Episode 64: You can’t handle my truth - Transcript & Subtitles

Welcome back to the paperless podcast where the number needed to watch is one. We are in the early stages of our YouTube station with my amigos who all have a face for radio. Hi, Linda. How are you? What the hell? Harsh but true. Sitting here minding my own business, and I get slanged on. Sorry, Linda. Go ahead. Say hi. Hello, darling. Linda, I'm not sure. I've even watched the Olympics. I have. We're in the middle of the Olympics. The Canadian women's rugby seven.

Just won a silver medal. I'm not sure if you saw this. I'm a big rugby fanatic. I played it in uni. This is the first time the Canadian women have medaled. Apologies to you if you're not a Canadian. Apologies if you're not a rugby fan. But this is a great day to celebrate. Linda, I'm hoping you saw a little bit of the game. I did. And if I remember, it's not part of it. They actually beat the world champions. They did. To get there. Well, they beat the world champions, the Australians. But then they lost in the finals to the Kiwis, which is a pretty powerhouse.

Yeah. is repeating gold medal winners back-to-back games. How Canadian is it to say that we're pretty happy to lose to those guys? Like that's a very Canadian statement. Yeah. Yeah, they're real good. Fact. They're good. So we're sorry. We're sorry that we beat you. did well. All right, Jason, what have you been watching at the Olympics? I've been working a lot. How sad is that? I watched the end of one of the Canadian women's soccer team games where they

came back to win against France in injury time. That was amazing. Outstanding. Like what it on both sides, amazing athleticism. I caught clips of women's gymnastics all around. Amazing, amazing athleticism. And I saw a couple of things about Celine Dion singing from the Eiffel Tower. And my first thought was don't jump or stay away from the edge. It was it's been an entertaining week. She was tethered, by the way. so we did the we did the composite of the Canadians apologizing for winning silver.

And then the Canadian soccer team are cheating using drones and the entire coaching staff has been fired and sent off and the Canadian government is withholding funding for the Canadian women's soccer team. So we're both into the spectrum here. We're not holding them now. We like to cheat just as much as everybody else. I think it's a misunderstanding. We're Canadians. We don't cheat, but we're really dumb at being a tourist. They were just trying to take pictures and then they got caught. They were told it's a no flies on. They're like,

but we're with the soccer team and then that didn't work out. All right, Lava, we put you in the difficult question. It's your paper. But before that, who are you cheering for? You live in States. It's hard to be seen in hard days. You have some Scandinavian blood. Karolinska wants you to be cheering for Sweden. But, you know, you grew up in the great white north, you loser. So which team is which team, or which country is your team? And living in the US.

I am nationally agnostic when it comes to the Olympics because like honestly, watching these athletes at the top of their game in so many ways, I'm just like so in awe and quite frankly, I don't know if you guys have, you play this game at home? If I wonder what Olympic sport I could do today, like is there, so John, like you, I rugby for I could do, right? could do napping, I could do Olympic napping. I played rugby for one season. I watched five minutes of that game going, nope, nope.

Nope, that is so not a Varpio thing again. like, yeah, like I want to know, is there something I could do that would get me in the Olympics? Because boy, that looks cool, but I don't think so. Yes, there is. There's something that we haven't seen yet. It's later on in the week. It's called kayak cross. And it seems to me like a combination of, of kayak slalom and bumper cars. I think you should do break dancing. I've seen you at a pub and I think break dancing would be awesome. Break dancing is an Olympic sport now.

It is check it. Look it up. If we call it falling down, then yes. All right. But friends, we are here to have a conversation about a paper today and actually it's a paper. It's a serious paper. And I want to start by saying we in this podcast, we have never shied away from difficult topics. And today we're going to look at yet another difficult topic straight in the eye explicitly. And we're not going to back down today. We're going to talk about mental illness and self -reporting of mental illness among physicians. I worry this might be triggering.

for some of our listeners. So listeners, please know if you need to skip this episode, we totally get it. So with that, what do we know? We know the rates of depression on residents are high. They're about 29 % of the rate of non -physicians. Among non -physicians, it's much lower. It's close to 8%. We know physicians die by suicide at a rate that is staggering. We also know that physicians suffer from mental illness. We know this is a problem. We also know...

that many physicians have real and justifiable worries about disclosing living with mental illness. They worry about not living up to the perfectionist ethics that dominates our field. They worry about disclosure, what it might mean for their license, about what it might be, how their social group might deem them as weak or problematic. And this is for me, like truly, I picked this paper because this is a problem for me. have the data. We know physicians are living with mental illness and yet we make it

ever so hard, if not impossible, for those individuals to disclose their experiences and get the help they need and deserve. So this study aims to address this conundrum. It's by Kassam et al. It's published in Perspectives on Medical Education. And it looks to explore the barriers and enablers of self -disclosure by understanding the perceived outcomes, both positive and negative, of self -disclosure of mental illness among medical learners. Now, you have each had very long careers in the field. And you know, I'm sure, people who live

practice as physicians who have disclosed and who have not disclosed. Maybe you can talk about how prevalent it is to disclose. I have no insight into what it's like to be a clinician. Do you hear about mental illness often, are struggles things that are talked about? Is it largely hidden? What's it like in the clinical context? I'm going to ask Jason, then John, then Linda.

I think it's changed over time and in dramatic ways. think for our generation and the generation ahead of us, it was not discussed. If people were mentally ill and very sick, they just went away and had a surgery or something like that. It was not discussed. It was definitely a lot of stigma, lot of framing around weakness. Other people allowed to be sick, but not us. I think that's really different. Now, generations have made differences in this. You hear people talking about definitely about burnout, definitely about needing a break.

Definitely people talk about depression. I still think there's a category that is verboten. I don't think people in my network, in my institution, talk about addictions. I think there's a couple of diagnoses that are less acceptable, like bipolar and maybe a little bit OCD. And whereas some other things like depression, burnout,

Even suicidality that people have gone through, eating disorders, people talk about those openly because they want the next generation to recognize risk factors and get help and that sort of thing. I think the world's really changed. I agree. I can think of some high-profile people on a national level and there's some friends of the show that have been really brave in bringing a spotlight to mental illness by talking about their experience, but it comes at a tremendous price to them leading up to that.

And I have no idea what happens on the other side. Knowing what social media is like, I can imagine is staggeringly awful with just the pulling apart of people's courage. I've seen it close in my own community and it's been encouraging there. You know, I've seen it at an institutional level that the prevalence is far larger than what we see in terms of the discussions that we're having.

And so the prevalence for accommodative learning accommodation and the increasing resources that we need to provide to our learners is, you know, at my deck and overall that I play, I'm just continually shocked at the prevalence that's happening. But I think about my own context and what it's like for me, health services seems harder. You know, I want to be cautious about not labeling clinical diagnoses, but the

prevalence of PTSD, which is a really tragic thing because of the things that our health professionals and providers experience. That prevalence is surprising to me. But in a broader sense, the moral injury of working in these systems that ask us to do impossible things without the resources and taking and carrying that emotional backpack, the empathy necessary to be a great health provider, but also realizing that you are in an impossible situation. Yeah, I can just see

burnout as one feature of mental health along a spectrum that leads to clinical diagnoses. And so I think this is a timely conversation. I think that is awesome and very enlightening. I'll agree with everything my esteemed colleagues and particularly as clinical teachers and clinicians have said. I think it is getting better because wellness has become something that's talked about.

I think it's still stigmatized. And I suspect it may differ by context or by discipline. What may be acceptable in one specialty may not be in another in terms of disclosure because people still view it as something that harms advancement professionally or personally. I think we see it as teachers who are also mentors. And when I say we see it, we may recognize that there are mental health issues with an individual

learner, mentee before they are willing to disclose. And it comes back to what can we do if we see somebody who's struggling and hasn't disclosed? I think it's probably up to us to sort of explore it a bit with them and make it easy for them to disclose without being stigmatized. Thank you for those comments, friends.

So I'm going to move us into methods and I'm going to try to do this really quickly. There's a beautiful rich description of their methods in the manuscript and I'll encourage all of our listeners to go to perspectives to find that. I'm going to go through it quickly because I really want to focus today's conversation on the results and discussion. So the authors work from a pragmatist orientation and conducts a mixed method study using a sequential qualitative research design, which means for this study that the survey acted as a selection tool and background framing the qualitative study.

The quantitative study consisted of two parts. First, there was several demographic questions that the research team used to provide insight into participants' intersectional identities, gender identity, racial, racial, racial, ethno -racial, sorry, identity, marital status, those sorts of things. The second part consisted of three previously developed and psychometrically tested questionnaires. They were the number one, the self-stigma of mental illness scale, the short form.

Two, the opening mind scale of healthcare providers. And three, the WHO, the five well -being index. In terms of analysis of the quantitative data, did continuous data were analyzed using independent sample t -test, comparing mean scores of the questionnaire subscales and demographic data that were not dichotomized. They used Cohen's D to determine the extent of the relationships between the data.

To my more abstract theoretical understanding of quantitative analysis, that didn't give me any cause but pause, but I'll look forward to your comments on that. This leads up to the qualitative component of the study where they conducted interviews with the participants who had self -disclosed their mental illness to anyone in their sphere of training. They used hermeneutic phenomenology, which makes perfect sense. They want to do deep exploration of the individual's experience of self -disclosing mental illness. Now,

They used 90 -minute interviews to solicit narratives of experience, and they also used any comments from the survey tools that they thought might help them. Wouldn't you, if you had extra data, use it? Fine. Analysis followed hermeneutic approach. They used the process described by Ajjawi and Higgs, great paper, by the way, to move from first to second order constructs via immersion, understanding, abstraction, synthesis, illumination, and integration. If this is new to you, but you're interested, I've dropped a link to the methods,

the lovely methods paper by Ajjawi and Higgs. I love their hermeneutic approach. So I'll stop there. I'm interested in your thoughts. Let's go Jason, Linda, John. You know what? In the last little while, we started to do a few more of these mixed methods. I thought this one was nicely written compared to a couple of others I've read, or we've covered. It nicely lays out their logic chain. I had to read the section a few times about the scales and why they were being used.

And I just want to flag for everybody that I didn't unpack this one as far as I could have because of time. But sometimes when people import scales from other contexts, especially when they say the short form scale, there's a bit of a yellow flag there that is it really had the same utility as it was developed for. The entire body of literature around burnout in physicians is contaminated by misuse of other scales. So we don't use scales the same way that

some psychologists might have developed it for. So just a little flag. Overall, I was very positive about these methods. So a couple of things. First of all, I certainly learned a few things because when I see the word pragmatist or pragmatic, I just think practical. And it was nice to see that there actually is a definition for a pragmatist orientation. Knowledge created from socially shared experiences and influenced by interactions.

So nice to learn a little bit about that. Secondly, the question I have for you, Lara, is what is bracketing? That was a word that was mentioned in the paper that I didn't understand as it relates to quantitative analysis. Having said that, I thought things were very clearly explained and they did do what a...

a mixed method study is supposed to do and that has used one part of it, in this case the quant, to inform the qual. Although they didn't actually tell us how they did that.

I have mixed feelings. See what I just said there about the methods. individually, each portion is rigorous, and they have an analytic approach, and I like the quantitative approach that individually makes sense. I will say that there's probably response burden problems. They make their survey 65 items long by the end of -

Six items, I'm not paying attention. So there is maybe some little nitpicking, but that's picking around the edges. I do not do hermeneutic analysis, but I know it's so much work. And because every time I read it, I like, that seems hard. So I know that they're getting lots of rich data, but I'm to take issue and I think I don't think this is a mixed methods study. I think it's a multi -method study. They try to integrate in their conceptual framework the rationale for why

They need to take these two different sources of data and integrate it together. But just as a quick check, there's no design diagram for this study. There's no joint display. I will say that at the end, if you look hard, implied in their discussion is the integration of the findings. But for most of the results, what you see is A and then B, A and then B. And that's not mixed methods. Even in a sequential design, you want to see

A informs B so that you get a complete sum, which looks like C and that's the meta inferences. It's the integration of those different parts of data that one is insufficient without the other to have a bigger output. And that's maybe a mislabeling of what they're doing here. So I thought that was implied. I do think they're doing as a multi -methods Thank you Sean. your socks off. I just, there's some things that I expect to see here, and I don't see it.

They imply it in a few places, but it's not, if you were a mixed methodologist, you'd probably say, hey, there are some issues that we might have concerns for. Jason, sorry, do you want to add to that? No, that really resonates with me. John's got a good point. It's kind of like they didn't do enough to make explicit how the two approaches were integrated. You don't see a diagram or a figure. It is very sequential. It's implied though.

So I'm going to jump right into the results because honestly, this is a really important topic, and this is where I want to make sure we spend our time. So if these results don't make you scream, you're a more composed human being than I am. admittedly, that's a low R. But we'll start with the quantitative results. 36 % of the respondents reported having disclosed a mental illness. 24 .7 % had only considered it. There were medium effect size found with

radicalized learners having more stigmatized attitudes overall and more stigmatizing attitudes with respect to disclosure, and learners identifying as women having lower stigmatizing attitudes than those identifying as men. Large effect sizes were found with learners who had close contact with a person with mental illness having lower stigmatized attitudes overall and with respect to disclosure. Okay, now it's going to get worse.

Well -being was shown across all participants. If that doesn't warrant a pause, I don't know what does. Residents had more negative attitudes towards people with mental illness and towards disclosing mental illness. People who identified as racially minoritized learners had higher, scored higher, sorry, in applying the stigma of mental illness to themselves than white learners. What did we do to these people? Okay. Qualitative results.

The authors first talk about enablers and barriers to disclosure. Nothing surprising when it comes to the barriers is about fear and stigma, fear of judgment from peers, fear of retribution and career outcomes for those with more structural power. Among med students, they had fears of appearing as though they weren't up to standards, not up to par. Residents described fear of negative outcome for their career, for future licensing issues. In terms of enablers, most prominent was supportive social relationships.

such as preceptors who were genuine and empathetic and understanding, supportive peers, having reassurance of anonymity and transparent policies. Can we underline that somehow visually? Anonymity and transparent policies. But what would happen if they disclosed? Participants talked about needing to give themselves permission to self -disclose, to overcome their internalized fears of being weak, of being less than, of not being worthy. Not being worthy of their place in the profession because you have mental illness. Like really? Okay.

We're not done. It just breaks my heart. Participants who talked about their journey to disclose, they talked about the journeys, but those journeys were highly variable in terms of perceived identity and diagnosis. This is something you alluded to earlier, Jason. There seems to be a hierarchy of what's OK to disclose and what isn't. One participant said being sensitive about their ADHD diagnosis, but they were very concerned about the stigma around their bipolar disorder.

Another participant was less concerned about their bipolar disorder, but they were very hesitant to talk about their obsessive -compulsive disorder diagnosis. And their perceived identity was also factored into the journey. If they felt like they were outside of the system because of their identity, it impacted their comfort with disclosure. So if it's hard to disclose your non -cisgendered identity, imagine trying to disclose that plus mental illness. Here comes my not.

favorite part of the results. I'm going to read this verbatim because I can't do better. Participants described a sense of hypocrisy, double standards, or duplicity. Several noted that an application process seemed to seek students who were well -rounded and that narratives of adversity were often anticipated. Yet their experiences in medical training were discordant to their expectations and their conceptualizations of what would make a good physician, end quote. I'm going to call that a bait and switch.

The authors leave us with a little bit of hope. Participants described feeling positive after disclosure. They felt better and more confident about themselves after disclosure. So I'm going to ask Linda, John, and Jason, are you as angry as I am about the findings from this study? I think they've hit the nail on the head in terms of results. Depressing as it may be to look at these results, I can certainly see that we have a lot of work to do, basically.

It's not something that we should be taking lightly. It's not just for educators either. It's the whole system. It's the administrators and department chairs and student health and you name it who needs to get together on this one.

I don't think I can say it any more powerfully than what the author said. I want to double click a couple of things and just say it again, because obviously the system is not listening. More than 50 % of respondents in the study, suffered from mental health. That, that if there's a crisis, that number says that we can just stop right there.

There is a potential antidote that the stigmatization rates decrease when you're vaccinated against stigma of mental health. So when you have close contact with somebody, presumably that you understand what it feels and looks like, fear of it, your ability to be supportive in the stigmatization that you present or push on to others, dramatically lessons. So there's opportunities for us to learn from that experience.

because this system, the medical education system is not doing anything to help these people as very clear from their data. And so I've kind of done the turd sandwich here. It's bad. We have a small, there is some hope, but the system is not helping. And it's very clear from the respondents that the system, the education system and the healthcare system makes possible the ongoing existence and probably the increasing prevalence of what's happening. And our current approaches are insufficient.

And so if there is, if you're in an administrative role, if you were in a leadership role in health sciences and health professions education, this needs to be front and center. This needs to be in your inbox. This needs to be something that you're thinking about. It is that this threatens the, this threatens our system. It threatens our learners. It threatens us. Yeah. I'm just going to stop there. Okay. This is a powerful paper. I'm, I,

I worry a little bit that somebody might stop listening right now. If it's not triggering, it might just sound really heavy and you're trying to drive to work and start your day or trying to work out. And maybe this is a tough episode to bring along with you. So I want to talk about the positive side of this. The epidemiology here is not new. We have a huge body of literature about the burden of illness in health professions. So that's not new. What's new is the depth.

and the richness of the descriptions here. It's almost like stories, right? So it's telling stories about people's lived experiences. I think that's really important. That makes this paper useful. We all slag the system in our discussion today and the system is us. It's all of us and our contributions to a system because the system involves all our ingredients. Many of us listening on this podcast have jobs of influence. We can make things better. I do...

believe what I said earlier in this episode that generationally we are doing better, incrementally better. We have a long way to go. The people who I work with have done some amazing things to make systems richer. The next generation of trainees who become the next generation of attendings have made things better. I really, really see that in most of the institutions that I direct. And some of my most rich personal experiences as an attending teacher, supervisor,

I've been with people who helped their remedial when they were struggling with an illness. And now they're superstars and they come to a different place in various ways. And those are the most rewarding experiences I've had. So all of us can take this paper and help make the world a bit better place. I wanted to add that. Thanks, Jason. I'm going to come to that exact same point, but I'm going to take privilege of having the final word here. Because when I read this paper and

When I chose this paper, I did it because I'm angry. I'm angry that we are perpetuating what is truly an unnecessary and yet consistent persistent contradiction. We say we care about the health of our trainees and our physicians in practice. The numbers tell us they're a crisis, but our traditions, our beliefs, our expectations for perfection, for grit, for Teflon -like resilience and invulnerability, we cling to these with such desperation that we're willing to inflict harm upon ourselves and each other.

We say we want a more diverse population of physicians, a population that reflects society. We advertise for them, and we invite them, but then we switch the rules, and we say, need to fit this norm, this mold, these expectations. This is what a good doctor is. And if you don't fit in, then the problem is with you.

There's no need for us to maintain these myths. They hurt us. We can let go of them. If the fear is legal repercussions, let's take on the lawyers and the law that we have supported. If it's fear of not getting good jobs, then let's flock to the places that will take us and drive those places that won't by voting with our feet. If it's this idea that a good doctor is perfect and never gets sick, let's show them by being more humane.

and taking care of each other and accepting each other with our imperfections and all of our diagnoses. Honestly, there's more of us than there are of them. And so as Jason said, we can all be leaders in this. We can be leaders at the individual level with our learners in the clinical space, in the learning classroom, one on one. If any listeners have leadership roles, we need to do better. You need to listen to this and do better because we can't let this persist.

What this study says and what all the other studies like this, they tell us that we have to change these norm because if we don't change these norms, we pay the price, and that price is just too high. And no, we're not going to vote on this. We're not going to vote on this. Yay, we're not going to vote on this because this paper stands on its own. To those of you who managed to listen all the way to the end, I want to thank you for listening to a hard paper for the authors. I'd like to thank them for taking on an incredibly demanding manuscript and idea.

And we would love to hear your thoughts, your reflections. You can find us on the internet at paperspodcast.com. And if you want to write to us, you can reach us at thepaperspodcast@gmail.com. And so with that, friends, I will say, I'll talk to you later.

You've been listening to the Papers Podcast. We hope we made you just slightly smarter. Podcast is a production of the @at the Karolinska Institutet. The executive producer today was my friend, Teresa Sörö. The technical producer today was Samuel Lundberg. You can learn more about the Papers Podcast and contact us at www.thepaperspodcast.com. Thank you for listening, everybody, and thank you for all you do. Take care.