It’s okay to not be okay

Experience #1 – Illness during Fellowship

During my first year of pediatric rehabilitation fellowship training, I moved across the country, necessitating a long-distance relationship with my soon-to-be wife and a vision for my future as a pediatric physiatrist. Suddenly in the first year of my fellowship, I had a pause in training. I noticed a testicular nodule, went for an ultrasound, and was subsequently diagnosed with localized testicular cancer which initially only required an orchiectomy – there had been no metastasis. I had a routine recovery. However, on first follow-up, labs and imaging noted metastasis to the lymph nodes and lungs. This would be a new, longer phase of care.

Treatment required several months of chemotherapy, several weekly appointments with various providers, and ultimately, a retroperitoneal lymph node dissection, which necessitated its own prolonged recovery time. At the time, I was not only in medical training but also in the process of applying for a subsequent sports medicine fellowship. Based on my personal goals, graduating on time was paramount to start my next fellowship on time. Additionally, I had moved away from my support system on the East Coast for my fellowship across the country, so I had to return home for my treatment regimen (i.e., away from my fellowship hospital). This enabled me to have closer access to my immediate family, weekly appointments, and the home and environment that I was accustomed to.

While I was focused on finishing my fellowship on time, my program director (PD) was focused on my health and providing me with the time and space required for recovery. Through consistent communication and updates, I worked with my PD to evaluate options to still graduate on time by doing non-clinical work. My PD continued to offer me time off that I needed to heal, while we worked together to maximize a schedule of research, presentations, and lectures. Personally, productivity was important to keep me focused on my goals, distract from my recovery, and to stay academically oriented.

I learned some valuable lessons during this time: First, make sure you attend all your appointments as recommended by your healthcare provider. If I had not initially made an appointment after noticing my nodule, I would have prolonged the time needed for treatment and may have had a different outcome. You can and should take the necessary time to address your own needs and work with your department and colleagues to ensure appropriate focus on personal care. In addition, I made a personal choice to do non-clinical work while getting treatment. However, everyone has different capacities and has to make their own decision about what’s best during treatment. For some, this may include abstaining from all work-related activities, and for others this may include doing part-time clinical work. Constant communication with my PD was essential to determine what was appropriate and fit into ACGME requirements with the balance of my treatment plan. Finally, routine testicular checks are both simple and potentially lifesaving. This topic, among other important health screenings, should be discussed with our young adult trainee population in the appropriate context.

Additional practical applications include taking advantage of the American Board of Physical Medicine and Rehabilitation (ABPMR) leave policy, which allows for four weeks of additional consecutive leave time to occur as a single event. ⁶ There are also various types of leave schedules available through the Family Medical Leave Act (FMLA), one of which includes intermittent leave, ⁷ which permits employees to take leave in separate blocks of time or reduce work schedules. This provided me the flexibility to attend any extra appointments or therapies related to my illness without having to miss time or work. Anyone who is ineligible for FMLA based on their employment ⁸ should maintain open lines of communication with their leadership to maximize time off needed during treatment. It is up to the individual to decide how much is appropriate to reveal, but it will be important to emphasize that the time off is necessary for their health needs. It is also important to think carefully about your benefits packages such as disability insurance and health insurance plans to best care for yourself and your family. For example, it may be cheaper to acquire a disability or life insurance policy when younger and you should consider differences in deductibles vs. premiums based on anticipated needs. There are also policies such as own occupation disability, ⁹ which allow you to collect disability if you are unable to perform the core duties of your profession, while still working another job or another duty (e.g., medicolegal work or consulting).

Experience #2 – Mental Health Challenges during Medical School

At the beginning of my third year of medical school, I was present during a double homicide, hiding in my bathroom until the SWAT team could safely remove me from the property. While I emerged physically safe, I struggled mentally with post-traumatic stress disorder. It took a while to admit to myself that I was struggling and needed help. Once I did, I wasn’t sure how to balance improving my mental health with my clerkships that were just starting. As I was in medical school at this time, I first reached out to the Assistant Dean of Student Affairs to see what resources were available to me. I also looked into taking time away from medical school, getting as much information as I could to help understand how this might impact my future and training schedule. I then had in-person meetings with my clerkship director and the attending whose service I would be on to discuss my struggles and make a plan to better my mental state, while minimizing missed clinical experiences. After multiple transparent and vulnerable conversations, I found a way to use medical school resources to attend therapy, recover, and become a better overall person and clinician.

In medicine, trainees are expected to be able to “handle” and “normalize” extreme amounts of stress and anxiety, including but not limited to, studying for and taking tests from which a score can determine your entire career, moving multiple states away from a support system to pursue training, constant competition with other trainees, and learning to deal with new academic demands. The transition into residency induces further stress involving newfound autonomy, balancing relationships with supervising physicians and team members, moral injury, learning a new team or subspecialty every few weeks when rotations change, and increased expectations from coworkers. Additionally, in training, one learns how to cope with the ailments they treat. Physiatry training involves treatment of those with catastrophic injuries and many life-changing moments for patients and families, which can further lead to struggles with emotional health as we try to help people in these circumstances. This is not commonly addressed in physiatry-specific training programs, though it affects all who practice the specialty.

There is often pressure to deal with this stress independently, to avoid seeking outside help and not let it affect our course work. According to a global meta-analysis, 34-44% of medical students experience anxiety and depression, while in residency 29% experience anxiety and 25% experience anxiety and depression. ¹⁰ However, only 16-23% seek help.^11–13 This discrepancy may be due to a lack of knowledge of available resources, limited time off, or fear of immediate or future repercussions. Therefore, it is extremely important for each program to publicly acknowledge that mental health struggles are common in training and that it is okay to seek help, and for leadership to promote available resources.

Sadly, for those wanting to seek help, there is much concern about being judged and fear about licensure requirements in certain states.^14,15 This is why it is of the utmost importance for a medical school or residency to offer anonymous mental health resources. This can be done by having a contract with a local psychology practice that gives the program a bill each month for a number of appointments, without a record of which trainees they saw or how often. It is also important to consider the timing of the appointments offered by the service chosen, as it can be difficult for trainees to schedule these around their clinical hours. Finding a service that offers appointments on weekends, before or after clinical hours, or during lunch hours can be helpful. Furthermore, it is important to make time off for appointments available to those seeking mental health help. This can be done by allowing them to skip a certain amount of patient encounters per week for appointments, not requiring trainees take an entire sick day to attend a shorter appointment, and helping facilitate conversations with the trainee and supervising attending to find non-clinical times for appointments.

It is important to create a culture in medical school and residency programs where one can feel accepted and respected no matter their mental health struggles, and where there is a safe space to ask for help. This does not mean increasing online modules to learn about mental health. It means opening the dialogue in small groups throughout programs, so trainees know what they’re feeling is okay and have trusted leaders in the program they can turn to when struggling. It is also helpful when leaders demonstrate vulnerability and share some of their past or present struggles, as this lets trainees know their feelings are okay and won’t hinder their careers in the future. For some, this looks like a “Friday Coffee Walk,” where the attending schedules 20-30 minutes weekly with each rotating trainee. This time can be used to check in on mental health, while offering a designated time for rotation feedback and deepening the relationship between the trainee and attending. For others, this can manifest as a sit-down with trainees after rounding on a particularly difficult patient, where the attending shares what they found hard about the encounter and opens the discussion up to the rest of the group. ¹⁶ Program directors and chief residents can also have scheduled biannual or quarterly casual meetings with each trainee, where the focus is not on current training or reviews, but on mental health, overarching life goals, and the marriage of personal and professional ambitions.

Experience #3 – Family Crisis during Medical School

There is a Turkish proverb that goes “fire burns where it falls.” Though trauma, grief, and stress can impact the patients that we care for, that “fire” can also burn and impact their family/caregiver/support system, the interdisciplinary and intra-disciplinary team we work with, and lastly, ourselves. We should not be comparing our “burns” to one another’s, but rather acknowledging the human experience. We should be providing empathy to sit in the darkness with others so they know that you are there with them once they are ready to crawl out of the darkness.

I am a child of two extraordinary parents who raised me in different cultures and experiences that have impacted the person I am today. I am shaped by the many positive memories and moments, and by the challenging ones. During my medical school journey, I was driven to be the “best” I could be – academically, clinically, and with medical school-affiliated extra-curricular activities. My focus was on medical school, and I had not really mastered having a balanced life, including time with my family and friends. Then, my mother was diagnosed with ovarian cancer and that changed everything. As the “health navigator” between her oncology team and my parents, I was the one to ask questions and explain medical jargon and procedures to them. I was on the opposite side of the patient-physician relationship, witnessing each interaction. With every surgery, chemotherapy, radiation, nasogastric tube placement, paracentesis, thoracentesis, being the “best” in medical school stopped being my focus. Time with my mother and with my family became a priority.

During this time, when I was in my medical school classes and rotations, I wasn’t focused and felt lost. My class was filled with brilliant people that I continue to admire to this day; and yet, at that stage, I didn’t know what I needed from them, and I didn’t seek out support from them. I took time away from medical school when my mother’s cancer metastasized, moved from my apartment back to my family home, and tried to focus on being a son. One of my medical school friends would check in on me, bring flowers for my mom, and upon her admission to the hospital would bring his guitar so we could sing Yellow by Coldplay. She loved that. She loved walking around the oncology floor, one hand holding her IV pole and one hand gripping tightly to my arm for support. We would stop and look at the park across the street from the hospital, breathe together, and let the warm rays of the sun piercing through the window touch our skin. After her passing, I moved my father to stay with me in an apartment, cared for him as we grieved, and created a new routine because there is no such thing as “returning to normal.” I returned to medical school with a new focus on the kind of healthcare provider I wanted to be for patients and their support systems. I became more intentional with each conversation I had with patients, families, and team members. Though I returned to a different medical school class, that same friend consistently went on long distance runs with me on the weekends, would watch movies with me, and grab food with me. My attending physician mentor in medical school would check on me, not just academically, but on an individual basis in the privacy of his office. The support - the longitudinal care that didn’t diminish days or months after my mother’s passing but continued - from these two and a few others meant the world to me.

It is that ability to respond to others that I want to highlight on a national level, with local systems, for team members individually, for our patients, and for ourselves. Information in this section comes from reflection and discussions team members in my residency had during the COVID-19 pandemic at Rehabilitation Institute of Michigan, from my fellowship at Children’s Hospital Colorado, and from the Trauma Informed Care team at Children’s Mercy-Kansas City.

Nationally, the Dr. Lorna Breen Health Care Provider Protection Act was passed in 2022, to support health workers’ mental health and wellbeing. It awarded $103 million in grants across 45 organizations with the goal of implementing evidence-informed strategies to reduce and prevent suicide, burnout, mental health conditions, and substance use disorders. This resulted in the creation of the Impact Wellbeing national campaign, whose aim was to create a system in which health care workers thrive. It focused on involving hospital leaders in implementation of evidence-informed operational policies, to remove barriers and reduce stigma around seeking mental health support, and to reduce burnout and improve professional wellbeing in hospital settings. Since its passing, less than 1% of the 6,120 hospitals in the country have received program funding from the Lorna Breen Act and 200,000+ healthcare settings are still left without the ability to help their workforce in crisis. We hold the power to reach out to our representatives demanding reauthorization and renewed funding for the Dr. Lorna Breen Health Care Provider Protection Act (HR 7152/S3679) to widen the reach to more hospital systems and to focus on reducing the administrative burden on health workers. ¹⁷

At the federal and state level, there has been a shift away from asking about and documenting mental health fitness to practice as this may potentially prevent physicians from seeking the help they need. There are an increasing number of national organizations that do not support/require states, hospitals, or insurers to ask about a physician’s mental health history. ¹⁸

Within your healthcare system and department, it is important to discuss what resources exist through the institution’s Center for Wellbeing (or equivalent) as well as confidential support resources locally, within the university system, and the hospital system.

When responding to a team member individually, it is important to reflect on the intention before offering support, approach privately, actively listen, and offer support. ¹⁹ While this approach may seem simple, it takes practice. For me, it was finding that space with the person individually and reaching out for support. I am the primary caretaker for my father who has mental and physical health conditions. I assist with setting up his medications, some activities of daily living, and taking him to and from his medical appointments. When I first took on this role after my mother passed, I was worried about how I could practice medicine, get a residency or fellowship, and dedicate the necessary time to care for my father. If he needed me emergently, could I step away and get to him in time? I adapted my priorities to intentionally and actively be a part of his care, and not just my own ambition and desires. It’s important to connect with your team, build trust, and discuss how to accommodate your needs as you cycle through the different roles you play. With every stage of my medical training journey, I proactively reached out to the chair, PDs, program coordinators, co-workers, and team members to ensure I could make time to be a clinical educator, grow as a physiatrist, and be a son and primary caregiver. I’m extremely grateful to those individuals who have supported me in acute moments of need and who remain present every day thereafter.

When considering our patients, the rehabilitation unit is often a safe space for them to recover both physically and mentally after a life-altering event. If our patients are experiencing trauma, there are ways to help them feel validated in their coping and struggles. We can help them understand that trauma is not normal; it’s okay to reach out when there is an inability to cope with emotional distress, when they want to take action in response to trauma, and when they need to be believed. It’s important that we increase our awareness of differing life experiences and be mindful of our biases and assumptions. The more we talk about assessing safety and trauma, the less stigma there is around it. It’s okay to have conversations with the patient’s parents, family, caregivers, and support systems to start, and then transition to private conversations without the family to work toward normalizing the conversation. ²⁰ You can standardize a script of opening phrases like “I am here to ensure your body is healthy and safe” or “We are made up of our experiences – good and bad. Some affect our health today and in the future. The goal is to build up what needs to be enhanced and increase the resilience we have.” Stressful things like food insecurity, violence, and loss are common and affect a child’s health and development. We can incorporate this by asking questions in each patient encounter. Stressful experiences can affect the health of many pediatric patients and answering questions can help to better understand the patient. Other standardized scripting for disclosure includes “Has anyone hurt or frightened you?” or “Have you experienced anything bad, sad, or scary?” If you note shame or embarrassment, you can acknowledge it and use a statement like “You don’t need to worry about anything you say here. We want you to be healthy and safe.” ²¹ After disclosure, scripting can include phrases like “I am so sorry this happened. I believe you and what you are sharing with me, and I will connect you with someone who can assist you further on next steps,” or “What happened is not your fault.” ²² For our patient populations, we can use the term “safe touch.” We can also ensure that we give the patient an opportunity to communicate. For those we care for who have a cognitive impairment, reviewing how they communicate can reframe our questions and give them autonomy to answer in their own ways using augmentative and alternative communication devices.

Caring for others can be personally draining, and it is important to maintain self-care practices along the way. The Circumstance, Thought, Feeling, Action, Result (CTFAR) model, (see Figure 1), is a metacognitive tool that can help a person work through circumstances that trigger certain thoughts and subsequently fuel actions and results. We can’t always change our circumstances, but we can change our responses through reframing our thoughts and feelings, which yields a novel action, result, and correlating sentiment. ²³ OPEN IN VIEWER