IAMSE Fall 2022 Session 3 Highlights

[The following notes were generated by Michele Haight, PhD.]

Presenter: Michael Redinger, MD, MA, Co-Chair Department of Medical Ethics, Humanities, and Law, Interim Chair, Department of Psychiatry, Associate Professor Psychiatry, Western Michigan University, Homer Stryker MD School of Medicine

Mental Health and the Struggling Learner

The goal of this presentation is to assist educators in understanding how mental health difficulties can interfere with student success, both academically and professionally, and provide strategies for preventing and remediating failures attributed to mental illness.

The challenging issue is how to work through when a learner has been identified as having a mental health issue and is struggling either academically or professionally in the curriculum.

Recognizing Mental Illness in the Struggling Learner

• As a population, physicians and medical students are under increasing stress that has been exacerbated by COVID, and they are experiencing high levels of occupational burnout, depression, and anxiety.
• Physicians and medical students are also poor at self-care, seeking assistance for themselves or colleagues, and assuming the patient role.
• Students who have had significant exposure to adverse childhood experiences (ACE) are significantly more likely to report a moderate to significant effect on their mental health compared to their peers.
• Students who come from other disadvantaged circumstances are more likely to experience ACE and might require more support.
• A significant number of medical students compared to other graduate level students develop mental health issues over the course of their training. This indicates that there is something about medical school training that predisposes students to some type of mental health issues.
• External stressors and not patient interactions are the primary drivers of medical school stress.
• There are observable signs and behaviors that might signal the onset of the conditions described in the DSM-5. Mood and anxiety disorders are the most common conditions in medical school. Substance-Related and Addictive Disorders are not uncommon in medical school.

Psychiatric Fitness-for-Duty (FFD): Ascertaining if someone is in a position to do the job with reasonable skill and safety, which might otherwise be impaired by illness or injury.

• Impairment: The inability to practice medicine with reasonable skill and safety as a result of illness or injury.
• Psychiatric illness includes substance use disorders (SUD).
• Consultation is often triggered by inappropriate or problematic behavior BUT these behaviors do not always result from disability or impairment from psychiatric illness.

Fundamental Questions:

• Does a psychiatric illness exist?
• If so, does that illness impair specific functions?
• To what degree do impaired functions impact job performance?
  (All three of the above need to be present before one is considered impaired.)
  Can functional impairment be mitigated to allow for successful job performance, and, if so, how?

Physicians as a population are not identical to the general population in terms of their cognitive abilities.

• Measures of the intellectual performance of medical students and physicians on standardized tests of intelligence historically have found that intellectual performance is approximately one to two standard deviations above the mean of the general public.
• 7%-10% of practicing physicians may be classified as impaired, and 16% may be classified as underperforming.
• Data on the impact of test-taking anxiety is weak, regardless of the assessment tool.
• Data regarding the impact of mental illness on academic performance is more robust for college and high school students, not medical students.
• In one study, physicians who were referred for competency (fitness-for-duty) evaluations scored lower than their colleagues, but not necessarily different than the general population.

Medical student cognitive norms are different than the general population.

• Medical students who are impaired may be functioning at the mean of a population-wide sample, but are impaired compared to physicians as a whole.
• Medical students don’t have to necessarily score at a level that is worse than the general population to be considered impaired when compared to their colleagues. This is an important consideration when thinking about accommodations and/or sending a student for cognitive assessments.

Mental Illness and Academic Performance

• There is insufficient, low-quality data to draw strong conclusions regarding the degree of impact specific mental illnesses have on medical student academic performance.
• We can infer from other populations that mental illness is likely to impact medical student academic performance for at least some students. The degree of impact remains an open question.

Mental Illness and Professionalism Impairment

• Most FFD evaluations are triggered by problematic behavior that occurs across specialties and demographics.
• The seeds of these behaviors are seen early in the course of one’s medical career.
• Personality disorders are significant contributors to maladaptive behaviors, but are much more difficult to diagnose.
• Studies suggest correlations between prior grades and test scores and professionalism scores and future disciplinary actions. (Cuddy et al. 2017, Papadakis et al., 2004, 2008) This is an indication that there might be the potential to intervene early.
• Research also suggests that students with flourishing mental health are less likely to commit even minor professional lapses.

At what point should a physician training program remove students or residents?

• Medical schools graduate 97% of matriculated students.
• Unprofessional behavior during medical school was associated with a threefold increase in subsequent disciplinary action by a medical board (Papadakis, 2005).
• Can we do something about this? Or should we be more judicious about those who we pass through the curriculum?

An Approach to Professionalism Remediation

• Responses to professionalism lapses need to be holistic and include mental health evaluations.
• Remediation goes beyond a mandated mental health evaluation.
• Consider what further efforts can be made to help students access these support and reverse this process?
• Appraise to what degree different services are mandated or enforced prior to having students return to the curriculum.
• Look at professionalism through a “just” culture, systems lens when considering remediation or discipline.
• Consider how we can reverse this.

In Summary:

• Mental health is a positive contributor to professionalism lapses and later misconduct.
• Treatment of SUD seems to be the mental illness most amenable to remediation.
• Depression and burnout are worth addressing. This may help with addressing and minimizing academic difficulties.
• Behavior change is hard, particularly for those with certain personality traits/disorders.
• Determining correlation versus causation is difficult in individual cases.
• No one knows how to do this really well.