Mental Illness and Medical School / Matching - NEJM

[Cura_te_ipsum]

Frush BW. To Those “Out There”. JAMA. 2017;318(12):1107–1108. doi:10.1001/jama.2017.10823

For anyone who has struggled with depression, anxiety, mental illness during medical school and how to present it for Residency Applications

To Those “Out There” | Humanities | JAMA | The JAMA Network

Like many of my fourth-year medical student peers, I find myself grappling with how to craft my residency application personal statement. Many struggle to avoid sounding pretentious while still demonstrating their achievements and qualifications. Some wrestle with how to describe meaningful patient interactions to illustrate what draws them to medicine. Still others find it difficult to articulate concisely why they find a given specialty compelling, or what characteristics they desire in a specific program.


Although these are issues seemingly every residency applicant faces, for students like myself, there is another question that looms larger and potentially entails more substantial ramifications. That is, whether and to what extent one should discuss one’s struggle with mental illness, for those of us who feel these experiences are an important part of our story.


Focus on depression, anxiety, and other forms of mental illness in medicine has intensified over the last decade in conjunction with heightened awareness of the burnout epidemic.1,2 This has fostered an encouraging movement toward destigmatizing these conditions and providing support for those suffering.3 Various measures to address this issue have been taken, but one of the most powerful seems to be those physicians who bravely and poignantly share their own mental illness experiences. These personal stories are immensely powerful, and frequently seem to engender a grateful and positive response from others in the medical community due to the honesty and vulnerability they exhibit. Witnessing this positive reception is especially heartening for those of us who have endured similar difficulties as medical students because they inspire hope that our mental health struggles might prove a source of strength rather than a burden or detriment.


I have certainly found this to be the case with my own experience. As a medical student, I have suffered two significant bouts of depression and anxiety, the second for which I took a brief leave for treatment. The faculty, staff, and students at my institution have been remarkably supportive throughout this process, and I have been delighted to experience firsthand the edifying responses to mental health difficulties that I read about in responses to the stories of others. Moreover, I have been surprised to never encounter a negative reaction to sharing my story, given the stigmatizing view I have heard many in medicine still hold toward mental illness.

Yet in the process of preparing my personal statement for my residency application, I have been disappointed to find that this positive response may not be the case elsewhere. In conversations with mentors about how to craft my statement, many have advised strongly against including this element of my journey, for fear that it could render me a less competitive applicant. None of these mentors have been anything but understanding of my illness, yet they all note that there are those who will view this factor as a decided weakness. When I press further about this to find out who and where these people are, what I hear is always the same frustrating and cryptic response: “Trust me, they are out there.”


Having not personally encountered or spoken with an individual “out there,” who reacts negatively to shared stories of mental illness, I feel compelled to address this audience on behalf of others who struggle with how and to whom to tell their stories. For those “out there,” I would like to offer three real problems with this pervasive stigma as it relates to those applying for residency and in career advancement in medicine more generally.


First, those “out there” contradict and stultify the prevailing message we learn in medical school about mental illness in medicine. For all of the (seemingly unanimous) administration and faculty voices that tell us that we are not alone, that say that mental illness is not something to be ashamed of, that encourage us to seek help and access resources, when we cannot be honest in this most critical juncture of our professional lives about mental illness, these messages amount to little more than lip service. For those “out there” who silently but potently countervail these supportive voices, please know that this sends a confusing message to students who hear one reality spoken but experience another.


Second, those “out there” cause medical students to deprioritize their own health. We are taught to create space for patients with mental illness to feel safe and vulnerable, and that attending to mental illness frankly and openly is a crucial component of overall health. Therefore, when students are tacitly discouraged by those “out there” from extending the same approach to ourselves or our peers in medicine, it follows that we are not pursuing our own health. This dissonance between the health we pursue for our patients and the health we pursue for ourselves indicates either that we hold ourselves to a different understanding of health than those we serve or that our own health must be subordinated to our work as physicians, neither of which is just.


Third, and perhaps most importantly, those “out there” undermine the moral component of medicine that is constitutive of good physicians. Since the time of Hippocrates, physicians have not simply been viewed as technicians or providers; they have been endowed with the task to fulfill their duty with integrity and honesty. If we feel compelled to lie to ourselves, our peers, and those reading our applications, we are setting a dangerous precedent for our future moral work as physicians. Students who feel pressured to present a false image of themselves in order to match at a program that may not be well-suited to accommodate their needs potentially do both themselves and the programs to which they apply a disservice. Moreover, such an assumption establishes a pernicious norm for what it takes to advance in medicine, namely to maintain a disingenuous veneer of perfection in the face of the deep imperfections we all hold.

There is no intent here to encourage medical students applying for residency to decide one way or another to divulge their mental illness. Such a directive would be misguided because these are intrinsically personal decisions that require much discernment about when, where, and with whom to share. However, it is crucial that we work collectively, including those “out there,” to cultivate an environment that is hospitable to honesty and vulnerability, that allows individuals to feel safe to share if they deem this fitting.


On behalf of others struggling with how to broach the subject of mental illness in the context of residency (or fellowship, or faculty) applications, I conclude with a modest proposal to those “out there,” one intended as earnest rather than antagonistic. Can we talk? Can we share our stories, but also learn from you? Can we discuss what informs the assumption that mental illness is better hidden than divulged? Can we explore the beliefs, both legitimate and misguided, that undergird this assumption? For in the absence of this discourse, I fear that those who are “out there” will ironically continue to make those who experience mental illness feel like the ones who are actually on the outside.


Section Editor: Preeti Malani, MD, MSJ, Associate Editor.

Back to top

Article Information

Corresponding Author: Benjamin W. Frush, MA, University of North Carolina at Chapel Hill School of Medicine, 321 S Columbia St, Chapel Hill, NC 27516 ([email protected]).

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and no disclosures were reported.

References

1.

Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. JAMA. 2015;314(22):2373-2383.PubMedArticle

2.

Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. JAMA. 2016;316(21):2214-2236.PubMedArticle

3.

Moutier C, Norcross W, Jong P, et al. The suicide prevention and depression awareness program at the University of California, San Diego School of Medicine. Acad Med. 2012;87(3):320-326.PubMedArticle​

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[Anti-PD1]

Love this so much. This needed to be said loud and clear. I'm glad it's in NEJM. Author is a skilled writer.

 

[Crayola227]

eh, I was much less than impressed

I don't think they said anything new, nor particularly helpful

their description of the problem is good enough, but there's not much more

first they assert how they've never experienced negativity surrounding their struggles from faculty/mentors/etc, but then reference "those out there"

they naively make it sound like a made up bogeyman, when in fact, it is not

 

[Anti-PD1]

eh, I was much less than impressed

I don't think they said anything new, nor particularly helpful

their description of the problem is good enough, but there's not much more

first they assert how they've never experienced negativity surrounding their struggles from faculty/mentors/etc, but then reference "those out there"

they naively make it sound like a made up bogeyman, when in fact, it is not

My assumption was that his name and affiliation are on the piece, he didn't want to call anyone out at his school. I guess you're right. Maybe here too, he felt the stigma.

 

[Salpingo]

Frush BW. To Those “Out There”. JAMA. 2017;318(12):1107–1108. doi:10.1001/jama.2017.10823

For anyone who has struggled with depression, anxiety, mental illness during medical school and how to present it for Residency Applications

To Those “Out There” | Humanities | JAMA | The JAMA Network

Like many of my fourth-year medical student peers, I find myself grappling with how to craft my residency application personal statement. Many struggle to avoid sounding pretentious while still demonstrating their achievements and qualifications. Some wrestle with how to describe meaningful patient interactions to illustrate what draws them to medicine. Still others find it difficult to articulate concisely why they find a given specialty compelling, or what characteristics they desire in a specific program.


Although these are issues seemingly every residency applicant faces, for students like myself, there is another question that looms larger and potentially entails more substantial ramifications. That is, whether and to what extent one should discuss one’s struggle with mental illness, for those of us who feel these experiences are an important part of our story.


Focus on depression, anxiety, and other forms of mental illness in medicine has intensified over the last decade in conjunction with heightened awareness of the burnout epidemic.1,2 This has fostered an encouraging movement toward destigmatizing these conditions and providing support for those suffering.3 Various measures to address this issue have been taken, but one of the most powerful seems to be those physicians who bravely and poignantly share their own mental illness experiences. These personal stories are immensely powerful, and frequently seem to engender a grateful and positive response from others in the medical community due to the honesty and vulnerability they exhibit. Witnessing this positive reception is especially heartening for those of us who have endured similar difficulties as medical students because they inspire hope that our mental health struggles might prove a source of strength rather than a burden or detriment.


I have certainly found this to be the case with my own experience. As a medical student, I have suffered two significant bouts of depression and anxiety, the second for which I took a brief leave for treatment. The faculty, staff, and students at my institution have been remarkably supportive throughout this process, and I have been delighted to experience firsthand the edifying responses to mental health difficulties that I read about in responses to the stories of others. Moreover, I have been surprised to never encounter a negative reaction to sharing my story, given the stigmatizing view I have heard many in medicine still hold toward mental illness.

Yet in the process of preparing my personal statement for my residency application, I have been disappointed to find that this positive response may not be the case elsewhere. In conversations with mentors about how to craft my statement, many have advised strongly against including this element of my journey, for fear that it could render me a less competitive applicant. None of these mentors have been anything but understanding of my illness, yet they all note that there are those who will view this factor as a decided weakness. When I press further about this to find out who and where these people are, what I hear is always the same frustrating and cryptic response: “Trust me, they are out there.”


Having not personally encountered or spoken with an individual “out there,” who reacts negatively to shared stories of mental illness, I feel compelled to address this audience on behalf of others who struggle with how and to whom to tell their stories. For those “out there,” I would like to offer three real problems with this pervasive stigma as it relates to those applying for residency and in career advancement in medicine more generally.


First, those “out there” contradict and stultify the prevailing message we learn in medical school about mental illness in medicine. For all of the (seemingly unanimous) administration and faculty voices that tell us that we are not alone, that say that mental illness is not something to be ashamed of, that encourage us to seek help and access resources, when we cannot be honest in this most critical juncture of our professional lives about mental illness, these messages amount to little more than lip service. For those “out there” who silently but potently countervail these supportive voices, please know that this sends a confusing message to students who hear one reality spoken but experience another.


Second, those “out there” cause medical students to deprioritize their own health. We are taught to create space for patients with mental illness to feel safe and vulnerable, and that attending to mental illness frankly and openly is a crucial component of overall health. Therefore, when students are tacitly discouraged by those “out there” from extending the same approach to ourselves or our peers in medicine, it follows that we are not pursuing our own health. This dissonance between the health we pursue for our patients and the health we pursue for ourselves indicates either that we hold ourselves to a different understanding of health than those we serve or that our own health must be subordinated to our work as physicians, neither of which is just.


Third, and perhaps most importantly, those “out there” undermine the moral component of medicine that is constitutive of good physicians. Since the time of Hippocrates, physicians have not simply been viewed as technicians or providers; they have been endowed with the task to fulfill their duty with integrity and honesty. If we feel compelled to lie to ourselves, our peers, and those reading our applications, we are setting a dangerous precedent for our future moral work as physicians. Students who feel pressured to present a false image of themselves in order to match at a program that may not be well-suited to accommodate their needs potentially do both themselves and the programs to which they apply a disservice. Moreover, such an assumption establishes a pernicious norm for what it takes to advance in medicine, namely to maintain a disingenuous veneer of perfection in the face of the deep imperfections we all hold.

There is no intent here to encourage medical students applying for residency to decide one way or another to divulge their mental illness. Such a directive would be misguided because these are intrinsically personal decisions that require much discernment about when, where, and with whom to share. However, it is crucial that we work collectively, including those “out there,” to cultivate an environment that is hospitable to honesty and vulnerability, that allows individuals to feel safe to share if they deem this fitting.


On behalf of others struggling with how to broach the subject of mental illness in the context of residency (or fellowship, or faculty) applications, I conclude with a modest proposal to those “out there,” one intended as earnest rather than antagonistic. Can we talk? Can we share our stories, but also learn from you? Can we discuss what informs the assumption that mental illness is better hidden than divulged? Can we explore the beliefs, both legitimate and misguided, that undergird this assumption? For in the absence of this discourse, I fear that those who are “out there” will ironically continue to make those who experience mental illness feel like the ones who are actually on the outside.


Section Editor: Preeti Malani, MD, MSJ, Associate Editor.

Back to top

Article Information

Corresponding Author: Benjamin W. Frush, MA, University of North Carolina at Chapel Hill School of Medicine, 321 S Columbia St, Chapel Hill, NC 27516 ([email protected]).

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and no disclosures were reported.

References

1.

Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. JAMA. 2015;314(22):2373-2383.PubMedArticle

2.

Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. JAMA. 2016;316(21):2214-2236.PubMedArticle

3.

Moutier C, Norcross W, Jong P, et al. The suicide prevention and depression awareness program at the University of California, San Diego School of Medicine. Acad Med. 2012;87(3):320-326.PubMedArticle​

There's a little bit of millennial entitlement built into this article. You SHOULD expect and deserve support from a community you're already a part of. Its been shameful to watch some upper tier college essentially kick out students from their communities due to the risk of having them on campus.

But thats different from applying for a job. The purpose of applications are to highlight your strengths, with opportunities to address red flags. You're one in hundreds if not thousands of applications, and the admissions/match process is not designed to take care of you, but sift through and find the best applicants for the position. Its not a chance to share your story, its a competition over a limited number of jobs.

It is the responsibility of the applicant to make sure there are enough resources and supports in place, and the institution to be honest about what they have available. There's a difference between asking "what do you have in the way of employee/student health services or support?" in an interview vs. "I have had mental health issues... is that going to be a problem?" on a personal statement.

And while there may be stigma, I don't think this is unique to mental health. Any chronic condition with a relapsing/remitting course is going to raise concern. If you bring up your struggles with epilepsy through medical school that led to a leave of absence, there are program directors who are going to be nervous about bringing you in, which is why its illegal to directly ask applicants questions about specific diagnoses.

 

[operaman]

I would like to wager $100 that the author above ends up matching at his home institution.

I would identify myself as one of those "out there" who, given the choice, would prefer not to work alongside people with serious mental illnesses. Not that I haven't had good experiences with such people before and probably many more with people I didn't know carried the diagnosis, but I've also had enough negative experiences that I would prefer not repeat.

Having a weak resident can be the difference between a good experience in training or a dismal one. Someone carrying a diagnosis is certainly more likely to struggle in the face of the stresses and exhaustion of caring for really sick people with limited resources. Many seemingly healthy residents struggle mightily through this crucible; those with mental illness can and do get pushed over the edge.

Forgive me if this sounds callous but I think it's how many people view these applicants. Even those who don't divulge it will often betray it through their application in other ways. The truth is that there are many other less stigmatized diagnoses that can also limit one's ability to practice certain fields of medicine.

Losing and/or replacing a resident can be extremely difficult on a program, especially a smaller one. Bringing on someone new with a higher than usual likelihood of not completing the program is just not a good risk.

 

[sliceofbread136]

I would like to wager $100 that the author above ends up matching at his home institution.

I would identify myself as one of those "out there" who, given the choice, would prefer not to work alongside people with serious mental illnesses. Not that I haven't had good experiences with such people before and probably many more with people I didn't know carried the diagnosis, but I've also had enough negative experiences that I would prefer not repeat.

Having a weak resident can be the difference between a good experience in training or a dismal one. Someone carrying a diagnosis is certainly more likely to struggle in the face of the stresses and exhaustion of caring for really sick people with limited resources. Many seemingly healthy residents struggle mightily through this crucible; those with mental illness can and do get pushed over the edge.

Forgive me if this sounds callous but I think it's how many people view these applicants. Even those who don't divulge it will often betray it through their application in other ways. The truth is that there are many other less stigmatized diagnoses that can also limit one's ability to practice certain fields of medicine.

Losing and/or replacing a resident can be extremely difficult on a program, especially a smaller one. Bringing on someone new with a higher than usual likelihood of not completing the program is just not a good risk.

And then we wonder why suicide rates in doctors are so high... personally I'm more than willing to pick up some of the workplace slack if it means I'm not stigmatizing mental illness (or apparantly any illness in your point of view) to the point where my collueges are reluctant or scared to mention their disease or seek help

 

[Redpancreas]

And then we wonder why suicide rates in doctors are so high... personally I'm more than willing to pick up some of the workplace slack if it means I'm not stigmatizing mental illness (or apparantly any illness in your point of view) to the point where my collueges are reluctant or scared to mention their disease or seek help

I would like to wager $100 that the author above ends up matching at his home institution.

I would identify myself as one of those "out there" who, given the choice, would prefer not to work alongside people with serious mental illnesses. Not that I haven't had good experiences with such people before and probably many more with people I didn't know carried the diagnosis, but I've also had enough negative experiences that I would prefer not repeat.

Having a weak resident can be the difference between a good experience in training or a dismal one. Someone carrying a diagnosis is certainly more likely to struggle in the face of the stresses and exhaustion of caring for really sick people with limited resources. Many seemingly healthy residents struggle mightily through this crucible; those with mental illness can and do get pushed over the edge.

Forgive me if this sounds callous but I think it's how many people view these applicants. Even those who don't divulge it will often betray it through their application in other ways. The truth is that there are many other less stigmatized diagnoses that can also limit one's ability to practice certain fields of medicine.

Losing and/or replacing a resident can be extremely difficult on a program, especially a smaller one. Bringing on someone new with a higher than usual likelihood of not completing the program is just not a good risk.

I think a majority of us sympathize with both perspectives. It really comes down to coming up with the most eloquent compromise until psychiatric advances lead us to understand and intervene on mood/psychotic/personality disorders to the extent that we do now on Coronary Artery Disease.

I think as @Goro has witnessed from his students, medical school can be a pressure cooker and bring out sub-clinical symptoms of mood disorders in all students if they're not careful. With advances in knowledge and technology, the practice of medicine is becoming more stressful. I think that because of this, many physicians-in-training are becoming increasingly tolerant of those more predisposed than others to mental illness. I definitely agree that we, as (future) physicians, should be equipped to recognize signs and understand what we can (and cannot) to support those with mental illness.

On the other side, @operaman brings up a very interesting point. If you want to talk about fairness, individuals who acquire cancer or other debilitating somatic illnesses are probably discriminated against just as much as someone with mental illness is so we need to really think about whether we are really singling out mental illness here. Residencies need physicians who show up to work and if they can't, does the reason really matter? First, I think we need to "de-glorify" Medicine as a career so that those with mental illness don't feel like not pursuing it is a failure (easier said than done). Second, we need to do a better job of communicating to the future generation of the realities of attempting to become a doctor with severe mental illness. It's not something to just persevere against and overcome. I suspect this is the viewpoint of the mentally-healthy who only know mental illness through introspection of themself. (Maybe at one point they thought they had a mental illness, but it went away when they took better care of themselves so they figured they had "beat" the so-called mental illness and everyone else who doesn't is an "entitled millennial" not willing to work as hard as they did).

 

[Crayola227]

I think a majority of us sympathize with both perspectives. It really comes down to coming up with the most eloquent compromise until psychiatric advances lead us to understand and intervene on mood/psychotic/personality disorders to the extent that we do now on Coronary Artery Disease.

I think as @Goro has witnessed from his students, medical school can be a pressure cooker and bring out sub-clinical symptoms of mood disorders in all students if they're not careful. With advances in knowledge and technology, the practice of medicine is becoming more stressful. I think that because of this, many physicians-in-training are becoming increasingly tolerant of those more predisposed than others to mental illness. I definitely agree that we, as (future) physicians, should be equipped to recognize signs and understand what we can (and cannot) to support those with mental illness.

On the other side, @operaman brings up a very interesting point. If you want to talk about fairness, individuals who acquire cancer or other debilitating somatic illnesses are probably discriminated against just as much as someone with mental illness is so we need to really think about whether we are really singling out mental illness here. Residencies need physicians who show up to work and if they can't, does the reason really matter? First, I think we need to "de-glorify" Medicine as a career so that those with mental illness don't feel like not pursuing it is a failure (easier said than done). Second, we need to do a better job of communicating to the future generation of the realities of attempting to become a doctor with severe mental illness. It's not something to just persevere against and overcome. I suspect this is the viewpoint of the mentally-healthy who only know mental illness through introspection of themself. (Maybe at one point they thought they had a mental illness, but it went away when they took better care of themselves so they figured they had "beat" the so-called mental illness and everyone else who doesn't is an "entitled millennial" not willing to work as hard as they did).

this goes in line with my argument that the current state of practice in the US is just unhealthy for practitioners mentally and physically

if working conditions improved in a variety of ways, having cancer, epilepsy, or say anxiety, might not have to be as career-damaging as they are now, for those in training and beyond

 

[operaman]

And then we wonder why suicide rates in doctors are so high... personally I'm more than willing to pick up some of the workplace slack if it means I'm not stigmatizing mental illness (or apparantly any illness in your point of view) to the point where my collueges are reluctant or scared to mention their disease or seek help

Perhaps I should better distinguish between applicants and colleagues. Absolutely, I think any of us would be more than willing to help out our fellow residents if they need help. I've lost count of the calls and whatnot I've volunteered to pick up when someone else needed it. I remember even as an intern when someone had to be out and the chiefs emailed the interns asking for volunteers to help pick up the calls, nearly the entire class replied in the affirmative.

Now, if I'm interviewing applicants or reviewing applications and one very openly reveals a serious mental illness and how they've struggled with it in the past and overcome it, I would probably not want to work with that person and take the gamble that entails. It's just a high risk-low reward situation from my perspective, especially when you have so many other highly qualified people to chose from.

Residency is a strange hybrid of real job and training program. The discrimination against people with chronic illnesses that could impact their work is one of the primary reasons employers aren't able to ask about it. The thought of someone applying for a high level position in finance or law or some other profession and drafting a cover letter that mentions their overcoming their depression and substance abuse issues is almost comical. Perhaps this is where the disconnect is coming from. Stories of overcoming personal tribulations make great fodder for school applications where they can set you apart and show your grit and resilience. These same stories are looked on by future employers as evidence that you might not be a reliable employee when you have an actual job to do besides simply learning.

I wish there were a nicer way to do this and my inner softie doesn't like the blatant unfairness. But there are pragmatic considerations and you have to hire people who can get the job done reliably. You wouldn't hire a resident into a microsurgical training program who lacks binocular vision not because you're discriminatory, but because they simply can't do the work no matter how great they are otherwise. I see the formerly-named Axis 1/2 disorders in a very similar light, suggestive that for whatever reason, that applicant may lack the fortitude and coping ability necessary to function in a highly stressful environment for 5-7 years.

This is not to crap on people with mental illness, but to offer a countering perspective to the article shared above. I would hate to see people naively think that it's now accepted to air this stuff in a job application. I feel like I'm at one of the most supportive and nuturing programs in the country and while I haven't seen this happen yet, can imagine that a personal statement about their struggles with mental illness would get them circular filed.

 

[failedatlife]

As a medical student who has experienced anxiety over preparation for Step 1....and later depression because of Step 1, I can relate wholeheartedly. But I would never even think about telling my future employer (family medicine physician assistant program) about this.

 

[NotAProgDirector]

I agree with much of the above. When the author of the piece talks about "stigma", it implies that programs may choose other applicants because they consider mental illness a "weakness" or a "moral failing". I'm sure there are people that feel this way, but I expect they are a small minority. Instead, the concern is purely pragmatic and two fold, and applies to anyone with a chronic illness whether psychiatric or medical. First is the issue of possible future LOA's. As mentioned, residency programs run on very tight schedules. If a student takes an LOA, it causes no problem to clinical care delivery in most situations. In residency, it requires a wholescale alteration of the schedule. Although this might seem like "no big deal", trust me if you have only 1-2 months of electives in a 12 month period and then are told that you're being pulled for one of those months to cover someone else's work due to an absence, it's hard to remain positive and supportive. Perhaps the problem is our schedules in the first place -- perhaps they should have more flexibility, or we should have backup systems such that if a resident is unable to work, that we don't need another resident to cover and can just have faculty/others do the work. But it's financially impossible to keep an NP/PA on the payroll without other duties "just in case" they are needed to cover somewhere, and if we have a system where faculty can just step in and do resident work, you tend to end up with an experience where residents get marginalized and faculty just do the work directly. And since residency tends to be more intense than being a student, these issues tend to get magnified -- but not always, some people do perfectly fine.

The other issue, not yet mentioned, is the ADA. Chronic mental illness definitely falls under the definition of a disability under the ADA. As a PD, I am very concerned about what happens when a resident asks for ADA accommodations. I could imagine a resident requesting no night shifts, or can only work 4 days in a row, or a maximum of 50 hours a week, because of their chronic illness. And I can totally understand that a resident with a chronic illness might be able to function with those accommodations, whereas they might fail without them. The question then becomes whether it's a "reasonable" accommodation, for which there's no clear answer. The argument in support would be that I could extend the time of training to make up any missed hours, so that overall they would get the same experience. Yet all of them will have profound effects upon the schedule and the work of their colleagues. It's a very difficult situation, as I want to support residents with chronic illnesses, yet I also need to be a good steward of the program and recognize that if a resident has a chronic health issue, that might impact the rest of the residents in a negative fashion -- and is that fair to them?

I don't have a solution. We try to assess each case on it's own merits. When these issues are severe, it's often hard for the student to completely hide the issue -- because there's an LOA, or a failed course, or some other marker of the problem. The question then becomes how much to share. We don't have a blanket policy, we review each situation and make a decision based upon the application. But it definitely causes psychic conflict between my desire to "help everyone succeed" , and my "do what's best for the program" side.

 

[Stagg737]

I wish there were a nicer way to do this and my inner softie doesn't like the blatant unfairness. But there are pragmatic considerations and you have to hire people who can get the job done reliably. You wouldn't hire a resident into a microsurgical training program who lacks binocular vision not because you're discriminatory, but because they simply can't do the work no matter how great they are otherwise. I see the formerly-named Axis 1/2 disorders in a very similar light, suggestive that for whatever reason, that applicant may lack the fortitude and coping ability necessary to function in a highly stressful environment for 5-7 years.

This is not to crap on people with mental illness, but to offer a countering perspective to the article shared above. I would hate to see people naively think that it's now accepted to air this stuff in a job application. I feel like I'm at one of the most supportive and nuturing programs in the country and while I haven't seen this happen yet, can imagine that a personal statement about their struggles with mental illness would get them circular filed.

I think the concerns you're expressing in your posts are valid concerns, but I think that a simple diagnosis is not enough to completely rule someone out of a position and that, like medical conditions, the severity of the disease has to be taken into account. Someone who had to take an extended LOA, multiple LOAs, or had to have significant accommodations for any chronic illness is very different from someone with a simple diagnosis who has had it under control for most of their life. I think that's where the stigma comes in. If someone were diagnosed with diabetes but had no major issues with it and didn't need accommodations, no one would think twice about them being a less capable candidate. However, if someone had no other problems but depression which was well-controlled and no accommodations were needed, people would still question their capability as a candidate. Imo that's where the argument of mental health being a stigma comes in and where a lot of people argue in favor of being more understanding towards mental illness issues.

I think most people would agree that someone who has had to severe illness (of any type) which would lead to them not being able to perform their job duties adequately should be looked at more closely, as it's detrimental to the entire team and patients if the candidate can't work. However, I think a person who's condition is very well-managed and who maybe had a hospitalization years ago but has been well-controlled since then, deserves the benefit of the doubt that they can manage their condition properly. So at least to me, it's more about the extent and severity of the condition/disease than the diagnosis itself.

 

[Peach Newport]

I would like to wager $100 that the author above ends up matching at his home institution.

I would identify myself as one of those "out there" who, given the choice, would prefer not to work alongside people with serious mental illnesses. Not that I haven't had good experiences with such people before and probably many more with people I didn't know carried the diagnosis, but I've also had enough negative experiences that I would prefer not repeat.

Having a weak resident can be the difference between a good experience in training or a dismal one. Someone carrying a diagnosis is certainly more likely to struggle in the face of the stresses and exhaustion of caring for really sick people with limited resources. Many seemingly healthy residents struggle mightily through this crucible; those with mental illness can and do get pushed over the edge.

Forgive me if this sounds callous but I think it's how many people view these applicants. Even those who don't divulge it will often betray it through their application in other ways. The truth is that there are many other less stigmatized diagnoses that can also limit one's ability to practice certain fields of medicine.

Losing and/or replacing a resident can be extremely difficult on a program, especially a smaller one. Bringing on someone new with a higher than usual likelihood of not completing the program is just not a good risk.

See, here's the problem with that.

People with mental illness aren't isolated bad apples who have breakdowns when things get too hard. Why would you associate "mental illness" with "weak resident?" You clearly draw an equivalency. This is an assumption based on stereotypes shown time and time again to be innaccurate, especially with people actually being treated.

People with mental issues are all around you. No matter where you go, you're going to depend on them.But that's okay, because most of them are being treated. They know themselves. They do just fine. They do just as well in residency as non-diagnosed people.

The problem happens when they A) have a severe diagnosis, and B) don't get treated. Usually, it's part B that causes the problems. There are definitely a few mental health diagnoses that preclude a career in medicine, but we're not talking about that.

What's the most likely reason why they won't get the help they need, if they need it?

People like you.

People who would "prefer to not work with someone with a diagnosis."

People who might cost them their jobs- not because they're incompetent-but because they make assumptions based on outdated and inaccurate stereotypes.

Stigma like you're perpetuating isn't making patients safe from crazy doctors, or keeping doctors safe from incompetent colleagues. What it is doing, however, is making it more likely that bad stuff will happen.

It's making it more likely that the intern thinking of seeking treatment will not get it (because of his coworkers find out, he's screwed!) making a "drop the ball" situation far more likely.

It makes it more likely that the doctor who develops alcoholism won't seek treatment, because he knows what seeking treatment will do to his career.

I'm not even going to trot out the well known scenario of doctors and medical students killing themselves.

Edit: I didn't mean to come off as unnecessarily confrontational (though maybe a little confrontational). I understand that you're approaching this from a utilitarian perspective, and especially in a field like medicine, that's pretty important and I respect it. However, I am also trying to approach the issue from a utilitarian perspective - I think your attitude toward the issue does more harm than good.

 

[sliceofbread136]

I think the concerns you're expressing in your posts are valid concerns, but I think that a simple diagnosis is not enough to completely rule someone out of a position and that, like medical conditions, the severity of the disease has to be taken into account. Someone who had to take an extended LOA, multiple LOAs, or had to have significant accommodations for any chronic illness is very different from someone with a simple diagnosis who has had it under control for most of their life. I think that's where the stigma comes in. If someone were diagnosed with diabetes but had no major issues with it and didn't need accommodations, no one would think twice about them being a less capable candidate. However, if someone had no other problems but depression which was well-controlled and no accommodations were needed, people would still question their capability as a candidate. Imo that's where the argument of mental health being a stigma comes in and where a lot of people argue in favor of being more understanding towards mental illness issues.

I think most people would agree that someone who has had to severe illness (of any type) which would lead to them not being able to perform their job duties adequately should be looked at more closely, as it's detrimental to the entire team and patients if the candidate can't work. However, I think a person who's condition is very well-managed and who maybe had a hospitalization years ago but has been well-controlled since then, deserves the benefit of the doubt that they can manage their condition properly. So at least to me, it's more about the extent and severity of the condition/disease than the diagnosis itself.

Agreed, however I feel like someone with something like a well controlled bipolar disorder would have a much harder time in getting a position than someone with something like well controlled IBD. Each could have an equal potential for leave of abscence however one definitely carries more stigma than the other and that's where the problem really lies

 

[sliceofbread136]

See, here's the problem with that.

People with mental illness aren't isolated bad apples who have breakdowns when things get too hard. Why would you associate "mental illness" with "weak resident?" You clearly draw an equivalency. This is an assumption based on stereotypes shown time and time again to be innaccurate, especially with people actually being treated.

People with mental issues are all around you. No matter where you go, you're going to depend on them.But that's okay, because most of them are being treated. They know themselves. They do just fine. They do just as well in residency as non-diagnosed people.

The problem happens when they A) have a severe diagnosis, and B) don't get treated. Usually, it's part B that causes the problems. There are definitely a few mental health diagnoses that preclude a career in medicine, but we're not talking about that.

What's the most likely reason why they won't get the help they need, if they need it?

People like you.

People who would "prefer to not work with someone with a diagnosis."

People who might cost them their jobs- not because they're incompetent-but because they make assumptions based on outdated and inaccurate stereotypes.

Stigma like you're perpetuating isn't making patients safe from crazy doctors, or keeping doctors safe from incompetent colleagues. What it is doing, however, is making it more likely that bad stuff will happen.

It's making it more likely that the intern thinking of seeking treatment will not get it (because of his coworkers find out, he's screwed!) making a "drop the ball" situation far more likely.

It makes it more likely that the doctor who develops alcoholism won't seek treatment, because he knows what seeking treatment will do to his career.

I'm not even going to trot out the well known scenario of doctors and medical students killing themselves.

Well said!

 

[Mad Jack]

Medicine is a brutal endeavor. You develop coping skills or perish. It is unlikely that will change any time soon. There are lower stress options in specialty choice for individuals with mental health issues, and they should be realistic with themselves about their ability to survive the rigors of a program given their diagnosis. Just as a person with epilepsy might want to shy away from certain fields, so too should a person with mental illness, as accommodations can only go so far.

 

[Mad Jack]

I agree with much of the above. When the author of the piece talks about "stigma", it implies that programs may choose other applicants because they consider mental illness a "weakness" or a "moral failing". I'm sure there are people that feel this way, but I expect they are a small minority. Instead, the concern is purely pragmatic and two fold, and applies to anyone with a chronic illness whether psychiatric or medical. First is the issue of possible future LOA's. As mentioned, residency programs run on very tight schedules. If a student takes an LOA, it causes no problem to clinical care delivery in most situations. In residency, it requires a wholescale alteration of the schedule. Although this might seem like "no big deal", trust me if you have only 1-2 months of electives in a 12 month period and then are told that you're being pulled for one of those months to cover someone else's work due to an absence, it's hard to remain positive and supportive. Perhaps the problem is our schedules in the first place -- perhaps they should have more flexibility, or we should have backup systems such that if a resident is unable to work, that we don't need another resident to cover and can just have faculty/others do the work. But it's financially impossible to keep an NP/PA on the payroll without other duties "just in case" they are needed to cover somewhere, and if we have a system where faculty can just step in and do resident work, you tend to end up with an experience where residents get marginalized and faculty just do the work directly. And since residency tends to be more intense than being a student, these issues tend to get magnified -- but not always, some people do perfectly fine.

The other issue, not yet mentioned, is the ADA. Chronic mental illness definitely falls under the definition of a disability under the ADA. As a PD, I am very concerned about what happens when a resident asks for ADA accommodations. I could imagine a resident requesting no night shifts, or can only work 4 days in a row, or a maximum of 50 hours a week, because of their chronic illness. And I can totally understand that a resident with a chronic illness might be able to function with those accommodations, whereas they might fail without them. The question then becomes whether it's a "reasonable" accommodation, for which there's no clear answer. The argument in support would be that I could extend the time of training to make up any missed hours, so that overall they would get the same experience. Yet all of them will have profound effects upon the schedule and the work of their colleagues. It's a very difficult situation, as I want to support residents with chronic illnesses, yet I also need to be a good steward of the program and recognize that if a resident has a chronic health issue, that might impact the rest of the residents in a negative fashion -- and is that fair to them?

I don't have a solution. We try to assess each case on it's own merits. When these issues are severe, it's often hard for the student to completely hide the issue -- because there's an LOA, or a failed course, or some other marker of the problem. The question then becomes how much to share. We don't have a blanket policy, we review each situation and make a decision based upon the application. But it definitely causes psychic conflict between my desire to "help everyone succeed" , and my "do what's best for the program" side.

Could not the same thing be said for pregnancy?

 

[mistafab]

I slightly disagree.

In these situations, I always ask - what if I was the boss? What would I feel like if this was MY employee?

My brother once said that at an interview, and interviewee on their first interaction said "I am a squirell-kin - how are you going to accomodate me?"

Realistically, this situation is an extreme. But it shows a point. If you have 20, 50, or 200 people vying for a spot, why would you hire anyone with any type of 'norm deviation'? It is just a headache. Unfortunately, the interview or first impression loses the point of why you should be hired, and just becomes a process of "what can you do for me?" Realistically, it is better to ask for accomodations AFTER you have the position. I would never lead with anything like a disability or special accomodation, which is why interviewees are granted the protections of not getting asked those questions before being hired.

I think the concerns you're expressing in your posts are valid concerns, but I think that a simple diagnosis is not enough to completely rule someone out of a position and that, like medical conditions, the severity of the disease has to be taken into account. Someone who had to take an extended LOA, multiple LOAs, or had to have significant accommodations for any chronic illness is very different from someone with a simple diagnosis who has had it under control for most of their life. I think that's where the stigma comes in. If someone were diagnosed with diabetes but had no major issues with it and didn't need accommodations, no one would think twice about them being a less capable candidate. However, if someone had no other problems but depression which was well-controlled and no accommodations were needed, people would still question their capability as a candidate. Imo that's where the argument of mental health being a stigma comes in and where a lot of people argue in favor of being more understanding towards mental illness issues.

I think most people would agree that someone who has had to severe illness (of any type) which would lead to them not being able to perform their job duties adequately should be looked at more closely, as it's detrimental to the entire team and patients if the candidate can't work. However, I think a person who's condition is very well-managed and who maybe had a hospitalization years ago but has been well-controlled since then, deserves the benefit of the doubt that they can manage their condition properly. So at least to me, it's more about the extent and severity of the condition/disease than the diagnosis itself.

 

[operaman]

See, here's the problem with that.

People with mental illness aren't isolated bad apples who have breakdowns when things get too hard. Why would you associate "mental illness" with "weak resident?" You clearly draw an equivalency. This is an assumption based on stereotypes shown time and time again to be innaccurate, especially with people actually being treated.

People with mental issues are all around you. No matter where you go, you're going to depend on them.But that's okay, because most of them are being treated. They know themselves. They do just fine. They do just as well in residency as non-diagnosed people.

The problem happens when they A) have a severe diagnosis, and B) don't get treated. Usually, it's part B that causes the problems. There are definitely a few mental health diagnoses that preclude a career in medicine, but we're not talking about that.

What's the most likely reason why they won't get the help they need, if they need it?

People like you.

People who would "prefer to not work with someone with a diagnosis."

People who might cost them their jobs- not because they're incompetent-but because they make assumptions based on outdated and inaccurate stereotypes.

Stigma like you're perpetuating isn't making patients safe from crazy doctors, or keeping doctors safe from incompetent colleagues. What it is doing, however, is making it more likely that bad stuff will happen.

It's making it more likely that the intern thinking of seeking treatment will not get it (because of his coworkers find out, he's screwed!) making a "drop the ball" situation far more likely.

It makes it more likely that the doctor who develops alcoholism won't seek treatment, because he knows what seeking treatment will do to his career.

I'm not even going to trot out the well known scenario of doctors and medical students killing themselves.

Edit: I didn't mean to come off as unnecessarily confrontational (though maybe a little confrontational). I understand that you're approaching this from a utilitarian perspective, and especially in a field like medicine, that's pretty important and I respect it. However, I am also trying to approach the issue from a utilitarian perspective - I think your attitude toward the issue does more harm than good.

Seeking help is one thing. Seeking help and then shouting that fact from the rooftops when applying for your next job is quite another. I'm not sure I accept your premise that encouraging applicants to keep quiet is equivalent to telling current residents to avoid seeking help, but I understand that there's a fine line there.

While mental illness may not ensure a weak resident, I would posit that of all residents who took LOAs(excluding maternity/paternity leave), quit, were fired, etc, an overwhelming number struggle with mental illness, substance abuse, and similar things.

The unfortunate truth about all stigmas and stereotypes is that they are based on a prevailing reality. The heartbreak comes from people who break the stereotype yet aren't given a fair shot because of it.

I wish I had a good solution beyond advising applicants to keep their mouths shut about their health issues. Perhaps part of the answer lies in steering people toward appropriate fields and programs that would mesh with their diagnoses. I can think of people with mental illnesses I've seen struggle in one field and be pushed out only to find success in something else. While I would love to buy in to the myth that we can all be anything we desire, that simply isn't true. People with substance issues should probably avoid anesthesia. People with other disorders who don't do well with stress should avoid others.

For students who want/need to be open about their issues, I think the best thing is to cultivate a great relationship with their home program. For students who really are managing their disease well, a home program would have the time to see that demonstrated over time.

 

[Peach Newport]

Seeking help is one thing. Seeking help and then shouting that fact from the rooftops when applying for your next job is quite another. I'm not sure I accept your premise that encouraging applicants to keep quiet is equivalent to telling current residents to avoid seeking help, but I understand that there's a fine line there.

While mental illness may not ensure a weak resident, I would posit that of all residents who took LOAs(excluding maternity/paternity leave), quit, were fired, etc, an overwhelming number struggle with mental illness, substance abuse, and similar things.

The unfortunate truth about all stigmas and stereotypes is that they are based on a prevailing reality. The heartbreak comes from people who break the stereotype yet aren't given a fair shot because of it.

I wish I had a good solution beyond advising applicants to keep their mouths shut about their health issues. Perhaps part of the answer lies in steering people toward appropriate fields and programs that would mesh with their diagnoses. I can think of people with mental illnesses I've seen struggle in one field and be pushed out only to find success in something else. While I would love to buy in to the myth that we can all be anything we desire, that simply isn't true. People with substance issues should probably avoid anesthesia. People with other disorders who don't do well with stress should avoid others.

For students who want/need to be open about their issues, I think the best thing is to cultivate a great relationship with their home program. For students who really are managing their disease well, a home program would have the time to see that demonstrated over time.

I can't really say I disagree with anything here.

I wasn't trying to say that telling people to keep quiet about their diagnosis discourages them seeking help. I was trying to say that making them afraid of that information being discovered does.

I agree that applicants should probably not be talking about mental health conditions - I'd give the same advice. Not just because of the stigma, but because to me, it should be no one's business unless there's a damn good reason to talk about it.

 

[Stagg737]

I slightly disagree.

In these situations, I always ask - what if I was the boss? What would I feel like if this was MY employee?

My brother once said that at an interview, and interviewee on their first interaction said "I am a squirell-kin - how are you going to accomodate me?"

Realistically, this situation is an extreme. But it shows a point. If you have 20, 50, or 200 people vying for a spot, why would you hire anyone with any type of 'norm deviation'? It is just a headache. Unfortunately, the interview or first impression loses the point of why you should be hired, and just becomes a process of "what can you do for me?" Realistically, it is better to ask for accomodations AFTER you have the position. I would never lead with anything like a disability or special accomodation, which is why interviewees are granted the protections of not getting asked those questions before being hired.

I'm not specifically talking about disclosing that information during an interview or asking for accommodations, I was referring to the general perception of individuals with mental health conditions and the idea that there is some higher burden placed on them to "prove they are capable" compared to individuals with other medical conditions. As others have said, I generally would advise against mentioning any kind of health issues at an interview, especially if they are well controlled.

However, I do think that when there was a major health concern that requires a LOA or causes a failure which has to be explained by an applicant, a mental health cause is addressed differently than a chronic medical cause, and I think that's where others are taking issue as well.

 

[Crayola227]

I often posit that maybe we need to change the training and practice of medicine to be such that it can better tolerate epileptics, diabetics, manic-depressives, preggos, arthritics, etc among its ranks.

True that in law and business you wouldn't put this stuff in your cover letter. Yes, the disconnect is, why is it our "business" to deal with human frailty, and then do such a poor job of doing just that? Will spare the the whole thing about "business" of human frailty being a problematic approach.

It might just be the way things are. Someone once said that perhaps we are diminishing just the sort of voices that we really need in our particular line of work. I think that is ironically sad, and I imagine better. It could be that I'm romanticizing here; that these voices matter more to medicine than to law or business, that they are lost, or that they matter at all.

 

[mistafab]

I can only comment as a med student - however, I really liked how you wrote this part here.

I often posit that maybe we need to change the training and practice of medicine to be such that it can better tolerate epileptics, diabetics, manic-depressives, preggos, arthritics, etc among its ranks.

True that in law and business you wouldn't put this stuff in your cover letter. Yes, the disconnect is, why is it our "business" to deal with human frailty, and then do such a poor job of doing just that? Will spare the the whole thing about "business" of human frailty being a problematic approach.

It might just be the way things are. Someone once said that perhaps we are diminishing just the sort of voices that we really need in our particular line of work. I think that is ironically sad, and I imagine better. It could be that I'm romanticizing here; that these voices matter more to medicine than to law or business, that they are lost, or that they matter at all.

 

[NotAProgDirector]

Could not the same thing be said for pregnancy?

For most healthy pregnancies, it's not a problem. We have 6+ months of notice to sort out the schedule. If someone gets pregnant the second half of the year, then we build the schedule the next year to accommodate that. Obviously you could have a pregnancy that is problematic and requires lots of bed rest -- and that causes similar problems but is rare. We don't have much 24 hour call left, and make sure that anyone pregnant doesn't have it in their 3rd trimester.

 

[Crayola227]

I remember reading on this board from a surgery resident how the program was encouraging the female residents to have abortions. Lawlz.

In fact, IIRC, there was a program that got sued by a resident where that got brought up...

I will say, that one of the programs I interviewed at, I mentioned that I *really* wanted to match there because my fiance was going to take a job at that location.

I was then asked what my plans were for pregnancy, and the interviewer looked pretty anxious about it.

I wanted to make a joke about how I was so committed to residency and putting off kids that I would have an abortion for this program, by Jove!!

I just settled for saying I was on birth control and putting it off until attendinghood.