Stanford Medical School Offers New Course on Finding Meaning and Balance in Medicine

A new course at Stanford’s Medical School, “Meaning in Medicine: Staying Connected to What Matters Most,” seeks to “immunize” students from future physician burnout by inspiring them to explore and connect with their personal motivations for entering medicine. 

Examples of weekly topics include: What Wellness Means to You, Spirituality and Faith in Medical Care, and Grief and Suffering. And mini lectures cover topics such as how to manage conversations with patients facing serious illness, distinguishing values from goals and preferences, and finding mentors. Each of the weekly sessions also leave space for open dialogue where students can entertain questions of faith, empathy, and what it means to care for a patient while also caring for themselves and their own wellbeing.

The course, developed by Henry Bair, a resident physician and Stanford Med alum, and Tyler Johnson, an oncologist at Stanford Health Care, was inspired by a podcast the two host together. The podcast, A Doctor’s Art, explores themes that seek to reconnect the practice of medicine to its mission, which all too often gets lost in the day-to-day burdens of administration, electronic health records, staffing, and corporatization. 

The response to the course has been overwhelming. Nearly a quarter of Stanford’s pre-clinical students have expressed an interest in taking the course before and just after it opened. And, at the conclusion of the course, every student who participated said that they would recommend the course to others. 

“In medicine, where science converges with art, suffering meets solace, and the human spirit confronts the limits of the body, it is increasingly easy to lose sight of our purpose and of ourselves. But our students have shown an eagerness to cherish their personal, intellectual, emotional, and spiritual motives for entering the profession; this eagerness, in turn, instills the courage and wisdom to seek balance and meaning. All medical trainees ought to be afforded the opportunity to do so, for this, ultimately, is just about the most effective way to individually prepare future clinicians against burnout,” Bair and Johnson wrote in an article for MedPage Today.

State Medical Boards Drop Broad Mental Health and Substance Abuse Questions from Licensure Applications

In a win for physician mental health, 21 states have opted to remove broad mental health or substance abuse questions from medical licensure applications, according to data gathered by the Dr. Lorna Breen Heroes Foundation.

Among these 21 states, the licensing application language is consistent with one of three options: it asks one question that addresses all mental and physical health conditions (consistent with the Federation of State Medical Board’s (FSMB) recommended language), does not ask about applicant health at all, or implements an attestation model with supportive language around mental health and “safe haven” non-reporting options for physicians who are receiving care.

The Dr. Lorna Breen Heroes Foundation, whose namesake died by suicide after experiencing severe burnout while working in emergency medicine during the early period of the covid pandemic in NYC, advocates for better mental health practices for physicians and policies that reduce physician burnout. Two components of the Foundation’s mission include working with state medical boards to remove mental health and substance abuse questions from credentialing applications, and increasing transparency around states’ policies.

The mission is personal for the foundation. Shortly before Dr. Breen’s death, she had shared her reluctance to seek help with family members. She feared that she would no longer be able to practice medicine if she did so. And, Dr. Breen’s hesitance is reflective of the physician population. According to Medscape’s 2023 Physician Burnout & Depression Report, 40 percent of physicians said that they would not seek help for burnout or depression out of fear of repercussions from their employer or state medical board.

The Foundation is not alone in advocating for changes that support clinician wellbeing. Other organizations within the medical community have also voiced support for reform. In 2020, over 40 professional medical organizations, including the AMA, the American Academy of Family Physicians and the American Psychiatric Association, signed a joint statement in support of changing disclosure practices about mental health. And, the AMA and FSMB recommendations support questions that focus only on current impairments rather than historical struggles.

According to the FSMB, "Application questions must focus only on current impairment and not on illness, diagnosis, or previous treatment in order to be compliant with the Americans with Disabilities Act." Similarly, the AMA recommends that any questions required of physicians be restricted to “conditions that currently impair the clinician’s ability to perform their job." And the Joint Commission, an organization that accredits hospitals, removed the requirement for hospitals to question applicants on their mental health history. “We strongly encourage organizations to not ask about past history of mental health conditions or treatment," they wrote in a statement. "It is critical that we ensure health care workers can feel free to access mental health resources."

Stay up-to-date on state policy using the Dr. Lorna Breen Heroes Foundation tracker, here.

New Jersey Bar Association Advocates to Remove Mental Health Questions from Bar Applicant Questionnaire

New Jersey is the latest state to seek to abolish the mental health questions asked on the “character and fitness questionnaire” required of all Bar applicants. Late last month, the New Jersey State Bar officially requested that the NJ Supreme Court remove item 12B from the bar applicant questionnaire: Do you currently have any condition or impairment (including but not limited to substance abuse, alcohol abuse, or a mental, emotional, or nervous disorder or condition) that in any way affects your ability to practice law in a competent, ethical, and professional manner and in compliance with the Rules of Professional Conduct, the Rules of Court, and applicable case law? 

Jeralyn Lawrence, New Jersey State Bar Association President, speaking to the New Jersey Law Journal, explained the reasoning behind her advocacy for the change. “We are a profession in crisis. The pace of our practice is not sustainable. We need to remove barriers in place for people to get help, and 12b, we believe, is a barrier to the bar. We’re advocating strongly that the court remove that question so that it’s not a detriment to people getting help,” she said. 

Virginia and New York removed its mental health questions from the bar admission application in 2019 and 2020 following similar advocacy efforts by law students and interested groups. And, in January, Ohio abandoned questions related to diagnosis and only asks about mental health as it relates to disciplinary actions or guardianship/conservatorship. 

According to the ABA: 

• Fourteen states do not request a candidate’s mental health status in evaluating their fitness for the Bar: Arizona, Hawaii, Illinois, Iowa, Maine, Maryland, Massachusetts, Michigan, Mississippi, New York, Pennsylvania, Tennessee, Washington, and Wisconsin. 

• Four states—Indiana, Idaho, New Hampshire, and Texas—ask about mental health only in the context of disciplinary action. 

• One state—Ohio—asks about mental health only in the context of disciplinary action and court appointed guardianship/conservatorship. 

• Two states—California and Connecticut—ask about mental health only in the context of court appointed guardianship/conservatorship. 

• Ten states—Louisiana, Montana, New Mexico, North Carolina, North Dakota, Oklahoma, South Dakota, Vermont, West Virginia, and Wyoming), and Washington D.C.—have adopted the three mental health questions drafted by the National Conference of Bar Examiners (NCBE) that are shown below: 

1. Diagnosis:  Do you currently have any condition or impairment (including, but not limited to, substance abuse, alcohol abuse, or a mental, emotional, or nervous disorder or condition) that in any way affects your ability to practice law in a competent, ethical, and professional manner? Note: “Currently” means recent enough that the condition or impairment could reasonably affect your ability to function as a lawyer. 

2. Treatment: Are the limitations caused by your condition or impairment reduced or ameliorated because you receive ongoing treatment or because you participate in a monitoring or support program? 

3. Defense/Disciplinary Action: Within the past five years, have you asserted any condition or impairment as a defense, in mitigation, or as an explanation for your conduct in the course of any inquiry, any investigation, or any administrative or judicial proceeding by an educational institution, government agency, professional organization, or licensing authority; or in 10 years, connection with an employment disciplinary or termination procedure?

• Eleven states that do not follow the NCBE test—Alabama, Arkansas (disciplinary action only), Colorado, Delaware, Indiana (disciplinary action only), Kentucky, Nevada, New Hampshire (disciplinary action only), Oregon, Rhode Island, and Texas (disciplinary action only)—ask at least one of the NCBE questions. 

• Fifteen other states ask questions of their own drafting.

Survey Finds Majority of Summer Associates Felt Law Firm Cared About their Mental Health

Summer associates surveyed by American Lawyer expressed positive feedback on their work experiences in the 2022 Summer Associates Satisfaction Survey. Over 5,400 associates responded to the survey, which asked questions on a range of topics including partner access and mentorship, associate interactions, interest in the work, and firms’ alignment with their own goals and self-image. Based on average scores across the categories, American Lawyer ranked the 2022 best firms for summer associates:

1. Blank Rome, 5.0 (tie)

1. Duane Morris, 5.0 (tie)

3. Kramer Levin, 4.993

4. Paul Hastings, 4.980

5. O’Melveny & Myers, 4.997

6. Stroock, 4.956

7. Allen & Overy, 4.944

8. Day Pitney, 4.935

9. Proskauer Rose, 4.929

10. Akin Gump, 4.915

The majority of the law firms received high ratings and nearly 90 percent of third year respondents said that they would accept an offer from their summer firm for full-time employment. Just under three-quarters of respondents said that they expected to have a career at their law firm. The survey also asked summer associates to rank their concerns. Alongside work-life balance, mental health and emotional well-being emerged as key priorities for respondents. Many summer associates felt that their firms adequately addressed those concerns and almost three-quarters said that they felt that their firm genuinely cared about their mental health. 

Law Student Wellbeing Study Showed Increase in Mental Health Struggles

A new study on law student wellbeing shows that, despite efforts to improve student well-being, even more students are struggling with mental health. The study, It is Okay to Not be Okay: The 2021 Survey of Law Student Well-being, recently published in the University of Louisville Law Review, provides an analysis of law student mental health for comparison with a similar effort from 2014. 

The survey, administered in the Spring of 2021, garnered 5,400 student responses. 

• Over two-thirds of respondents, 69 percent, reported needing help for emotional or mental health problems in the past year. This was an increase from 42 percent from the 2014 study. Of the 69 percent, 56 percent received counseling or help from a mental health professional. Females were more likely to report that they sought help than males. 

• A larger percentage of students, 11 percent, reported experiencing suicidal thoughts in the past year. This is an uptick of five percentage points from 2014. About 5 percent of students reported that they had thought seriously about suicide in the last 30 days. 

• A larger subset of the law student population reported that they started law school with a previously diagnosed mental health issue. Nearly one-third of respondents reported that they had been diagnosed with depression (18 percent of this group was diagnosed after starting law school), compared to 18 percent in 2014. Nearly 40 percent of respondents reported they had received an anxiety diagnosis at some point in their life (22.5 percent of whom received the diagnosis after starting law school), a dramatic increase from 21 percent in 2014.

• A slightly larger percentage of respondents reported using (with a prescription) sedative/anxiety medications in 2021 (15 percent) compared with 2014 (12 percent), while the percentage using antidepressant medication (again, with a prescription) almost doubled jumping from 12 percent in 2014 to 23 percent in 2021. Fewer students reported using prescription drugs without a prescription in 2021 (less than 12 percent) compared to 2014 (14 percent). 

• A bright spot amidst the alarming findings came in decreased binge drinking. The number of students who reported that they drank enough to get drunk in the past 30 days fell from 53 percent in 2014 to 44 percent in 2021. Similarly, the number who reported binge drinking at least once in the past two weeks fell from 43 percent to 33 percent. The researchers did note that the timing—spring of 2021—may have contributed to this decrease, as there were possibly fewer opportunities for “social drinking” during the pandemic. 

David Jaffe, Associate Dean of Student Affairs at American University’s Washington College of Law and study co-author in 2014 and 2021, spoke to the findings in an interview with Reuters. "It's disappointing that we didn't make more headway as law schools generally," he said. "We still have our work cut out for us."

New Physicians that Train in Surgery or Identify as a Sexual Minority are More Likely to Struggle with Mental Health During Intern Year

The trials of residency, particularly in the first year after completing medical school, are well documented. First year residents or interns work long and demanding hours in a high stress environment, and do so on little and irregular sleep. And two new studies out of the University of Michigan, which used data from the Michigan Neuroscience Institute’s Intern Health Study, show that two groups are at higher risk for developing negative mental health outcomes during this time: surgical trainees and those who identify as a sexual minority (lesbian, gay, bisexual, or other non-heterosexual).

The first study led by Tasha Hughes, MD, MPH, and an assistant professor in the University of Michigan Department of Surgery, explored changes in surgical residents’ mental health during the intern year, and also looked at how surgical residents’ experiences compare to those of other (non-surgical) residents. 

Hughes and her team found that, initially, surgical interns enter the program with lower rates of existing depression symptoms than a similar age cohort within the general population. However, after the intern year, almost one-third (32 percent) of interns screened positive for depression, based on their scores from at least one mood survey. 

Among the surgical interns, some demographic groups were more likely to develop depression—females, sexual minorities, singles (those with no partner), those working the most hours on average, and those with a history of negative childhood experiences. However, even after adjusting for these demographic factors, surgical interns were more likely than other interns to develop new-onset depression, except for when work hours were taken into account. Additionally, among those who screened positive for depression, 64 percent continued to report signs of depression on a later survey. 

Perhaps, equally worrisome, was that many of the surgical interns did not seek assistance. Just 26 percent of those whose scores were consistent with depression sought mental health care during their intern year. Hughes explains the importance of the findings for promoting a healthier learning environment. “Surgical training, especially in the United States, can be a period of intense stress, which we find is linked to new onset of depression,” said Hughes. “These findings suggest a need for surgical program directors, leaders, and health systems to continue to find ways to mitigate the effects of surgical training, normalize help-seeking, make mental health support easily available, and pay special attention to those with characteristics that might put them at increased risk.”

The second study, led by Tejal Patel, a student in her senior year at the University of Michigan, looked specifically at interns who started training in 2016 through 2018 and who identified as lesbian, gay, bisexual, or other non-heterosexual. 

At the commencement of the intern year, the sexual minority group’s depression scores were higher than those of the heterosexual group. However, rather than remaining consistent over time, the study found that the gap increased throughout the year with larger differences in mental health occurring in the second half of the year. “These results indicate that interns who are part of sexual minority groups may experience unique workplace stressors leading to a widening disparity in mental health,” said Patel. 

ABA Report Calls for Action to Help Young Lawyers Struggling with Student Loans

A study released this week by the Young Lawyers Division of the American Bar Association (ABA) shows that student debt is impacting law graduates’ lives and mental health. The survey, which included responses from 1,084 law school graduates from the last ten years, found that not only are almost all law school graduates impacted by student loan debt, but that it affects them personally and professionally. The study also found that lawyers of color were disproportionately impacted.

Just over 95 percent of survey respondents took out student loans for law school and more than 90 percent of respondents graduated from law school with at least $65,000 in student debt. The mean loan balance post-JD was $164,742, which includes undergraduate loan balances averaging $17,512. Notably, while about a quarter of white respondents hold over $200,000 in debt at graduation, this proportion increases to at least one third among Asian, Black, Hispanic, and Multiracial respondents.

For many, these loans also grow over time, with the reported current mean loan balance ($171,036) slightly higher than the mean at graduation. Most respondents reported that their loans were higher or the same as they were at graduation; 40.4 percent of respondents reported higher and 11.7 percent said the same. Among Black respondents, however, a staggering 67 percent reported higher debt now than at graduation. Even among the more tenured lawyers, those who graduated before 2014, 45.4 percent have higher levels of student debt currently than at graduation. Though the report acknowledges that there may be reasons explaining the increased debt, including strategic repayment plans, loan forgiveness plans, and/or unemployment, it illustrates the structural burden of such high debt.

Almost all respondents, 89.8 percent, reported making at least one personal decision based on debt. Over half of those surveyed postponed or opted not to take a vacation (58.3 percent) or postponed or decided not to buy a house (55.6 percent). More significantly, almost half of respondents, 48 percent, postponed or decided not to have children due to their debt, while about 28.8 percent postponed or decided not to get married.

Professionally, 37 percent chose a job that paid more money over a job that they really wanted, and 33.5 percent took a different career than originally expected. Among those lawyers working as corporate counsel or in private practice, over 40 percent (43.2 and 42.1 respectively) said that they took a job that pays more instead of a job that they really wanted. Similarly, large proportions of those working in government/military and public sector/non-profit (63.8 percent and 50.9 percent respectively) chose a job that qualified them for loan forgiveness over a job that they really wanted. 

Perhaps most importantly, the report calls out the emergence of mental health as a theme in the responses of survey participants, despite participants not being prompted to discuss their mental health. The survey included an open-ended question that asked how student debt has impacted respondents’ lives, and the responses consistently mentioned stress, anxiety, mental wellness, depression, and anger. The report summary noted that the responses were “jarring” in both content as well as the frequency in which mental health and related issues were mentioned.

The ABA calls the report “a call to action” and urges a new approach to student loan advocacy, stating that if changes are not made soon, entering the profession could become cost prohibitive.

UNC Kenan Flagler Provides Alumni with Strategies to Avoid Post-MBA Burnout

Earlier this month, the Financial Times published an article on workplace wellbeing and burnout. The article included the results of a reader survey on how employers support employees’ mental health. Two-thirds said that their work had a somewhat to extremely negative effect on their health. Forty-four percent said that they did not think their organization took mental health seriously and half said that they either didn’t know where at work to go or had nowhere to go if they needed support. While the survey respondents were self-selecting, the results show a significant issue with employer support of mental health, including stress, burnout, anxiety, and depression.

 The article warns us that the problem runs across sectors, but may be particularly relevant to graduates of law, business, and medical schools; the authors note that “Fields such as law, finance, and consulting seem particularly prone to intense, demanding workplace cultures, but the issue affects people in all sectors. One doctor dies by suicide every day in the US.” Similarly, Blind, an anonymous social app for tech employees, surveyed its users in May 2018 and 57 percent of the 11, 487 respondents said that they were burned out. Only five of the 30 tech companies represented had an employee burnout rate below 50 percent, and 16 of the companies had a burnout rate higher than the average (57 percent). Later surveys, also by Blind, found that 52 percent of tech workers responded that they do not have a “healthy work environment” and that 39 percent of tech workers said they were depressed.

The FT survey also found that reasons behind burnout clustered into four themes: overwork, cultural stigma, pressure from the top, and fear of being penalized. The article suggested that many experts point to an epidemic of overwork resulting from the common expectation that employees be available and responsive to client needs 24/7. “In his book, Dying for a Paycheck, Stanford professor Jeffrey Pfeffer posits that this crisis is getting worse over time, amid stagnating wage growth and an increasing reliance on the gig economy. ‘We are on a path that is completely unsustainable,’ Pfeffer says. ‘The CDC [Centers for Disease Control] tells you that chronic illness is 86 percent of the $2.7tn US healthcare spend. Many come from stress-related behaviours. If you’re going to solve the healthcare cost crisis, a piece of that solution has to go through the workplace.’”

In an acknowledgment of the intense positions that many post-MBA graduates find themselves in, Robert Goldberg, an affiliate UNC Kenan-Flagler faculty member, recently led an interactive session for UNC alumni to build awareness of and strategies for preventing burnout.

First, Goldberg encouraged alumni to explore various “energy zones” which, described below, he adapted from The Power of Full Engagement (Loehr & Schwartz, 2003).

• Performance zone: Passionate, enthusiastic, engaged, optimistic, alive, challenged, and absorbed

• Survival zone: Anxious, impatient, angry, irritable, defensive, fearful, and frustrated

• Burnout zone: Hopeless, exhausted, sad, discouraged, lost, empty, worried, and depleted

• Recovery zone: Calm, peaceful, grateful, relaxed, receptive, relieved, rested, and renewed

Goldberg said that to stay in the performance zone, you must enter the recovery zone before you enter burnout. As such, those in intense professions may need to spend time recovering every working day. This can be done using various energy management techniques, including physical (stepping away from the desk at regular intervals), mental (prioritizing competing demands), emotional (feeling valued and appreciated), and spiritual (connecting work to higher purpose). 

Finally, Goldberg addressed the importance of “personal resilience” to maintain strong performance, defining resilience as “the ability to become strong, healthy, and successful after something bad happens.”

Goldberg shared the following five factors, summarized below, for building resilience capability:

• Perspective: Take some space to view a situation, accepting the negative aspects and finding opportunities. “Recognize what can be changed and what can’t.”

• Emotional intelligence: Become present in your emotions and name what you’re feeling. Don’t feel guilt or shame over the emotions that you experience, but give yourself time and space to process them.

• Purpose, values, strengths: Be aware of the purpose that you find in your work, and how it relates to your larger moral compass. Use this awareness to stay centered during chaotic times.

• Connections: Form relationships with your friends and colleagues and give and receive support from this network.

• Managing physical energy: Take care of yourself. Exercise, eat well, and have hobbies and activities to engage in apart from your work.

Graduate students, particularly within business, law, and medical school, may want to consider incorporating these strategies into their lives now. Building healthy and sustainable stress management habits, within the hectic graduate school environment, will be good preparation for managing career stress, avoiding burnout, and maintaining wellness in the future.