, we encounter barriers that prevent us from reaching out on our own accord.  I find myself asking: when it is a good time to bring up such a topic? Is it fair to place such a burden on others who did not ask for it? Will they view me differently if I share my insecurities?  My anxiety convinces me that sharing will make others uncomfortable, beginning the vicious cycle of negative self-talk that I try so hard to avoid.  I then feel that it will be easier for all if I deal with my doubts alone.  This option becomes more appealing to me to protect myself from the guilt, discomfort, or judgment I fear may come with allowing myself to be vulnerable. When I have been brave and shared, however, I’ve found that I am not alone and that others do care and sincerely want to help. I doubt I am the first person to wind up trapped in the self-imposed isolation these fears can create.

 

Vulnerability is an important skill that, like other skills, takes time and practice to learn. Whether you’re struggling with biochemistry concepts, having difficulty managing depression, or possibly grappling with suicidal ideation, remember that you are not alone.  Students in medical education are held to a high standard and are told to behave like future healthcare professionals. Unfortunately, the very individuals we are meant to model face significant stigma and barriers to admitting when they need help, so it’s no surprise that we find it difficult to stray from these behaviors. 

By sharing our experiences here, we hope to help students realize that they are not alone and that being vulnerable is not a weakness, but a way to reduce the stigma and isolation which many of us experience.

 

Sofie Kjellesvig and Sadie Jackson are medical students at MCW-Central Wisconsin. Sofie is an M1 at MCW-CW who is interested in internal medicine. She is from Eau Claire, WI and graduated with a degree in biomedical engineering from the University of Minnesota prior to coming to MCW. Sadie is an M1 at MCW-CW who is interested in family medicine. She is from Stoughton, WI and graduated from Kalamazoo College with a biology major and studio art minor.  

Minding our Mental Health

 From the 5/14/2021 newsletter

 

Perspective/Opinion

 

Minding our Mental Health

 

Toni Gray - Office of Diversity and Inclusion

 

Ms. Gray writes about her family’s experiences and how unconscious bias disproportionally affects communities of color …

 

I was nineteen when I got the call. My mom was in the hospital. She had swallowed several pills. She had attempted suicide. The emotions that filled my body included anger, sadness, shame, and back to anger. My mom, a mother of seven, felt that the best thing she could do to solve her anguish, her sadness, was to take her own life and leave the lives that she had help create; searching for answers and never getting them.

Fortunately, my mom survived, but she would continue to deal with depression and anxiety. It is something that runs in our family, and I would soon lose two cousins at early ages to suicide.

As I reflect on why I wanted to write about this painful subject, it was clear that my personal experience was important to me. One of my favorite quotes is: “Make your mess your message.” Isn't it true how so many of us suffer in silence because we are ashamed of the personal struggles that we face, the trauma that we hold, and the doubts that we cater to? They hold us in a guilty place where we do not often know who we can turn to and trust with our deepest, painful secrets.

However, mental health is becoming less of a stigma and I am so grateful for that. We are opening up the door for conversation and connection which allows compassion to reign. But we dare remind ourselves that part of the mental health stigma depends on the color of your skin and your culture.

In the African American/Black community, there is a strong spiritual basis that we hold to our hearts that is handed down in tradition by our great grandmothers and grandfathers, and our ancestors. That is the idea that a higher power can heal all our illnesses. And that if we have depression or anxiety, we are not relying on the higher power enough which compounds the feelings of guilt that we may already be holding. Our faith is called into question. This stigma has plagued the African American/Black community for many decades. Besides that, we still have the effects of systemic racism where African American/Blacks were denied access to health care and now even in the 21st century health care still remains an access and economic issue plagued with unconscious biases.

When you are trying to open up your heart with innermost thoughts, you want someone that you can trust and someone who may relate to you. Compounded by the economic restraints and access to therapist is that often you cannot find a therapist that looks like you if you are a person of color. They say representation matters. I second that and elevate that it is imperative. People feel connected to people who look like them in a society that villainizes you for looking a certain way. We need to find people who can relate to the unique societal struggles that people of color face.

As an institution, I believe we are truly committed to creating equity in healthcare. We are committed to building awareness with intentionality around intersectionalities that people come in with and finding ways to address unconscious biases that impact health care outcomes for people of color. That includes the mental strain of poverty, police brutality and profiling, the killing of Black and Brown bodies by police officers, on top of the ongoing effects of this pandemic. We have much work to do in the mental health space, but I am grateful that we are now understanding that our mental health matters just like any other health concerns we may have.

As I reflect on my mom’s journey of resilience, I am comforted by her story. She realized the need to see a therapist to get the tools she needed to deal with her depression and anxiety. Hearing stories like this makes us feel not so alone in our pain. We are human; we bend but we do not have to break. However, we need the resources accompanied by compassion so that we can stand up straight again and embrace a full life we all deserve to live.

 

Toni Gray serves as the Learning and Growth Program Coordinator in the Office of Diversity and Inclusion at the Medical College of Wisconsin. She’s been with MCW for 10 years. She oversees, leads, and creates learning and growth experiences in the equity, diversity, and inclusion space.

 

 

Why Suicide Prevention, Kerri?

 From the 5/14/2021 newsletter

Perspective/Opinion

 

Why Suicide Prevention, Kerri?

 

Kerri Corcoran writes about why she has found a calling working is suicide prevention and provides resources for those who are in crisis …

 

Hello, I’m Kerri, the Student Behavioral Health and Resource Navigator in the MCW Office of Student Services. I am active in the MCW Suicide Prevention Council and in the implementation of a pilot suicide prevention program at the Central Wisconsin Campus.

I have been reflecting on the idea of my “why” and, honestly, feeling a bit…underwhelmed. As a mental health professional, one might assume there is some existential reason behind my career choice and dedicated focus on promoting wellness. There must have been some major life event which led to this greater purpose of supporting those who find themselves feeling hopeless and in crisis. The truth is that I have been very fortunate to not have had a significant personal experience with suicide. As a licensed clinician working in community mental health over the past eight years, I have had experiences with assisting those in crisis and having clients die by suicide. Even when taking these difficult experiences into consideration, I found myself questioning my own ability to claim some part of this initiative. I know there are individuals serving alongside me in this council who have been through some of the biggest challenges this world has to offer. Is it possible to have Imposter Syndrome as a member of a council? Apparently so.

And then, it dawned on me. Maybe, this is the point? This is the purpose of developing a program which trains as many individuals at MCW as possible in heightening comfort around discussing suicide, in training student peer supports, and making sure everyone is aware of the mental health resources available. Suicide prevention is not the job of just those who struggle with mental health, or who have lost a loved one to suicide, or who have struggled with suicidal ideation in the past. Suicide prevention is the responsibility of everyone.

Everyone at MCW needs to be a piece of preventing suicide and showing those within our community that we care; really care. Common humanity is my “why.” Knowing that life is truly worth living, unconditionally, is my “why.” My love for my community is my “why.” 

And I think that might just be enough.

 

If you or someone you know is struggling, please reach out! See the linked decision trees to learn more about the available resources at your campus.

Milwaukee Campus “Assisting Student in Distress or Crisis”

Green Bay “Assisting Student in Distress or Crisis”

Central Wisconsin “Assisting Student in Distress or Crisis”

 

 

Kerri Corcoran is a Licensed Professional Counselor and Clinical Substance Abuse Counselor. As a Behavioral Health and Resource Navigator, she provides students with a safe and secure space to talk about challenges and work closely to implement solutions. She works in the Office of Student Services at MCW.

 

 

How Graduating from an MCW’s Regional Campus Prepared me for Residency

 From the 2/19/2021 newsletter

Perspective/Opinion

How Graduating from an MCW’s Regional Campus Prepared me for Residency

Bradley Zastrow, MD

Dr. Zastrow, a current resident in MCW’s psychiatry residency program explains how attending medical school at the MCW-Green Bay campus provided him with several unique experiences that better prepared him for his journey …

Prior to attending medical school at MCW – Green Bay, I lived in Milwaukee for six years. While applying to medical schools, I knew I wanted to work with underserved populations outside of the relatively resource-rich city during medical school. Access to mental health treatment in rural Wisconsin is currently one of the most pressing issues facing our state. My experience training in a rural location was the first necessary step in preparing to help try to remedy this issue.

At its core, medical school calls on us to adapt to learn and work in a variety of settings. The most obvious example is rotating through different specialties. When primarily training at an academic center, students are typically restricted to rotation sites within a short drive of the main hospital. By completing medical school at a rural campus, however, I was able to rotate within a variety of hospital systems throughout northeastern Wisconsin. Family medicine in Oconto Falls, inpatient neurology in Appleton, and acute care surgery in Door County were just a few. What solidified my pursuit of psychiatry was the opportunity to rotate at the Wisconsin Resource Center (WRC) in Oshkosh, a joint effort between the Department of Health Services and the Department of Corrections, that serves the state prison population.  Patients in this setting require specialized mental health services. Without the unique access provided by a rural campus, the opportunity for medical students to learn in this innovative setting would not be possible.

 The expanded set of rotation sites at MCW – Green Bay afforded me the chance to work with several underserved populations. From members of the Oneida tribe to veterans in northern Michigan making their way to Green Bay’s VA outpatient clinic, I saw firsthand the healthcare disparities facing those who live outside of an urban or suburban setting. For example, where I completed my outpatient pediatrics rotation in Sturgeon Bay, the county lacked any formal child psychiatry services. As a result, this pediatric clinic was responsible for managing all patients with psychiatric conditions in addition to their general medical concerns. To contrast, in Milwaukee, these patients are routinely followed by, or at least have access to, a fellowship-trained child psychiatrist. My preceptor in the Door County clinic dedicated years of medical education credits to learn how to better serve this population. She was one of many physicians I met dedicated to expanding their scope and caring for those who needed it most.

 On Match Day, I was thrilled to learn I would be returning to Milwaukee for residency training. Thus far, I have found that my years of experience at the rural medical school campus complement my residency training in a more urban setting quite nicely.  During medical school I observed the challenges that patients and providers face with a lack of resources; in residency I am seeing programs and interventions that may help address those challenges.  As a psychiatry resident, I see patients at the Milwaukee County Behavioral Health Division with acute mental illness that I rarely encountered in the northern counties. Fortunately, Milwaukee County has developed resources to provide care for these patients who may not otherwise receive it. Within the county hospital, Psychiatric Crisis Services (PCS) provides an emergency department for this population, who may otherwise overwhelm the capabilities of other community emergency departments. The majority of the patients treated through PCS are those who would otherwise be unable to access mental health resources, whether that be due to lack of insurance, inability to navigate the system, or acuity of illness. This is one example of a program uniquely developed to triage and treat a highly underserved population.

 

In returning to Milwaukee, my goal has been to learn as much as I can from public health interventions already in place. I hope to take these and similar initiatives with me and adapt them to more rural populations, where I have seen how great the need is firsthand. Whether expanding access to patients waiting to establish or improving the access for those who already rely on our care, there is much we can take from models and programs in more urban areas like Milwaukee to improve psychiatric care throughout all of Wisconsin.

Bradley Zastrow, MD is a PGY2 resident in the Department of Psychiatry and Behavioral Medicine at MCW. He graduated in 2019 from the MCW-Green Bay campus.  

Growth Mindset and Wellbeing: Getting off of the Roller Coaster

 From the 2/5/2021 newsletter

Perspective

 

Growth Mindset and Wellbeing: Getting off of the Roller Coaster

 

David J. Cipriano, Ph.D.

 

 

Dr. Cipriano shares that developing a “growth mindset” can help learners smooth the bumps along the way, viewing setbacks as opportunities rather than signs of failure …

 

 

“Tell a story about you at your best.”  

 

“Now, tell a story about you at your worst.” 

 

For many, there would be a sharp decline in mood with the second part of this exercise.  But not for people with a growth mindset – for them, both outcomes would be taken in stride.  Both scenarios would be followed with, “What did I learn from this?” and the worst scenario would be followed by, “What will I do differently next time?”  Growth mindset – the belief in our capacity to change and grow our abilities, not just our skills or effort, but our supposedly innate abilities – is a natural self-esteem preserver.

 

 

Growth mindset v. fixed mindset 

 

For folks with a fixed mindset – the opposite of a growth mindset – failure is a sign that they are not up to the task; that it’s time to pack it up and move on to something else.  For these people, failure, as a New York Times article points out, has been transformed from a verb (“I failed”) to a noun (“I am a failure”) and, indeed, an identity.  But there is an almost equally dangerous attribution for success among those with a fixed mindset – that this is proof of my God-given talent and validates my awesomeness!  Here’s the problem in Dr. Carol Dweck’s words: If you’re somebody when you’ve succeeded, what are you when you’re not successful?  

 

Dr. Dweck is the originator of this concept and she’s been at it for a while now.  Back in the 1970s, she began asking third graders why they thought they were struggling in math.  This research, firmly grounded in attribution theory led to the discovery that, depending on your belief about how changeable the outcome is, you would be more likely to persevere – and even come to enjoy – math.  People with a growth mindset attribute their failures mostly to effort, but even when they attribute to ability, they have the belief that this ability can grow.  People with a fixed mindset almost always attribute to ability, and without the added benefit of believing this can change.  So their destiny is set, there’s not much reason to consider how they might develop from this.

 

I’ve been steeped in this stuff nearly as long.  Back in the 1980s, my master’s thesis was based on attribution theory and my doctoral dissertation touched on it, as well.  I never thought I’d use these concepts in psychotherapy, though.  Back then, I was going to be a social psychologist and do research like Dr. Dweck.

 

Fast forward to the new century and I find myself working with medical, pharmacy, and graduate students, a high-octane group, to be sure!  When they’re succeeding, they’re great.  But, when they’ve failed, they don’t feel so great.  For people with a fixed mindset, failure can even lead to depression.  Now, failure stings for all of us, but it doesn’t have to define us. In psychotherapy with these folks, I examine the self-talk occurring, which is almost always self-recrimination and self-demeaning.  When I challenge this, I hear, “Being so hard on myself is how I’ve gotten where I am today!”  To which I say, “Your ‘self’ can only take so much of this beating, before it freezes and stops trying.”  

 

 

The fixed mindset leads to a “roller coaster” of self-esteem

 

Imagine the roller-coaster that their self-esteem is on.  If you have a fixed mindset, you’re more concerned about the judgment of others and more worried about making mistakes.  When you’re succeeding, it is confirmation that you are the superstar you’ve always been told that you are.  Feels great – especially if you don’t have to try – because having to try negates the notion of having a ‘gift.’  But, when you’ve had a setback or a failure, it is confirmation of your worst fears.

 

 

Getting from roller coaster to journey

 

A good therapeutic outcome with people stuck in this cycle is for them to separate out their identity from their performance – to rid them of that notion that “I am my grade,” or “My worth can be measured in my performance.”  

 

Imagine, instead of being stuck on a roller coaster, they are enjoying the journey.  Learning is savored, and not a threat.  Mood is stabilized in the knowledge that mistakes are to be expected and will make one even better.  Self-worth is preserved in the belief that there is value in getting knocked down and getting up and trying again.

 

 

For further reading:

Dweck, C.S. (2016). Mindset:  The New Psychology of Success.  Ballentine Books:  New York.

 

 

 

David J. Cipriano, Ph.D. is an Associate Professor in the MCW Department of Psychiatry and Behavioral Health and Director of Student and Resident Behavioral Health. He is a member of the Community Engagement Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. 

 

Student and Resident Behavioral Health at MCW: A Personal Perspective

From the 9/4/2020 newsletter

Perspective 

 
Student and Resident Behavioral Health at MCW:  A Personal Perspective
 

David Cipriano, PhD – Director of Student and Resident Behavioral Health
 

Dr. Cipriano describes the challenges and rewards of running the Student and Resident Behavioral Health program at MCW. Sign up here to hear him describe the state of our program at an upcoming Kern Connection Café …
 

I became Director of Student and Resident Behavioral Health about four years ago and I’ve always had a knack for being in the right place at the right time.  At that time, the institution as a whole was really beginning to sit up and take notice of learner mental health and well-being in a comprehensive way.  Now, MCW has always taken care of its students and residents with mental health services and available wellness activities.  But, four years ago, MCW tackled the issues in a really planful and big picture way – looking at curriculum, community, and culture.  Since then, I have been riding a wave of enthusiasm and support for this mission – the mission to increase protective factors for our learners – such as access to care and a supportive community – and to decrease risk factors such as stigma and shame and isolation.  I’ve never had a job where I had so many people coming to offer ideas, suggestions, and resources.  

 
 
Results of the 2017 survey
 
Being a data guy, I wanted to “take the pulse” of our students’ behavioral health (if you haven’t been able to tell already, I am using “mental health” and “behavioral health” interchangeably).  In 2017, we conducted our first Mental Health Climate Survey of our medical students (shame on me for not including our graduate students at the time – and I’m a product of graduate school!).  We found high levels of depressive symptoms among our students (higher than the general population, but actually a little lower than estimates of medical students nationally).  We also found a certain number of our students dealing with suicidal thoughts daily or weekly; not out of line with general prevalence numbers, but still frightening.  Almost 20% of our respondents said that they didn’t know if they had a mental health diagnosis, telling me that I needed to work on mental health literacy with this group.  Finally, it turned out that despite high visibility of our services, a large proportion of students who said they needed help did not seek it.  Barriers to getting help included time, cost, and fear of stigma or – worse – negative implications for licensure.  
 
 
What we did next
 
Since then, we’ve worked hard to break down stigma by having faculty and students share stories of their own struggles.  We’ve tried to address the time issue by setting up special student clinics on Thursday afternoons when they have the most flexibility and a resident clinic on Tuesday evenings.  We’re giving students and residents more opportunities to self-assess, trying to increase that self-awareness and literacy piece.  A new online, self-help, cognitive behavioral therapy program called SilverCloud was brought onboard last year – talk about accessibility – it’s available 24/7!  We re-booted our website (www.mcw.edu/thrive) and rolled out support groups that are drop-in and usually include lunch (when we’re all back together!).  And, new this year we have added a student assistance program with a range of services, including an expanded network of providers (of course our learners can still choose our own MCW providers).  And, perhaps most importantly, the school expanded the benefit for students to ten no-cost sessions per academic year.  
 
Personally, I have never felt so energized and rewarded by a position.  Our learners are an at-risk population.  Healthcare trainees, including those in pharmacy, health sciences, and medicine, have higher levels of depression, anxiety and burnout than their age- and education-matched peers.  With an already stressed healthcare workforce, it benefits us all to see that we turn out the next generation of healthcare workers and scientists primed to be resilient and healthy.  
 
We re-did the Mental Health Climate Survey in early 2020 (actually before COVID-19 struck) and I’ll be sharing the results of that at the upcoming Kern Connection Café on September 17^th.  We’ve seen some improvements and some stubborn findings that simply tell us that we have to keep working at it.  I hope you’ll join us to share in the discussion.
 
 
David J. Cipriano, Ph.D. is an Associate Professor in the MCW Department of  Psychiatry and Behavioral Health and Director of Student and Resident Behavioral Health. He is a member of the Community Engagement Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. 

The Moral Imperative to Promote Well-Being in our Learners

 From the 9/3/2020 newsletter

Guest Director’s Corner

The Moral Imperative to Promote Well-Being in our Learners

Cassie Ferguson, MD - Kern Institute Student Pillar Director

Dr. Ferguson shares her work exploring the gaps between what we know about well-being and our ability to reliably intervene with our learners …

Early in my career as a physician, I learned about the intimate connection between our own individual well-being and the quality and safety of care we provide to our patients. My interest developed out of my work in quality improvement and patient safety. Over the past ten years, this has led me to focus on the critical importance of promoting well-being among medical students, trainees, and physicians.

As I've learned about the depths of our un-wellness as a profession, my interests have shifted to advocacy; I now see the promotion of well-being and the support of those of us caring for others in the health profession as a moral issue.

Identifying the scope of the problem

It is unconscionable that nearly 40% of medical students are depressed. It is unfathomable that over 400 physicians die by suicide every year. And it is unjustifiable that we have neither centralized the efforts to improve well-being nor pushed them to the forefront of every leader’s strategic plan. As we attempt to understand and work toward solutions, we must begin by acknowledging that many of the drivers of unwellness exist at organizational and societal levels; when the canary dies in the coal mine, you don’t blame the canary’s lack of resilience.

Organizational and environmental factors – like productivity-driven staffing models, lack of diversity, cultures of blame, and workplace violence – absolutely drive our unwellness. Societal factors like systematic oppression and structural violence may impact us personally, particularly if we are a member of a marginalized community, and bear witness to this type of violence regularly.

When we think of interventions, however, we tend to dichotomize well-being into those aspects driven by systemic factors and those driven by individual factors. In reality, these cannot be separated. They are inextricably linked. What this means is that we cannot expect that the impacts of workload, inequitable compensation, or tolerance of institutional prejudice and microaggression will be mitigated by lunch hour meditation for students or yoga classes for clinicians. By the same token, it is just as important to understand that our individual well-being – our capacity for compassion and empathy for our colleagues, our ability to self-regulate, our recognition of the impact that our presence, our biases, our attitudes have on those around us – collectively contributes to the learning environment and workplace culture and thereby the well-being of the entire institution.

I do not define well-being by the absence of depression or suicidality, but rather by a more holistic vision that assumes that, as physicians and physicians-in-training, we might flourish; a vision that leads to encompassing physical, mental and emotional health, embracing joy, and finding meaning.

Recognizing the gaps in our understanding of wellness

To realize that vision, many have called for to shift the focus from what drives our unwellness to what may help keep us whole. To that end, the National Academy of Medicine (NAM) launched the Action Collaborative on Clinician Well-Being and Resilience in 2017; one of their goals is to “advance evidence- based, multidisciplinary solutions to improve patient care by caring for thecaregiver.” The ACGME has partnered with the AAMC and the NAM to co-chair this action collaborative to help “create a healthier, safer medical community.” Leading researchers in this realm continue to call for more robust research studies designed to evaluate interventions aimed at improving well-being.

Despite these efforts, there are still no multi-center, randomized, placebo- controlled studies that definitively point to interventions that, if implemented, will make us all well. Frankly, I do not believe that even the most perfectly designed study will ever reveal the value of such an intervention. In the studies we have done with medical students at MCW through the Kern Institute, it is quite clear that what works for one student may not work for another. And my three-year experience as the chair of the professional health committee atChildren’s Wisconsin has helped me to understand how local, even systemic, drivers act.

Understanding this, I propose that, in our quest to elucidate effective well- being interventions, we shift from asking, “what works?” to “what works for whom, under what circumstances, and why?”

To this end, our team has shifted to using Design Thinking tools, quality improvement methodology, and profile analysis in this work. Although we can efficiently summarize testing results from students on psychological, behavioral, or social measures into a “mean score,” it is fair to say that the mean often provides very limited information in helping students, because it masks differences that exist in student trajectories. That is, the mean can often hide the trajectories of students who have different patterns, needs, strengths, and weaknesses, hiding heterogeneity by homogenizing everyone to one value. As educators, the differences in trajectories is where our first lever of facilitating change lies.

Expanding the analyses of student wellness diversity

We need to go beyond the mean by focusing on analyses that will allow us to understand groups of students with similar patterns of responses across a variety of important behavioral, cognitive, and social dimensions. This is where analyses like latent profiles analysis (LPA) comes into play. LPA is a statistical analysis that helps researchers identify groups of individuals that have similar and different responses patterns on measures or tests. Combining LPA with trajectory analysis (time series/growth modeling) results in a very powerful way to look at students over time. These types of analyses help uncover sub- groups of students, map their trajectories over their medical school careers, and provide a way to understand what helped students improve, decline, feel joy, or struggle. Supplementing these analyses with student voices through open-ended questions, focus groups, and interviews creates a deeper understanding of our students. This information can help educators design and enhance curricula that support students with various needs, leaving no student behind on either end of the distribution, with a long-term focus on supporting their growth over time.

Ultimately in our well-being work at MCW, the goal is to combine LPA, growth trajectories and qualitative analyses to understand how a number of psychological (e.g., mindfulness), social (e.g., perceived social support) and behavioral measures (e.g., intrinsic/extrinsic motivation) relate to skills fundamental to the practice of medicine: how students’ communicate with patients and colleagues, how they work in teams, and how they navigate the complexities of being present for the suffering of other humans.

Acknowledgement: Thank you to Tavinder Ark, PhD of the Kern Institute for her contributions to this article and for her consistent and innovative work in the study of student well-being.

Cassie Ferguson, MD is an Associate Professor of Pediatrics (Emergency Medicine) at MCW. She leads the MCW M1 and M2 REACH curriculum focused on promoting wellness. She is the director of the Student Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.