Empathy and Experience: The Importance of Physician Mental Health

Host Dr. Lindi van Niekerk is joined by Dr. Sidney Zisook, co-founder of UCSD’s HEAR program, and Dr. Christine Moutier, Chief Medical Officer of the American Foundation for Suicide Prevention (AFSP). Drawing from personal experience and decades of clinical expertise, Dr. Moutier and Dr. Zisook delve into the hidden burdens that many doctors carry, including eating disorders, anxiety, depression, and the pervasive stigma that prevents many from seeking help. Their candid discussion examines the historical and cultural challenges within the medical community that discourage vulnerability and perpetuate silence and how innovative programs like UCSD's HEAR program, and the AFSP are breaking down those barriers and providing a path for others to follow. 

This podcast is brought to you by Symptom Media - Mental Health Education & Training

For more information about the resources shared in this episode you can visit:

• American Foundation for Suicide Prevention

Other Important links from AFSP:

• https://afsp.org/suicide-prevention-interventions-and-treatments/
• https://afsp.org/healthcare-professionals-mental-health-and-suicide-risk/https://afsp.org/get-help/
• https://afsp.org/support-after-suicide-loss-for-healthcare-professionals-and-organizations/
• UCSD'S Health & Physician Wellness Infrastructure
• Dr. Lorna Breen Heroes’ Foundation

If you or anyone you know is in crisis... Call or text 988 or text TALK to 741741

To learn more about Symptom Media and its mental health resource library visit: https://symptommedia.com/

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Transcript

0:11

Hello everyone and welcome to another episode of the Symptom Media podcast, Bridging the Divide in Mental Health. I'm your host, Dr. Lindy Fannikar, and I'm grateful you're here. To learn more about Symptom Media's mental health resources, visit symptommedia.com. Our mission here is simple but vital, to bridge the divide between the clinical and the experiential. In this episode, we're pausing to look beneath the white coat, to the very human hearts and minds of us as physicians, while we spend our days safeguarding the health of everyone. Many of us carry our own invisible burdens. Burnout, disordered eating, depression, and even thoughts of suicide. And the same culture that prizes strength and self-sacrifice often makes it hard for us as doctors to reach out for the help we need. To hold this conversation with the care we deserve, I'm joined by two remarkable physicians. Dr. Christine Youmoutier is the Chief Medical Officer of the American Foundation for Suicide Prevention. And she's a tireless champion for dismantling stigma and reshaping the way we talk about suicide in the United States. Dr. Sydney Zizek is a distinguished professor of psychiatry at the University of California, San Diego, director of the Physician Peer Support Program and the co-founder of HEAR, the Healer Education Assessment and Referral Program that offers education, stress and depression screening and support to UC San Diego's health learners and workers. Together, Christine and Sydney bring decades of expertise, heartfelt advocacy and lived experience to this dialogue on the mental health challenges of physicians. Let's dive in. Christine said, thank you so much for joining today. I think you're on both on opposite side of the countries. Yes, I live in New Jersey, but today I happen to be visiting my son in Vermont. and I'm here from sunny San Diego. So I know you both have storied careers as physicians, but what after all these years still fuel your passion for your work? You know, for me, just contributing to the dialogue and uplifting people, the population's mental health and trying to prevent suicide, it never gets old. It continues to be the most meaningful pursuit. And I feel fortunate every day to have that privilege and honor and responsibility to try to make a difference at the national level for the population's prevention of suicide. Well, I can think of a couple things that's always fueled me as my connection with trainees and colleagues. You know, I've been blessed with having a wonderful group of people to work with and to learn from, and especially trainees that I get to see early in their careers and work closely with and see them grow and mature and contribute. A case in point is Christine, who I've known since she was a medical student and through her residency and training and been so proud of watching her growth. continues to fuel my career. But also, every once in a while, we get feedback about the importance of the work we're doing. just remember not too long ago, somebody approaching me on the grass in front of our medical school building saying, you don't remember me, I'm sure, but. And he went on to tell me that he credits me with saving his life when, as a medical student, He was ready to drop out of school and he was referred to talk to me so I could train talk him into staying in and in speaking with him understood very quickly how depressed he was and it was his depression speaking and I was able to help him get into treatment which really altered the trajectory of his life in his career. Now he's a successful surgeon with a family happy to be alive and and so those kinds of events really fuel our career. We're doing important work. And lastly, being part of a field that is growing and exciting. When I was a resident, psychoanalysis was basically the treatment we had for everything. And since then, we've developed a host of medications, evidence-based treatments. When I was a resident, homosexuality was a disease. And we've come so far in our understanding of mental illness. So those are the things that keep fueling my love of the field. You know, Sid, I was just saying to my husband Jacques this morning that it's been 30 years or a little more since you became my training director and then mentor. It's a testimony to the power of mentorship, peer to peer interactions, how much a difference we make in each other's lives at all levels, but certainly for those involved in, medical education. But really now in my current role, it's about everyone wears multiple hats and we all have the power to. influence one another's just sense of value and validation and purpose and finding meaning in life. You know, we all play a role with that. The brain is the ultimate sort of mediator between all circumstances and the outcomes and our experience of life. So it's just profoundly meaningful. And again, I think all of us who work in the healthcare space, but certainly in mental health and for me, suicide prevention, it's so profoundly meaningful. for people to have even incremental changes occur in their ability to realize that they don't have to be passive in the experience of their own life. I view mental health as sort of the foundation from which so much of our functioning and our thinking and our perceptions, our sense of self springs from. Christine, could you maybe add to that what made you focus your efforts really on this important but neglected area of really looking into the mental health of people in general, but also physicians? So I trained as a psychiatrist first and then became very interested in educating others and had the opportunity to become a dean in the UCSD School of Medicine. So I think it really had started with my own lived experience of a very severe and sort of insidious mental health condition that I had been developing from the start of medical school. And that experience shapes... shaped my life in terms of the sense of shame and isolation you feel when you live in a culture that you perceive as completely judgmental and in fact not even recognizing of the experience of suffering in the way that I was at that time. But you know, that continues to shape. I think it made me... have a natural empathy for anyone who is suffering, anyone who's keeping things in silence for fears of what might happen if you share what's actually going on on the inside. I was very attuned to that. And the more that somehow that exuded out of me, in the course of my residency, when I was chief resident early in the faculty, I heard hundreds of stories. By the time I was a pretty junior psychiatrist in an academic medical setting and hearing other stories, really was, I think, one of the most powerful experiences to realize that there is a major disconnect between the way that people are appearing in their work life and their functioning. They may appear very successful and that reality that the underbelly of what people are thinking, perceiving, feeling, and certainly thinking of themselves is oftentimes not what it seems to be. And so, yeah, I think that... was just this combination of my own lived experience, professional training as a psychiatrist, and then the opportunity to be a safe resource in a place where the suffering was and is probably enormous and mostly hidden from view. And so it became almost a driving force in my decision to stay in academic medicine for the. you know, 15 or 17 years that I did before I left for the American Foundation for Suicide Prevention work that I've been doing for the last 11 or 12 years. Like probably originally felt like kind of a secret mission because it's still, you know, you feel like you're swimming upstream in a culture that is not very recognizing of these realities for human beings and that physicians and trainees are human beings. And frankly, helping others is a way to... to heal and is a source of purpose and meaning and hope and connection to others. It's incredibly meaningful. What about you? Like Christine, I know you're a psychiatrist. I know you've already said you care really about the generation that comes after you. What catalyzed this for you? Well, specifically in talking about physician mental health, when I was a resident, we lost a fellow resident to suicide and no one talked about it. When I was a junior faculty at University of Texas, we lost a faculty colleague to suicide. No one talked about it. When I came here to UCSD as a faculty member, my personal physician died by suicide. We never talked about it. and more events like that. Finally, Christine and I had an opportunity to have a physician's family who had died by suicide, encourage people to talk about it and learn from it and try to prevent the next one. And that really set us off on both of our personal journeys in this area. Well, I resonate a lot with both of what you shared because I think my kind of inquiry into suicide and suicidal ideation in medical students started in the same way by losing a colleague and a friend and kind of being awoken to the suffering that's within myself and in so many others. Christine, you mentioned the power of stories and I think that's something we're really trying to do with the series is share people's stories so that others realize they are not alone. Would you mind telling us a little bit about your personal experience and your journey with mental health. Yes, I don't mind because I have learned that it for me has not only been a safe thing to do, but it has opened up the opportunity for others to potentially open up and get the help that they need. So I realized that, you know, sharing and self-disclosure may not be always the right thing for everybody at every moment in their life, but I would just encourage everyone that there are safe. people in your life that you can at least start with. And actually my start in sharing my mental health story was probably when I was getting to know Sid and other faculty when I was a medical student and I was applying to residency and it was a choice whether to disclose it or not. And that's a big decision people with mental health experiences when they're applying to residency have to make. And I got positive feedback at that time. So that was the start. But my story really... was that really until medical school, I had never experienced anything that probably was in the category of the recognizable suffering of a mental health condition. But once I was in medical school, I had majored in piano performance in college. I had taken the bare minimum requirements. I entered a very scientific, heavy curriculum at UCSD, as most are, and really felt kind of out of my league and afraid for the first time in my life. It had just always been like, it'll work out, you know, school. But I had fear grip me from the beginning of medical school. And I think that anxiety that I had never actually learned how to even recognize what that experience was, let alone to be able to tolerate it, process it, you know, do something productive with. that sort of signal that anxiety is. And instead for me, it really spiraled into a full blown eating disorder. I probably developed all sorts of maladaptive coping with it, know, stuffing the feeling of anxiety and just going towards actions such as, you know, over exercising and disordered eating cycles that, you know, once you start going down that path, it took hold. So it was sort of like a force of its own that those behaviors became almost addictive and reinforced. And I then felt trapped over the course of about two to three years. And in the first couple of years, I was in medical school. My mode of coping with the academic fears and stress was to essentially never stop studying. It would have been unbelievable to me at the time. that a few years later would become a dean and would be teaching medical students about the importance of sleep and exercise and caring for your own mental health and physical health and spiritual health and social health, all of that. But at the time, I didn't know any better and I really didn't even have a language for what I was experiencing and I minimized and remained in much in denial, even though it was. really becoming an experience of, again, feeling like I couldn't control those symptoms anymore or the behaviors. And it was actually some peers in my med school class, as I was losing weight and probably exhibiting some warning signs of anxious or depressed or not my healthy, normal self kind of behavior, they approached me and really asked me if they could help me. find treatment. So that was the first foray into getting a little bit of therapy. But it wasn't until I got married after boards after the end of second year and I deferred the first clerkship and started as a third year medical student on the wards in a full blown uh state of the eating disorder still just daily. uh multiple times a day, mean, really in the grips of it and still kind of in denial about what it was. Although I knew, I had kind of almost accepted, I had read about it, of course, as a good medical student does, and had sort of come to this belief that I would live with this condition lifelong and I would just have to self-modulate it. It was a very kind of fantasy version because what ended up happening, is at the start of my third year of medical school. I really couldn't even function under the, you know, it's a big transition, obviously, starting on the wards and the way the curriculum was at the time. And so, yeah, so I went to my dean for student affairs and she was not necessarily under, I didn't have a good language for what I was experiencing. So in a way, understandably, you know, she heard me saying things like, I don't fit in here. I don't. you know, I don't feel I'm able to continue. Well, what would you rather be doing? All I could come up with was the one moment of peace I had had, which was swimming. And so I probably said that. And she just said, but you've gone to all this work to come to medical school. You know, so was sort of this non sequitur, not really feeling heard or understood, but she may have been more attuned than I realized because She would not let me drop out. I really was asking to disenroll. And she said, why don't you take some time off? And so I engaged in therapy and treatment for the first time, you know, sort of for real. And it was life-changing. uh I believed that I did not have value unless I was achieving and performing and pleasing everyone around me. And, you know, some of these very early childhood internalized beliefs and messages were very strong. inside me and again, until I went to therapy, I was utterly unaware of that. One of the linchpins for me in that early course of therapy that was so miraculously just effective was that I took a look at how I viewed others in my life or in the world and I had tremendous compassion and grace for anyone's suffering or imperfections, all the hardships that humanity faces and yet I did not afford that to myself. I was operating as if I was somehow unique and different. And so it was sort of like this interesting, the illogicalness of that was very helpful in this, the type of therapy I was getting was not really a pure form of cognitive behavioral. It was not really purely psychodynamic. It was probably a combination of several modalities. Totally unbeknownst to me, because again, I was not advanced enough in my medical school or training or even like that well-read or knowledgeable to understand. what was happening in the room with this older female psychiatrist who sat in a rocking chair. I expected something so different to have my eating disorder addressed through a regimented system of behavior change and nutrition. And all we did was talk. And it was a lot about the early childhood stuff and what was happening internally. And not that this is necessarily the treatment of choice these days for an eating disorder, but for me, over a period of several months, the behaviors just sort of began to dissipate. it's like my sort of internal operating system started to get rewired in a really significant way. It was a major turning point. I started to live free and autonomously, and like I had choices and I had agency. Bye. Well, it's both common and unique. And I think everyone's story is very unique to them, but there are threads that clearly many other students experience. One was this self-doubt that Christine expressed. That's very common. Sometimes we call it imposter syndrome. It's just feeling you don't belong and someone else could do it better. And that can be healthy to some extent because it can motivate and drive learning and learning from mistakes. But when it's there too much and too long, it can really get in the way and can... really turn into guilt over things that you're not responsible for or a drive for perfection that is unrealistic because you can never do enough to feel you've really achieved everything that is your goal, or you want to, or you need to. And another thing that was very common about it, as a teacher, and again, I knew Christine as a medical student and as a resident in all she was going through, I never knew she was going through any of that. She hit it so well. She's smart. She's accomplished. She's compassionate, she's beautiful, she's got everything going for her and is able to hide what she's going through. Very bright, competent medical students are capable of doing that even when severely depressed. They're capable of doing enough to keep everyone at arm's distance and not knowing. The progression from self-doubt to start with to a more serious eating disorder to depression is not an uncommon progression at all. And the notion that we're superhuman and we can do everything and we can do everything well and never make a mistake is very common and the fact is we're human and we're just as prone to human foibles, we're just as prone to mental illness as anyone else. One of the very unique things about Christine's journey was her ability to ask for and receive help reasonably early in her trajectory and that made such a huge difference and that's not as common as we'd like to see. Many, many physicians suffer with burnout, with depression, with other mental conditions and very few of them ever seek help. And that's a real tragedy because help is available. I thought, of course, so much about that crisis period of my life. And at the time, it felt nearly unbearable and just beyond, out of control and hopeless. And you can't see a path through it. And so I wouldn't want to go through that again. And I wouldn't wish it on my worst enemy or anyone. However, I think that it happened the way it did in as extreme severity as it did. that I had to take time off. I could not function any longer. If I had been able to function, I wouldn't have stopped. And I would have kept going. I would have put a band-aid on it or who knows what else what might have started to happen to try to cope. uh People get into all sorts of other things, substance use and other forms of maladaptive coping. But because it was a full stop and a major crisis, it's oddly a silver lining because again, It couldn't be a band-aid experience. I had to go deep. got very lucky with finding a therapist who absolutely got it and was equipped. And I am grateful because as I would look around over the course of the years that followed, I could see what was happening in my colleagues who weren't able to get their mental health needs addressed either at all or. as significantly and to prioritize it in the way that I did and I had to. It also gave me the gift forevermore it is a priority in my life and for those around me. We make life decisions in raising our kids and for our friends and colleagues, it's a major foundational principle that if you don't have your mental health, you're... not able to function or live profoundly in a different way. So it is a massive priority. And I think that's something that society is catching up on, doesn't quite share that seriousness of that value. And Christine, can I ask you, what about the systemic organizational factor? So I mean, you've described, like you said, you've unpacked a lot about your childhood and how that could have influenced you. But what was it about the environment or the system that you entered into that you think really almost made all this come alive and forced you to come to that point where you had to stop? Well, I think there are really important health system and training system issues that we can talk about. But in my journey, it was a lot about my perception of the environment, which felt like I could not take time to get help, but also where it would, the system would not. tolerate an imperfect being that I was realizing I was. So it was a perception of sort of this very extremely judgmental, we could call it toxic environment where human qualities of imperfection and like what I eventually learned to embrace, which is a philosophy about progress, not perfection. In fact, I very intentionally reject the concept of perfectionism because because I tend towards it, to be honest. What we can think about are the ways that the system can be reshaped and has been reshaped with greater flexibility and recognition that these are not weaknesses. These are merely facts about human health and human existence that we have to consider in order to build a sense of healthy thriving, which happens when you feel connected to others, when you have enough sleep. enough good nutrition and hydration where you're learning about healthy boundaries and relationships and taking care of yourself and the importance of all of these features of mental health that we're talking about. I think of Christina, it wasn't just your perception. I think to a large extent, it was true that that was the culture of medicine, especially at that time. It's gotten better. But the culture of medicine we really inherited was, you know, be tough, stick it out. You're weak if you ask for time off. You're putting an onus of responsibility on your classmates and colleagues who have to pick up for you and they're already overwhelmed and you're just adding to that. and who has time for exercise and good food and family. Those are much less important than being perfect and taking care of your patients. That's not the culture of wellness, but that was the culture of medicine for a long, long time, for over 100 years. And the perception you had was even exacerbated by the fact that you were depressed, because when you're depressed, stigma is much greater. and you feel that perception even more intentionally than it is. And I think that was another contributor. Fortunately, things are getting better and medicine is beginning to prioritize the mental health of us and our trainees and our colleagues. We still have a ways to go, but that culture is beginning to shift and that's the good news. Well, I'd like to pick up on the paper that you, Christine and Kerry Cunningham wrote around preventing clinicians suicide. And in there, was written, asking for help was not in my armamentarium. I'm pathologically driven and stubborn. I had built an internal fortress over a lifetime. And like you've just said, we train to help people, but we're not really trained to accept help or ask for help. Are there any other internal fortresses that you kind of see physicians build up over time and how do those kind of play out in their careers? One of the critical things is education, talking with each other, connecting with each other, and people telling their stories. know, having leaders, people we respect, people in the field talking about their own challenges, their own getting into therapy, getting help. I think those are all very helpful. think a lot of schools now have wellness directors, have wellness champions who are paid to... to pay attention and prioritize the health of the people they're working with. There's a big movement towards peer support, having physicians learn to be compassionate listeners, to reach out to people who are struggling, to help motivate them to treatment, to provide resources. So I think we're seeing lots of movement to counteract that kind of innate reluctance we have to accept our own human frailties and to get help for them. think about how our identity, our sense of ourself and self-worth, it gets shaped in a very fortress-like way around a sort of monolithic purpose as a helper, as a healer, which is so positive in a way, the desire to help others. And that's, of course, where so many physicians start. But where we, I think, have made some strides but probably could do more is in building into medical curriculum, the recognition that that natural journey for many towards this really intense sense of identity built around one's occupation and the helping of others, it doesn't attend to the realities about getting our own needs met. And that it actually over practices and over emphasizes a sense of stoicism, which many many physicians and other, nurses and others probably have to begin with. It's maybe linked to pride, sense of vulnerability, which we all might naturally reject. But honestly, I think, again, through storytelling and even curriculum, you can actually teach and model this incredible, I believe, reality that we are complex human beings. We are greater when we recognize our vulnerabilities. and actually tend to them in a way that's proactive. And I am very fortunate at AFSP and in our work, relationships like I have with Sid, that there is no stigma. When you actually allow yourself to be surrounded by that and really believe it, that stigma-free living, you know, there's still plenty of challenges in life, but it allows you to make decisions based on, I think, just more accurate data. You know, and I think we think of ourselves, particularly as physicians, as being so data-driven and evidence-based. And the truth is, we're so irrational and in denial and minimizing so much until perhaps we go through some type of experience. Or the idea is that not everyone should have to go through that, but that we can learn from each other. You mentioned identity and we've just heard that over and over in so many of these conversations where so much of our identity is on being the helper. And I was wondering, where did it start shifting for you to realize that you are more than just the medical student, you're more than just the physician, the provider of care, but that there's so much more to you as Christine than your work. Well, I think it wasn't about shifting away from being a helper. It's that I saw that my roles with patients, medical students, I was also becoming a young mother, my family, my friends, know, community member of as a community that I would need to prioritize my wellbeing and mental health for the sake of being a better all of those. So as neurotic as that is, that that's how it was justified. That is how I was able to justify it, make practical decisions about, I ended up as a dean really hitting these points very strongly with incoming medical students and all throughout and mentoring, that it's very practical. You actually have to learn how you tick, which activities bolster and fuel your coping reservoir the most, and you use a calendar and you schedule them in. And you have some ongoing touch points with peers or mentors. to really continue to keep tabs on that. And then over time, I think as I've sort of grown more mature and wise over the years, I do embrace now that I'm a full human being and I get to have fun and enjoy things, like whatever that might be, knitting, dancing, exercise, that I really take great pleasure and joy. And I also see how it augments my professional roles. I've always also not been one to sort of categorize that you leave home and you're at work and that's who you are. It doesn't work like that for me. I bring my full self into all the spaces where I am. Of course, we have to have good boundaries about all of that and what role we're in. But our brain is still in there and our spirit and our mood and our exuberance, it can all carry through. And conversely. challenges will carry through as well, obviously, from home life to work life and the other way around. think one of the things that we need to do is spend more time reflecting on our values and then orchestrating our life to be consistent with those values. You know, I'm proud of the papers I've written and grants I've gotten and patience I've taken care of, but I'm even more proud of my family and my kids. And one of most meaningful experiences of my life was coaching little league baseball and soccer for kids. Those... Values, think, are things we sometimes lose sight of. And it's so important to reflect on those intermittently and then live a life that maintains those values as well as our work ethic. Well, this is such, I think, such helpful advice and it's been what I've been trying to learn as well for many, many years and still learning as I go. And that, like I think you said, Christine, that it's possible to have fun without a purpose and that actually makes you better at what you're doing or investing in your family, said I. I think that's so valuable. Maybe to take. Quite a bit of a hard shift. I want to ask you both around what the suicide landscape looks like for physicians in the US. I know you've done a lot of research on that. you work for the American Foundation for Suicide Prevention. Could you share a little bit more about that? uh Every suicide is a tragedy and there are lots of them and I've known and Christine has known several friends, acquaintances, colleagues who have died by suicide. But it may not be quite as bad as we thought for many years. We used to think that physicians had much higher rates of suicide than other non-physicians and that's probably not the case. However, female physicians do have higher rates of suicide than other females, in part balancing two full-time careers. is next to impossible and other issues that relate to that. For male physicians, the rates probably are no higher and maybe even lower than other males who are not physicians. The rates haven't really gone down in recent years. They're still considerable. And the opportunities are at least the likelihood of physicians who are depressed or have other mental conditions that may be drivers of suicide. So many of them still aren't receiving treatment and treatment's hard to come by these days. So we do know that there are a few unique features of physicians who die by suicide compared to other individuals who die by suicide. One of those is work stress is a more common associated finding. And so things like burnout and work trauma and work stress are important to think about. And maybe avenues towards prevention. of some suicides. We know that legal problems are actually more common in physicians who die by suicide than in others. And part of that is not practices, which can be so incredibly stressful for physicians going through them. And those are avenues where we can provide additional support and help. And the highest cause of death amongst residents is suicide. Whatever we can do to not only enhance the wellness and well-being of health of the residents, but also to recognize that a residency, that span of life is a time when people have lots of stresses and strains and families are growing and also a not uncommon time for depression to first make its appearance and substance use and eating disorders, et cetera, that we need to be more sensitive to mental health to prioritize it and to make mental health care accessible, way more so than it currently is. And I'll just highlight another thing that Sid said, which is that mental health struggles and mental health conditions are just as common among physician suicide decedents, but are less likely to be getting addressed through treatment. And that is one of the greatest prevention opportunities we have, is to really be aware and teaching and speaking out about self-medicating, self-prescribing. or curbside sort of informally when a colleague asks you for help by asking for a sleep prescription, you know, for medication or things of that sort, that we are not doing them a service even though they want it. We want to please them and help them. But the way that I see it from a suicide prevention standpoint is you're foregoing that person's opportunity to have a thorough. real assessment of what is going on clinically and you're putting again that band-aid on it that may actually contribute to risk in a way because it's left to to fulminate without an actual effective treatment plan around it. The regular practice of speaking with someone you trust whether it's a peer, a mentor, a therapist or a family member and hopefully a group of those because there isn't one person one size fits all to meet all of our different needs going on in life. the studies that show that peer-to-peer facilitated process groups or that paired mentor trainee experiences, but not that it just in name, but where they're actually meeting on a regular basis. It's so underappreciated that speaking with someone and processing, just working through These experiences, you your internal gauge might tell you, there's like a little twinge, but we just move on. Whether it was something didn't go well interpersonally or something about patient care or whatever it is, we just ignore all of those little helpful signs that are telling us that's something to put a bookmark in and come back to in whatever, you know, session you have with a mentor or a therapist. None of us grew up with any common. knowledge in our homes and school environments, let alone in medical training environments, were these kinds of powerful experiences for good in terms of increasing that coping reservoir and protecting mental health and protecting from suicide risk. None of them were really part of the landscape that we learn and just sort of embed into the background of our mindset. And so again, that's part of a public health strategy for the nation that I'm very glad to be a part of. that is really trying to build in some of these new basic little building blocks of how we protect our mental health and really thrive optimally. In part, often being a physician in training and studying is a lonely pursuit and whatever we can do to help people feel connected and understood and part of a larger community can reap great benefits. Racine, mean, in your story, you mentioned as well that you were keeping people at arms length, you were trying to hide it away. And if it wasn't for your friends who kind of asked you and said, listen, this looks serious. You may not have addressed it. How do you think the landscape has changed in terms of breaking down the stigma that exists around everything from suicide to mental health issues and what more needs to be done? I feel you both have mentioned some very helpful things already. But as you're looking at it at a population level, what needs to be done to break down that stigma even further. There's just this really interesting moment that we're in where I think the culture has changed significantly, broadly, around mental health being recognized as an important, real part of human health, as are more important than physical health, that our Harris Poll survey show at AFSP. However, what hasn't happened yet as much is a deepening that goes farther than just sort of that, like it's out there in the air that we can talk about mental health. I think when it comes to when you're the one who's struggling or when it's your own loved one or colleague who's struggling, the what to do or the uncertainty around, it just stress? Is it just the circumstance? Will it just pass, you know, the wash and wait approach? I don't know what to do. I don't want to offend them. We even have, you know, some, I think really terrible narratives that counter the importance of seeking a psychiatrist or a psychologist evaluation. you know, early on. I just want to say that we are undermining our suicide prevention efforts and our mental health, you know, optimizing by making assumptions about stigma or what a school might think or the negative aspects of medications, which have been tremendously over. sold, perhaps highlighted by the FDA's decision for the black box warning on antidepressants for young people. So there are a lot of forces that I think are countering the advancement of what I would call deepening mental health and suicide prevention literacy so that it's actionable in our everyday lives. And the thing that I always want to leave people with, including physicians and trainees, is this practical step that, you what does all this mean? Well, since we are so good at hiding distress, we have to actually pay attention in a more finely tuned radar. Even though people are going through the motions and they're showing up to work, something in your gut, probably if you're a tune, if you know your colleagues patterns of behavior, their general pattern of speech, even their inflection, their tone of voice, we notice when it goes off course, but We often don't do anything about it because we're not sure that it's our role and we don't want to offend. a very important step that we can all learn is to trust your gut instinct on when someone might be going through something. Of course, it doesn't mean that they are necessarily at risk of suicide, but what is the harm in moving closer to them? Oftentimes we'll talk to everyone but the person we're concerned about. moving right in towards them to say, hey, I noticed you might not seem yourself. You I noticed you can say exactly what you notice. So they're not wondering. You have to say it outright. You're not in trouble. This is because I care about you and only for that reason that I'm coming to you now and wanting to maybe set up a time where we can just chat more about how things are going. I want to be the best colleague, friend, loved one, whatever your role is. And so the conversation is for that purpose. So I can. know you better and have the opportunity to understand what it is you might be going through. Just very open-ended. So I just want to point that out that the cloaking of distress doesn't mean that there aren't actual warning signs to pay attention to as subtle as they may be. And so all those lists of suicide risk factors and warning signs that you see, those are very real. And I would also say, let's even dial up our kind of sensitivity on our radars to say, any change in usual behavior patterns is actually something to take note of. I know that might sound really overboard, but we are such creatures of habit in our behavior patterns. And that might sound a little bit reductionistic because of course we also have free will and free choice. But if you just think about it, we tend to do the same things with an hour off. We are incredibly predictable creatures. And I just look at the brain, there's a physiology to our brain, there's a physiology to our body, our lungs, our heart, our liver, chemistry. And we have ranges within medicine where we look for changes in sodium levels that go outside. And we're very attuned to that. psychiatry as a field has been, I think, inappropriately and inaccurately sort of criticized, assumed to be it's all subjective. That is not true. That is just simply not the case. There's so much about shifting that awareness that we have on others, which we are so good at diagnosing and picking up the signs and symptoms onto ourselves. Sid, how do you kind of train or equip students, residents that you work with, maybe around how to have those conversations? Like if they notice a colleague who may be at risk of suicide or they notice their mental health is deteriorating, how do you teach people to have those conversations? I think all the things Christine said are part of that message, know, that trust your gut. Sometimes people feel that maybe they would upset the person more if they were to confront them or ask them how they're feeling or feel they're being intrusive when in fact that's generally not the case, that people do feel supported. When you let them know, hey, I'm concerned, you're not acting like your normal self. What's going on? Let's find a time to talk. So we have sessions with residents and trainees where we talk about that. The AFSP has made a beautiful four-minute video, just that question, and how do you reach out and how do you talk to somebody and how do you initiate that conversation. We show that and then we have discussions. I think more and more when we give talks, on depression or physician suicide or burnout. We try to include people who have had a lived experience as part of that story to help destigmatize it, to bring it home, to let people know that we're all human and we're in this together. So I think talking about it and acknowledging it is the first major step. Once you acknowledge it and talk about it and provide an opportunity for people to express themselves, to connect, to share stories. I think a lot of the effort then just moves by itself and I think we need to do more and more of that. We also have to make the operational changes. I think we have to make sure that our trainees get enough rest, get enough sleep. If they do need mental health care, we need to provide time. We need to private access. Most cities, even if I tell someone, hey, you're depressed, you need to see someone and they say yes, well, go find a psychiatrist who's available in the next four months or who will take insurance. So we need to have accessibility by having people available who can work with anyone who's struggling, but in our case particularly our own trainees, our own colleagues, our own students. And that's a work in progress that we all need to continue focusing on. and as Sid has alluded to, is that in the early, maybe mid 2005, six, seven timeframe, there were a number of losses to suicide within our institution at the time at UCSD and the Maida family, but also the leadership of the hospital and the medical school decided and were finally motivated due to the tragic experience of multiple losses, that it was worth exploring, could something be done? were there, are there evidence-based ways to have a sort of public health approach towards suicide prevention of the workforce and the learning and the trainees. So it's kind of just an interesting thing because we might think of suicide prevention through the clinical lens with patient care. And of course, that's a really important and also advancing field that everyone, including primary care and other mental health professionals need to learn and get updated on because things have moved. in the patient care to prevent suicide. But from a public health standpoint, in a learning and working environment, we really did have that opportunity to start something. It's called the UCSD Here program, and it involved a massive education campaign. It utilized the AFSP's interactive screening program that allowed for real-time connection for those who are really becoming at risk. to safely engage with a counselor who, as Sid was just mentioning about making referrals that are attuned to the person's schedule and insurance and cost and like specific clinical. I mean, that here program has counselors that have been in place now over these, you know, now it's been about 16 years that have learned how to do that and how to help move people who, like myself for years are in a state of not readiness and not seeking any kind of help and yet are at high, high risk of suicide and helping them move to a state of readiness and then giving that help to find the right path forward in a way that feels safe. That's a huge part of it. The barriers are real and institutional and access to good mental health care. There are also internal barriers that we can all take steps to help overcome for those who might be suffering around us. Thank you, Christine, for mentioning that because I know UCSD has been such a leader, I think, in this area. So I want to circle back to this paper that you, Carrie and Sid wrote together and then Sid, maybe you can tell us a little bit more around how the leadership has really taken on board this culture of wellness at UCSD. In your paper, you wrote, the outworn medical culture of subverting personal and family priorities for patient needs, stoicism, self-sufficiency, and never asking for help. is slowly being updated to make room for a culture of wellness that also prioritized time with family, friends, loved ones, adequate sleep, nutrition, hydration, exercise, accepting humanness and imperfection, staying connecting, asking for help and sharing control. Sid, how did leadership take those things? It sounds very nice to say that, but how does those things become a reality in a medical environment? It's aspirational, it's not all happening, but some of it is happening slowly. It's changing culture takes time and effort. Leadership buy-in is important. In part, we've gotten leadership buy-in because people realize the medical costs of physician burnout and especially physician suicide are incredibly high. And an ounce of prevention is worth a pound of cure. And putting it into monetary terms. really help. It may be up to like a million dollars to replace a physician who dies prematurely by suicide or leaves the field of medicine prematurely in terms of replacing them and all that other stuff. And so leadership listens to that. But they're also learning, you know, paying attention in their own lives to mental health issues and I think the conversation is such that Everyone is now paying attention. I think the fact that we've, you know, a lot of celebrities have come forward with their struggles with mental illness. Suicide is not as hidden. The media has learned much better how to portray instances of suicide. It's a learning process, but they're getting better. The AFSP has had a real lead in educating them. So slowly but surely we're coming there and the success of the HEAR program, and it's been about 16, 17 years now. There's not been a single physician suicide in our institution who's died by suicide. There has been a medical student, which is a tragedy, but not a physician. Since nurses were included in 2016, there hasn't been a nurse suicide in our institution, whereas there was a series of both before. And that speaks loudly. It's not going to last forever. We know that. And we can't take full credit for that. There are a lot of other things going on. But I think we need to let people know of the success of the program. We need people who have benefited from the HERE program to shout it out, to let others know, to let the leaders know. Everything about our program is very transportable to other institutions, and a lot of institutions are starting to incorporate parts of it. Particularly, Christine mentioned the questionnaire that is part of a screening program for screening for dys... distress and suicide risk. And that screening program has embedded in it a way of engaging those physicians who screen positive or who have a lot of distress. And a lot of institutions are now using that screening program and benefiting from it. So, you know, I think we're in the early stages of a real change in our culture that we just need to keep sustaining. I think that's just so encouraging for anyone who's listening from any corner of the world to know it is possible. And I think what you've been able to achieve shows that it's doable. It may not, like you say, last forever, but the results you've seen is really remarkable. Christine, maybe as we draw to a close, you've mentioned that you've brought so many changes into your own life to protect your own mental health. But I want to ask you again, How else have you cultivated a culture of acceptance, connection, wellness for yourself, and what advice could you have at a personal level, how any of us can cultivate that culture for ourselves as well? Well, as I mentioned, there was a really pivotal turning point during medical school when accessing mental health treatment and really engaging fully at a moment when I was highly motivated because it was going to be the difference between being able to go back to medical school or not and making that choice. that was step one. I would point to another really pivotal moment in my life when I was having my children. And even during my pregnancies, I still had a bit of that old mindset that there is no limit to my activities, my energy, know, sleep that I might need. That I felt still had this sort of illusion of being superhuman. It was a very concrete, you know, before and after picture of making choices to prioritize my pregnancy and uh I did that by, again, just really by very simple practical things. Your brain is a sensitive organ and these inputs really matter. Look, mental health, physical health, our lives as humans, it's extremely dynamic. Other things have happened in my life where I again needed to prioritize health and mental health. But I think the difference now is that I'm extremely attuned to when it starts to change and when it starts to deteriorate. I don't let it get as far, in fact, you know, and everyone in my life. who I work with and my family members know that this is an open topic, that we can talk to each other about what we're noticing, that we won't take offense, we will actually take it to heart. Because sometimes it does take external people to tell you what they're noticing. Mental health has short-term and long-term sort of prognostic implications. So I take all of that actually very seriously for myself. and my family members, and of course navigating that with others is that art of relationship and communication because you can't make those decisions for others. mean, certainly when your children are young, you can more, but as they grow up and the adults who are loved ones in your life. They are on their own journey and finding a way to respectfully but lovingly keep that priority in front of us as a family has been a real learning journey. And actually it's something that I've brought into the education that we create at the American Foundation for Suicide Prevention because there aren't a lot of guides about the in the moment as a parent or a loved one if a loved one is struggling or becomes suicidal. And back to your first original question about What is it that for me has made an entire life's work be sustainable and of interest around these topics of mental health and suicide prevention? And I think I am wired for it in certain ways, but I also think that the lived experience didn't stop with just myself, whether it's genetic or environmental or whatnot. Most of my family members have also had to contend with or continue to live with very serious. significant mental health conditions or experiences. It's a continual learning journey. so I wish that one day I would not have to continue to benefit from this lived experience, expertise, but that has been very real for me as well. Let me add one thing to your experience. It was unfortunate that one of Christine's pregnancies occurred when she was chief resident. And she was a wonderful chief resident and the residents were all very, and the faculty were very dependent on her being a terrific chief resident. And it was with some guilt that she took time off for her health, knowing how much we would miss her. But, you know, important as she was, we did fine without her. We did well. The residents got good training. And it would have been better if we could have offered her to come back part-time for a long period, which we can't do in the, it's not allowed in residencies to have someone working part-time, which is crazy. But she was able to prioritize her health at that time. And we were able to function without her for that period of time. And I think it's important because we, again, we have this exaggerated sense of our own importance and responsibility. And we need to overcome that knowing that we're part of a team and we're human. And in fact, that I finished, I ended up delivering my first child and then finished residency and started my faculty position on maternity leave, on parental leave still. I mean, that is not every institution. that would embrace that and the fact that it was met with just race and generosity that was afforded to me and it's something that I'm always grateful for. So it's a relationship as well as self, you know, individual choices that we're making. Christine said, thank you so much. You both are, I mean, accomplished so highly in what you do, but I think it's just this willingness to lead by example that is gonna really usher in this culture of wellness that will be so different for the next generation. And through all these conversations, if anyone thought physicians or health workers don't care, I think it's just coming out so loudly just how deep people still care about their work and about what they do and their love for humanity. And I think these conversations will hopefully help. us realize that the beauty in the vulnerability and in our own humanity that exists as well and embrace those. So thank you so much for joining today. Thank you, Lindy. Thanks, Sid. Always a pleasure. Absolutely, thank you. Thank you for taking the time to join us for this discussion. To learn more about our guests and access the resources mentioned, please visit the Sim2media podcast page at sim2media.com. We look forward to having you with us again for our next important conversation.