Opening the Gate for Student Mental Health Needs

From the September 15, 2023 issue of the Transformational Times

Opening the Gate for Student Mental Health Needs

Kevin Bozymski, PharmD, BCPS, BCPP

Dr. Bozymski, a board-certified psychiatric pharmacist, discusses the mental health stressors faced by health care students, and shares his journey of training future pharmacists to become mental health “gatekeepers” for their peers (and themselves) …

Expanding beyond algorithms

When people ask me what I do for a living, it’s not as straightforward as saying teacher or pharmacist—or even the phrase, mental health pharmacist. It usually involves a back-and-forth dialogue, with me imperfectly describing my winding path as the audience inquires, prompts and clarifies. Upon reflection, the emphasis on one-on-one connections is what got me on my path. 

While healthcare practitioners and researchers value the scientific method (me included), I’ve often found algorithms too restrictive. That’s why psychiatry resonated with me as a student pharmacist, where the right pharmacologic choice cannot be made without considering an individual’s preferences, values, and environment.

It’s also why academia called to me as a resident pharmacist, where a “one-size- fits-all” teaching approach does not meet every learner’s preference, needs, and background. 

Unfortunately, it’s easy to fall into the algorithm trap as a teacher when discussing student mental health, especially when we aren’t taking care of our own mental health. We look back in our own life to how we handled stress as a learner, assuming our experience will translate well to another’s. We worry about finding time to dialogue, looking toward rating scales used in clinic appointments as a model for triaging student concerns. This solutions-first mindset shows in our health care learners, as a recent scoping review of medical student literature found fears of decreased career opportunities, nonconfidentiality and personal stigma as the top individual barriers to care.

Before walking in someone else’s shoes, it’s worth asking about their journey so far and how they find themselves now. 

From stress to burnout to on fire 

As the psychiatric pharmacist on faculty within Medical College of Wisconsin School of Pharmacy, I am invited to give perspective about student mental health on many interdisciplinary councils, committees and workgroups. The most impactful discussions, though, come in one-on-one discussions with my student pharmacist mentees. 

These quarterly meetings have a brief agenda,  and are open-ended for me to actively listen and ask: How is your quarterly session going? What has been a surprise since we last spoke? Where do you want your shoes to take you, and how can I help them do so?

It's no secret that the MCW PharmD curriculum is stressful, with students completing four years of traditional coursework in just three. And while it’s unclear to what extent stress correlates to burnout and mental health concerns, published U.S. student pharmacist surveys identify positive response rates of 19% to 40% for clinical depression (via PHQ-9) and 21% to 41% for clinical anxiety (via GAD-7). (see references 2-5)

Furthermore, the American Academy of Colleges of Pharmacy has released a statement encouraging pharmacy schools to proactively promote overall wellness and stress management techniques.

There’s no easy algorithm to determine who develops clinically significant concerns, but it is near-impossible to do so unless a student is connected enough to their academic community to be asked.

Who’s at the gate for mental health care?

Access and stigma are two driving barriers in psychiatry, and certainly student mental health is no exception. Therefore, gatekeeper training—programs teaching how to identify warning signs of mental crises and connect people to needed services—have been spreading across the globe. Such programs are not just for healthcare practitioners, but for anyone with a desire to improve mental health in their area. Thanks to funding from the Kern Institute, the MCW Pharmacy School, and Advancing a Healthier Wisconsin endowment, I’ve had the honor as a certified Mental Health First Aid instructor of teaching 60 first-year PharmD students (so far) how to open the gate for their peers, their communities, and themselves.

While students over the years have commented on its benefits, one anonymous comment from a course evaluation struck me the most:

“These skills were amazing to learn. It has helped with not only my family and friends but also has been used in practice with my peers. To have the ability to learn about what people go through and how to be able to approach and talk to people about a mental health crisis is something everyone should learn.”

If we cannot break down every systematic gate standing between an individual and mental health resources, we can at least ensure the keepers know how to help passersby. And even if my student pharmacist self from over a decade ago does not fully understand the unique stressors of this generation, I can at least dedicate myself to learning from and conversing with them in a non-algorithmic way - using the information gained to better appreciate, reassure, and connect.

After all, with mental health, an imperfect response is better than no response at all.

Take action:

Interested in becoming trained as a MHFA instructor (or just completing MHFA certification yourself)? Please contact Dr. Kevin Bozymski or Dr. Himanshu Agrawal for more information. 

For further reading:

1. Berliant M et al. Barriers faced by medical students in seeking mental healthcare: a scoping review. MedEdPublish (2016). 2022; 12:70.

2. Koutsimani P et al. The relationship between burnout, depression, and anxiety: a systematic review and meta-analysis. Front Psychol. 2019; 10:284.

3. Fischbein R et al. Pharmacy and medical students’ mental health symptoms, experiences, attitudes, and help-seeking behaviors. Am J Pharm Educ. 2019;83(10):7558.

4. DeHart RM et al. Prevalence of depression and anxiety among student pharmacists. Int J Med Pharm. 2020;8(2):1-8.

5. Shangraw AM et al. Prevalence of anxiety and depressive symptoms among pharmacy students. Am J Pharm Educ. 2021;85(2):8166.

6. American Colleges of Clinical Pharmacy. AACP Statement on Commitment to Clinician Well-Being and Resilience. Accessed https://www.aacp.org/article/commitment-clinician-well-being-and-resilience on September 5, 2023.

7. Suicide Prevention Resource Center. Choosing A Suicide Prevention Gatekeeper Training Program: A Comparison Table. Accessed https://sprc.org/wp-content/uploads/2022/12/GatekeeperMatrix6-21-18_0.pdf on September 5, 2023.

8. National Council for Mental Wellbeing. About MHFA: What is Mental Health First Aid? Accessed https://www.mentalhealthfirstaid.org/about on September 5, 2023.

Dr. Kevin Bozymski, PharmD, is an Assistant Professor with appointments in the MCW Pharmacy School Department of Clinical Sciences and the School of Medicine Department of Psychiatry & Behavioral Medicine. He is a certified Mental Health First Aid instructor, providing training through an Advancing a Healthier Wisconsin endowment. He also provides clinical services at both the MCW Tosa Health Center and Froedtert Hospital Complex Intervention Unit.

Professionalism Lapses in GME: Oops, Can’t, and Won’t

From the August 4, 2023 issue of the Transformational Times

Professionalism Lapses in Graduate Medical Education: Oops, Can’t, and Won’t 

Chad Carlson, MD, FAAN 

Program Director Carlson shares takeaways about remediation in residency training: Intent is important. In broad terms, the categories of “oops,” “can’t,” and “won’t,” divide learners into those who have a lapse in behavior they know and understand, those who currently lack or cannot access a set of skills or tools, and those who choose not to do something, despite having access to and knowledge of the appropriate path forward... 

Anyone involved in medical education, regardless of the level of learners, can relate to issues of professionalism in situations needing to be addressed.  If you are like me, this is followed by a pit in the stomach and concerns about the best next steps: Can I fix this? How do I help? Is this even a “fixable” problem?

These thoughts are often compounded by a feeling of relative isolation; while we all help learners address these issues, we often feel like we are doing so in a relative vacuum. Often, our own experiences and feelings complicate remediation and lead to the belief that these sorts of problems cannot be fixed.  

The concerns and limitations program directors face in addressing issues of professionalism prompted us to focus on this topic at the Medical College of Wisconsin Affiliated Hospitals (MCWAH) Program Directors retreat. A presentation and discussion session led by invited speakers Betsy Williams, PhD, MPH, FSACME (Clinical Director of the Professional Renewal Center) and Karen Warburton, MD, FASN, FACP (Associate Professor of Medicine and Director of GME Advancement and Clinician Wellness Program at the University of Virginia Health System) outlined several key features and highlighted some common themes. The retreat also focused on the potentially daunting topic of remediation of professionalism issues in graduate medical education through interactive and case-based talks. 

Key takeaway: Professionalism issues are not inherently irremediable.

The process of remediation itself can be broken down into: Identification, Assessment, Active Coaching, and Ongoing Evaluation

Identification has already occurred if you have a pit in your stomach about what comes next with a resident. But most medical educators can recall situations where, if they had better documentation or more feedback or input, they would have better understood both the scope and nature of issues with a learner. The earlier that identification occurs, the less likely it will negatively impact the timing of training for a learner. Dr. Williams lamented the frequent occurrence of hearing about a struggling learner in April or May of their final year of training when there is little time to implement an effective coaching plan.  

Within the realm of assessment, intent is important. The difference between an “oops,” “can’t,” and “won’t,” is an important distinction.  

In broad terms, these categories divide learners into those who have a lapse in behavior they know and understand, those who currently lack or cannot access a set of skills or tools, and those who choose not to do something, despite having access to and knowledge of the appropriate path forward. 

A comprehensive assessment also includes looking for potential mental health contributors. Evidence supports that about a third of struggling learners have an underlying mental health concern such as anxiety, depression, and cognitive or learning disorders. It is no surprise these underlying conditions often contribute to a “can’t.” 

The results of the assessment should drive the approach to coaching (or discipline). 

While a program or course director’s approach is often to take the lead on remediation or other issues to spare busy faculty colleagues and team members, in these settings, the program director may not be the best person to do the coaching. 

Involve someone not part of the Clinical Competency Committee (or recuse that person from discussions in the Clinical Competency Committee if this is unavoidable).  

Planning the intervention

In planning the type of intervention, the concept of intent is important. 

• Support with little formal coaching is likely adequate for an “oops." 
• Formal coaching is typically necessary for a “can’t.” 
• In the case of a “won’t,” rapid escalation beyond coaching to formal disciplinary measures may be necessary. 

In thinking about a “can’t,” we need to consider both the realm of teaching about professional norms and recognize when there are barriers (personal or systemic) to following them. 

As educational leaders, we need to look at individual professionalism violations and consider whether the issues represent a broader systemic issue or are related to individual factors alone. 

Ongoing systemic monitoring and intervention is critical 

Importantly, whatever the remediation methods, one cannot think of this as a single episode or course of treatment; a systemic approach for regular monitoring and evaluation must be in place to identify potential lapses in professionalism, prior to them rising to the level of a problem.   

The systematic approach to thinking about issues of professionalism was a welcome discussion during the retreat. But perhaps more important was the recognition that these are challenging, but not insurmountable problems with which we, as educators, all struggle. 

The desire to help our students, residents, and fellows succeed is--and should be--strong. But the frustration and disappointment when those expectations are not met is very real for all involved. This can be particularly true in graduate medical education, where we work closely with small classes of trainees, typically for multiple years. These personal bonds can be both a strength and a liability when professionalism is challenged.   

Our community of educators is our greatest resource

Our community of educators committed to improving learner well-being is, undoubtedly, our greatest resource; learners struggling with professionalism issues are not unique to any one campus, course, or program. We can, and should, make use of the depth of expertise across the institution instead of staying in silos in our individual departments and programs.   

Drs. Warburton and Williams made it clear through their experience and work on this topic that learners who encounter these issues can, in most cases, be helped and put back on a path to success. 

Proper diagnosis and management, just like in patient care, is the key to success. 

Chad Carlson, MD, FAAN, is a Professor in the Department of Neurology at Medical College of Wisconsin and serves as the Program Director for the Adult Neurology Residency, Associate Program Director for the Clinical Neurophysiology and Epilepsy Fellowships, and Vice Chair of Education.  

Whoosh! Goes My Heart

From the December 21, 2023 issue of the Transformational Times

Whoosh! Goes My Heart  

Himanshu ‘Tinu’ Agrawal, MD, DF-APA 

Dr. Agrwawal shared this story from his childhood in the holiday issue of the Transformational Times. You can read other stories by Transformational Times team members, Kathlyn Fletcher, Bruce Campbell, and Karen Herzog.  

From ages six until nine, I lived in London. My mother worked in the Indian embassy there, and one day she brought home a chocolate-filled Santa, sitting on a plastic sleigh. 

“Oh my God!” I squealed. ”Is it from Santa Claus?” I couldn’t believe it; it was finally happening. After hearing so much about the big guy from kids at school, I was finally getting a gift from him!  

"No, it’s from Mrs. Malhotra, she works on the desk next to me, you’ve met her,” my mother responded. 

“No! It’s from Santa Claus. You’re teasing me aren’t you, Mom?” I smiled. I could see through her attempts to trick me. 

“I told you. It’s from Mrs. Malhotra,” she repeated. 

“No! It’s from Santa!” I insisted. 

“No! It’s from Mrs. Malhotra!” she snapped back. My mom wanted to make sure poor Mrs. Malhotra received the credit she deserved. 

“You’re lying, Mom! Why are you lying?!” I yelled. I wanted so much to believe Santa had finally read my letters. 

A slap on my face ended any further arguments, as it usually did back in those days.  

Whoosh! went my heart.  

A couple of years later, we returned to our apartment in India, where Santa did not make pit stops. 

Now, four decades later, I find myself back in the land of Santa.  

Now, my son is 8 years old, and he writes letters to Santa every year. 

Now, every Christmas Eve, we tuck in, and I read him ‘Twas the Night Before Christmas by Clement C. Moore. 

Whoosh! goes my heart. 

Whoosh! Whoosh! goes Krishna’s heart. 

Whoosh! is the sound that magic makes. 

And you can’t snuff it out with a slap on the face. 

Himanshu Agrawal, MD is an Associate Professor in the Department of Psychiatry and Behavioral Medicine at MCW. He is one of the co-Editors-in-Chief of the Transformational Times. 

The Gift of Presence

 From the December 20, 2023 issue of the Transformational Times

The Gift of Presence  

Karen Herzog

“Greetings from Milwaukee! It’s the season of miracles, and we have a little one named Kelsey Marie. She views the world through big, blue eyes, and has an Eveready smile. Seven months into her life, we’re still in awe of everything she does. All Kelsey wants for Christmas is to crawl, and we believe she’ll get her wish any day now…” 

– Our Family’s 1995 Christmas letter 

Despite the magical lead-up to our firstborn daughter’s first Christmas, a painful ear infection and high fever made her inconsolable, and left us at wit’s end, on Christmas Eve. We finally did what many parents do when physician offices are closed and there’s no urgent care: We bundled her up in the wee hours of Christmas morning and drove her to the ER of the small hospital in my hometown, where we were visiting my parents. 

Kelsey was the only patient at that hour, and the ER was peaceful before her crying pierced the silence. Thankfully, relief was on the way when a young resident appeared in the examining room. The amoxicillin he prescribed (with a dose of reassurance for her anxious, sleep-deprived parents) was a small Christmas miracle. 

I wish the bleary-eyed resident who crawled out of an on-call room bed at 4 a.m., because of a crying child’s non-emergency ear infection could have seen that tiny patient a few hours later, once the amoxicillin kicked in. There’s nothing sweeter than a sweet baby, cheeks still flushed from fever, staring in awe at the twinkling lights on her grandparents’ Christmas tree, her first Christmas morning. 

Of course, first holidays of life often stand in contrast to last holidays of life. I can’t think about one without the other, as my mom died four days before Christmas four years ago. She was 90. 

The awe I felt at the end of my mom’s life was for the healthcare workers. Their presence was as warm as the Christmas lights that filled her room in a skilled care facility. 

This holiday season, my wish for healthcare workers who make tremendous sacrifices to “be there” for patients in hospitals and skilled care centers is to know their presence is a gift that will hold a special place in the holiday memories of those they touch. 

Karen Herzog is the copy editor of the Transformational Times. In a previous life, she was an education reporter at the Milwaukee Journal-Sentinel.