“Partly, but there were other issues. Let me tell you about the influence my committee roles had first. I’ve always been involved in leadership activities. In high school, I was on a principal’s student advisory committee, and in college I was heavily involved in student politics, usually focused on fees, student rights, and supporting the many diverse groups of students whom we felt needed more of a voice, such as the LGBT community. In medical school I volunteered to be a student representative on the curriculum committee for my first 2 years. That was fascinating because we were making big changes to the overall curriculum to make it more relevant to students. From my third year on, I’ve been on what we call the ‘student progress committee,’ which reviews students who are getting behind in their course, failing, or showing unprofessional behavior.”

“That’s a good combination of experiences. You must have learned a lot about medical education. But I’m not sure why that would turn you toward psychiatry,” said Dr. Harrod.

“Well, as you know, the devil is always in the details. I’ll summarize what I learned from being on the curriculum committee. The major task of the committee was to modernize our course after a fairly critical review by AAMC¹ at our last accreditation survey. I had to spend 2 years sitting through meetings that were essentially a fight between various groups of faculty, all of whom insisted they could not take any of their own teaching time out of the curriculum. They had been told to add new topics and competencies relevant to modern medicine, such as informatics, multimedia skills, genomics, communication skills, reasoning and big data analysis, business and organizational systems, human diversity, leadership, self-care, and physician well-being, to name a few. Several of the faculty on the committee, particularly those from anatomy and physiology, seemed especially powerful and were always better prepared than the clinical faculty, especially when it came to rules and regulations, but to me they seemed hopelessly out of date in terms of what information today’s medical students need to learn. At one meeting, we actually got down to whether it was more important for students to know all the names of the bones of the foot or to understand how to recognize if a colleague is suicidal, and the ‘bones of the foot’ group won. Certainly we need to know about both, but not one over the other. I was frustrated, and so were all the other students when we passed on our reports of the meetings. Some of the events I witnessed on this committee made me quite disillusioned with medical school. I thought the aim was to create a curriculum designed to help train us to be the best doctors possible now and in the future, not doctors from a past century.”

“I can understand that, Justin. Knowledge of the anatomy of the foot is important to learn, but so are the things you just mentioned. How does this relate to psychiatry?” said Dr. Harrod.

“We students finally put forward a list of topics that we thought needed to be in the curriculum, and the activity of the two psychiatrists on the committee was impressive. Along with a colleague from public health and another from internal medicine, they were the leaders for change and modernization of the curriculum, and they worked closely with us, supporting our requests. For instance, I brought up LGBT health care in the committee; I had been interested in that in college, and we had a number of medical students who were openly gay, both male and female. However, the reaction to my suggestion was generally fairly negative, and most of the faculty, although prepared to tolerate such topics in the curriculum, clearly were not enthusiastic. Once again, the two psychiatrists were helpful and met separately with me and my three student colleagues on the committee to plan a joint strategy for introducing a course on LGBT health, which I’m glad to say is going to start next year. After 2 years on that committee, I found that the psychiatrists seemed most open to change and modernization of the curriculum, including taking a more student-focused approach. They seemed to be listening to our ideas more and were less interested in just protecting their academic ‘patch’ like the others. But the past 18 months on the student progress committee have been even more influential on me.”

“Interesting,” said Dr. Harrod. “What happened there?”

“Well, as you know, all medical schools have these committees, and their job primarily is to review those students who are failing, on academic probation, or at risk of being dismissed from school. They deal with some very difficult situations, and a lot of their work is highly confidential, to the extent that the student members sometimes have to leave and are not given access to all the information about their colleagues. Unfortunately, as a member of this committee, I learned that medical school could be difficult sometimes for students who were not Anglo-Saxon whites, even in this day and age. My being black made people uncomfortable occasionally. I’m pretty sensitive to being treated differently because I’m black, and I can see it happening to others in subtle and not-so-subtle ways. This type of prejudice can be demoralizing. Then I tried to help one of my best friends at medical school who was struggling, but I failed in the end. That experience helped me decide that psychiatry was right for me, rather than surgery, so that I can work on preventing the things that happened to her from happening to medical students in the future,” said Justin.

“That sounds very serious, Justin. Can you tell me broadly what happened and how it intersected with your decision to go into psychiatry? Are you talking about suicide, by any chance?”

“Yes, tragically. Janelle died 6 months ago of an overdose in her final year of medical school. And what happened to her was so preventable,” Justin said sadly. “I’ve learned through hard experience that we need to look after ourselves as students and doctors a lot better than we have in the past.”

“I am so sorry. What happened?”

“Well, Janelle was in the year above me, but we were in the same school-based internal college. She was assigned as my student mentor when I started medical school, and she was incredibly helpful. She took me under her wing, making sure I knew the best way to sign up for classes and understood the whole orientation process. She introduced me to lots of other people in our college group and made sure I had a smooth transition into school. We got on really well, and despite our many differences, we soon became good friends, socializing in the same group and sharing similar political views. Both of us had been politically active previously.”

“What were your differences, Justin?” said Dr. Harrod. He was fascinated by Justin’s story and very sensitive to the issue of suicide in medical professionals; an anesthesiologist colleague at the university had died from suicide the previous year.

“We could hardly have been more different. Janelle was a gay Hispanic woman who was former military. Before medical school, she had been a medic in Iraq and had done two tours of duty. She was very bright, and after her service she went back to school as a mature student and eventually obtained entry to medical school. Our school was close to a major military base, and a lot of ex-service people lived locally and were strongly encouraged to obtain degrees from the university. Each year of medical school had at least two or three students who were former military. It’s something everyone was proud of—until Janelle’s fate, that is, and the impact that her death had.”

“Interesting. Here, when we think of diversity, we tend to only think of racial and ethnic differences, but the military component of diversity is also important, and I imagine that had an impact on the culture of the whole school,” Dr. Harrod commented.

Commentary

This chapter is really about Janelle, an increasingly unwell medical student who eventually died from suicide, as seen through the lens of her younger colleague, Justin, as he is applying for residency. Both Janelle and Justin were likely on the receiving end of a raft of discrimination and implicit biases at medical school, eventually leading Justin to choose a residency program where these were less likely to occur. The other concepts of importance in the chapter are the need for diversity—racial, ethnic, and attitudinal—among medical students and faculty and how to provide care and support for some of these diverse groups, as well as the importance of including such topics in the medical school curriculum. Finally, the scenario demonstrates a need for some doctors to become expert in treating other doctors and medical students, as Dr. Losara did. Incoming medical students have less burnout and depression and higher level of resilience than age-matched peers, as discussed in Chapter 2, yet we know from the literature that by the second year of medical school, medical students are doing worse on burnout indices than their peers, that nearly 30% of medical students endorse symptoms of depression, and that one in nine have suicidal ideation (Yellowlees 2018). We also know that distress in medical students is associated with less professional behavior and less empathy, so they clearly need to receive help, and psychiatrists seem to be an ideal group who are clinically well trained to take on this task (see Chapter 7).

So what do we know about culture, discrimination, implicit biases, and awareness about these important cultural issues in both medical students and their teaching faculty? And how has the selection process for medical schools changed over the past decade as a starting point to providing a solution for some of these difficult issues? How can we improve the processes currently in place to enable students to seek care for themselves and to make good career choices? As physicians, we like to think that we are always fair and egalitarian in our interactions with our patients and our colleagues. Unfortunately, this is simply not true.

What, then, is implicit bias? Why is it so important in health care? And why did this likely lead to some of the difficulties experienced by Janelle and Justin? In brief, implicit biases are unconscious associations we all make that lead us to negatively evaluate someone else based on characteristics such as race or gender. FitzGerald and Hurst (2017) explored this issue in detail in a fascinating systematic review of the literature. They found that health professionals at all stages of their careers exhibit the same levels of implicit bias as the wider population—despite the core professional and ethical assumption that all patients, no matter what their background, should receive the same level of treatment and care. They found that the sociodemographic characteristics of physicians and nurses were correlated with the level of bias and that this affected treatment decisions of all types. The most common biases found related to gender, color, ethnicity, nationality, and sexual orientation, but studies involving health care professionals have also found biases against people with Middle Eastern– or African American–sounding names, the mentally ill, people who are overweight, and those who are economically poor. FitzGerald and Hurst concluded that the health care profession needs to address the role of implicit biases in disparities in health care and to reduce the inherent prejudices and the tendency to stereotype both patients and colleagues such as Janelle experienced, to her detriment.

Given this background, it is not surprising that Janelle and Justin had a hard time setting up an LGBT chapter at medical school, although some very helpful resources are available that they could have consulted. The organization Health Professionals Advancing LGBTQ Equality (previously known as the Gay and Lesbian Medical Association) has an excellent website (glma.org). The American Medical Students Association’s (2019) Committee on Gender and Sexuality, for instance, has produced a well-thought-out guide on how to “Paint Your School Pink” for student leaders who want to start an LGBT medical student organization at their school, as was mentioned in the scenario. This guide provides essential instruction and advice for student leaders as well as links to projects and resources on topics ranging from promoting institutional and curriculum change to mentorship and strengthening student organizations. Information is available for students who wish to work in this area and create local chapters, including a very useful series of 10 recommended steps to take to set up a local chapter (American Medical Students Association 2019):

1. 
   

   Find an administrative or faculty advisor

   
   
2. 
   

   Assemble founding members

   
   
3. 
   

   Start a confidential mailing list

   
   
4. 
   

   Name the group

   
   
5. 
   

   Determine the group’s mission

   
   
6. 
   

   Affiliate your group with your school’s AMSA chapter

   
   
7. 
   

   Seek advice on the LGBT climate at your school; notify administration about your group, but do not ask permission to create it

   
   
8. 
   

   Find funding through events and administration

   
   
9. 
   

   Keep records of your group’s leaders and activities

   
   
10. 
    

    Have fun and do great advocacy work

Unfortunately, Janelle’s illness, and her aggressive approach, likely contributed to the failure of the LGBT chapter. It would have been much easier for her if she had had a mentor who could support her more thoroughly and, in particular, have taught her more about the impact of implicit bias (and, of course, sometimes explicit bias) and how this can counteract change in groups and systems.

This concept of implicit bias and solutions for its consequences are starting to attract some interesting research. Hall et al. (2015) described how such bias influences health care outcomes adversely. In their review, they concluded that most health care providers appear to have implicit biases on the basis of color, with positive attitudes toward whites and negative toward blacks. These researchers focused on some possible solutions, noting that health care providers in some disciplines, such as pediatrics, tended to exhibit less implicit bias. They suggested that reexamination of the curricula and comparisons by specialty might be useful and that interventions for bias may have to be different according to the needs of particular specialties.

Solutions to the problem of implicit bias are sorely needed, and this issue has been addressed by the Institute for Healthcare Improvement (IHI; IHI Multimedia Team 2017) and The Joint Commission (2016). The IHI has developed a list of strategies that can be used to reduce implicit bias and should be included in all medical school and residency programs. These include the following (IHI Multimedia Team 2017):

• 
  

  Perspective taking—put yourself in the other person’s shoes

  
  
• 
  

  Individuation—see the other person as an individual rather than as a stereotype

  
  
• 
  

  Stereotype replacement or opposite imaging—recognize a stereotypical response and imagine the individual as the opposite of this stereotype

  
  
• 
  

  Increase your contact with people from stereotyped groups, especially socially

  
  
• 
  

  Partnership building—reframe the interaction as an equal collaboration

Others seeking solutions have emphasized the importance of understanding different cultures and social groupings as well as recognizing the power of unconscious bias and situations that may magnify stereotyping behavior. All of these topics should be included as core learning material in any medical school curriculum and as part of any professionalism training program for physicians and other health care providers at all stages of their careers.

Caroline Elton (2018), in her sensitive and insightful book on the inner lives of doctors, made the point that only the psychological needs of one half of the doctor–patient dyad have been widely recognized—those of the patient. She described how doctors’ psychological needs are denied, ignored, or not even considered, suggesting that a systemic “psycholectomy” has been performed on the profession as a whole. In my previous book (Yellowlees 2018), I explored and examined the psychodynamic upbringing of many physicians, noting their tendency to develop delayed gratification as a habit and lifestyle, with many physicians preferring to sacrifice present-day rewards for future potential gains. Of course, this means that doctors inevitably become used to living less in the moment and learn to ignore their unconscious needs, leading to a tendency to be more subject to the implicit biases held by all of us.

It is important to focus on teaching about implicit bias in medical school and residency and to educate physicians about bringing these biases to a conscious level, but what about the impact of implicit bias on faculty who have never been so trained, particularly with regard to the medical school admissions process? We know historically, as Elton (2018) described, that approximately half of U.S. medical students come from the top 20% income bracket, whereas only 5% are from the bottom 20% bracket, so these social backgrounds are emblematic of today’s faculty. Most medical schools are changing in alignment with AAMC admissions initiatives and are attempting to increase the diversity of their classes so the population of future doctors will eventually more closely parallel the national population from a gender, ethnic, and racial perspective. Given the current faculty population, however, this can hardly be done using traditional interview methods where white faculty have tended to choose white students.

Two major approaches to this, ideally performed together, are 1) training faculty in implicit bias so that they change their selection behaviors, and 2) changing the traditional admissions process to medical school.

Capers (2019) described the process of implicit bias training for faculty at Ohio State University College of Medicine. When it was introduced in 2012, all members of the admissions committee were required to take various implicit associations tests. The results showed that many committee members exhibited implicit white race preference, implicit bias against homosexuals, and unconscious associations of men with “career” and women with “homemaker.” This led to the development of annual implicit bias mitigation workshops and to the admission of a significantly more diverse medical student population. Capers described how the following educational interventions have since become routine:

1. 
   

   The admissions dean leads two half-hour implicit bias workshops each year for the entire medical center community.

   
   
2. 
   

   Annual, mandatory implicit bias mitigation training sessions are provided for all application screeners and admissions committee members, who participate in 45-minute moderated discussions of implicit bias vignettes and evidenced-based strategies to reduce bias.

   
   
3. 
   

   Recommended research readings on implicit bias are provided to the admissions committee and included in the admissions committee manual.

   
   
4. 
   

   An interview-day “cheat sheet” that reviews a bulleted list of strategies to reduce implicit bias is provided to all interviewers.

The second major approach to reducing the impact of implicit bias is to change the medical school admissions process so that it is not so dependent on the results of one or two interviews between students and faculty, as has been the case historically. Eva et al. (2004, 2018) at McMaster University in Canada have developed a multiple mini-interview (MMI) format that has now been adopted by most U.S. medical schools and many other schools worldwide. This format consists of 10 stations lasting 8 minutes each, with 2-minute intervals between them where evaluators can complete standardized evaluation forms and candidates can read about the next station. Each candidate is therefore observed for about 80 minutes by eight evaluators performing a wide range of tasks, both individual and team based, including problem solving and interviewing, communications skills, and decision making. As an MMI evaluator, I have observed students—opposite trained actors playing various roles—help a person with alcoholism reduce his smoking and alcohol consumption, help an anxious work colleague with a flying phobia get on a plane, and apologize to an angry motorist whose car they have just dented. These are excellent tests of decision making and empathy. I have seen other students solve problems that involve teamwork, creativity, leadership, and collaboration before they are tested on ethical responses to situations or prove their capacity for critical thinking by rapidly reviewing some marketing materials. Unfortunately, I have also seen candidates being insensitive, callous, uncaring, and dismissive, all traits we do not wish to see in future doctors and that may be hard to detect in the traditional one-on-one interview. The MMI interview processes are much more objective than traditional interviews and seem to markedly reduce the opportunity for the implicit biases of faculty to affect the outcomes, so they are increasingly becoming standard practice. This is good, but the question remains: Why is the MMI not being used in other areas of medicine, such as at entry to residency, where traditional one-on-one interviews are still primarily used?

Moving back to the scenario, how best can mental health care, as well as counseling regarding career choices and decisions, be provided for medical students? How can the topic of self-care and the care of colleagues become core to the curricula of medical schools? All medical schools have administrative faculty whose role it is to provide such career, support, and decision-making services, and most provide medical students with access to counselors, psychologists, and psychiatrists for mental health assessment and treatment. A number of schools, such as the University of California (UC) Davis, also provide students with access to online tools that allow them to self-assess for depression, anxiety, substance abuse, and suicidality (Yellowlees 2018) and with useful online resource pages (University of California, Davis Health 2019). The UC Davis website is a good example of a comprehensive program of support and triaging for medical students, with regular blogs on wellness and sections and links on counseling and support services, crisis intervention, wellness events, stories, and resources as well as some with a focus on military careers and military mentors, as well as regular newsletters.

The AAMC, whose members comprise all 147 accredited U.S. and 17 accredited Canadian medical schools, is taking a lead in this area and has issued a statement on clinician well-being that summarizes their perspective as follows:

The AAMC is committed to enhancing patient care and welfare, and to the belief that the optimal delivery of care requires an environment where all health care providers can thrive; where faculty, staff, and learners feel supported and well treated; where diversity, inclusion, and health equity are promoted; and where patients are empowered to make informed health care decisions. (Association of American Medical Colleges 2019)

Although as yet no formal, national “well-being curriculum” has been developed that can be widely implemented in medical schools, I have described the beginning of a framework for such a curriculum (Yellowlees 2018) and mentioned several topics discussed in the scenario here. The following topics comprise an extended version of this original framework and should be considered for inclusion in all medical school curricula:

• 
  

  Regular participation in process-oriented reflective small groups and membership of multiyear internal colleges that provide student peer-support and mentoring

  
  
• 
  

  A wide range of mentoring and mentee supervision opportunities so that these become part of the post–medical school culture (see Chapters 3 and 4)

  
  
• 
  

  Ways of creating opportunities to strengthen professional and social relationships and to network widely and appropriately

  
  
• 
  

  Career planning and creation of individual development plans (see Chapter 4)

  
  
• 
  

  Decision making and clinical reasoning that takes into account future changes in medicine, such as the need for physicians to be expert in large data analysis and pattern matching as well as excellent diagnosticians who can take into account massively increasing and disparate datasets (see Chapter 8)

  
  
• 
  

  Content on the various specific psychiatric, substance abuse, and personality disorders that affect physicians and how to recognize and treat them in any physician, including the individuals themselves

  
  
• 
  

  Content and discussion of personal identity development and transformation, the interaction between burnout and physician health (including suicidal thoughts and behaviors), empathy, compassion, resiliency, and how to become reflective practitioners

  
  
• 
  

  Active participation and learning about resilience, mindfulness, exercise, nutrition, communication. and relationships

  
  
• 
  

  Instruction about organizational systems and the interactions that occur within them, and an understanding of institutional awareness and resources that can be used to change institutions

  
  
• 
  

  Specific skills development in interpersonal professional relationships

  
  
• 
  

  Modules and discussion groups on caring and compassionate leadership, financial, and business skills

  
  
• 
  

  Media training, combined with experiential training using multiple communications technologies with patients and colleagues

Many of these topics are being introduced at individual medical schools, perhaps even in place of anatomy at some, but a comprehensive curriculum in well-being is still lacking anywhere. For how long will this continue?