Sarah Sofka, MD, FACP, noticed a pattern. As program director for the internal medicine (IM) residency at West Virginia University, Morgantown, she was informed when residents were sent to counseling because they were affected by burnout, depression, or anxiety. When trainees returned from these visits, many told her the same thing: They wished they had sought help sooner.
IM residents and their families had access to free counseling at WVU, but few used the resource, says Dr. Sofka. “So, we thought, let’s just schedule all of our residents for a therapy visit so they can go and see what it’s like,” she said. “This will hopefully decrease the stigma for seeking mental health care. If everybody’s going, it’s not a big deal.”
In July 2015, Dr. Sofka and her colleagues launched a universal well-being assessment program for the IM residents at WVU. The program leaders automatically scheduled first- and second-year residents for a visit to the faculty staff assistance program counselors. The visits were not mandatory, and residents could choose not to go; but if they did go, they received the entire day of their visit off from work.
Five and a half years after launching their program, Dr. Sofka and her colleagues conducted one of the first studies of the efficacy of an opt-out approach for resident mental wellness. They found that , suggesting that residents were seeking help proactively after having to at least consider it.
Opt-out counseling is a recent concept in residency programs – one that’s attracting interest from training programs across the country. Brown University, Providence, R.I.; the University of Colorado at Denver, Aurora; University of Pennsylvania, Philadelphia; and the University of California, San Francisco have at least one residency program that uses the approach.
Lisa Meeks, PhD, an assistant professor of family medicine at Michigan Medicine, in Ann Arbor, and other experts also believe opt-out counseling could decrease stigma and help normalize seeking care for mental health problems in the medical community while lowering the barriers for trainees who need help.
No time, no access, plenty of stigma
Burnout and mental health are known to be major concerns for health care workers, especially trainees. College graduates starting medical education have lower rates of burnout and depression, compared with demographically matched peers; however, once they’ve started training, medical students, residents, and fellows are more likely to be burned out and exhibit symptoms of depression. The ongoing COVID-19 pandemic is further fraying the well-being of overworked and traumatized health care professionals, and experts predict a mental health crisis will follow the viral crisis.
The Accreditation Council for Graduate Medical Education recently mandated that programs offer wellness services to trainees. Yet this doesn’t mean they are always used; well-known barriers stand between residents, medical students, and physicians and their receiving effective mental health treatment.
Two of the most obvious are access and time, given the grueling and often inflexible schedules of most trainees, says Jessica Gold, MD, a psychiatrist at Washington University, St. Louis, who specializes in treating medical professionals. Dr. Gold also points out that, to be done correctly, these programs require institutional support and investment – resources that aren’t always adequate.
“A lack of transparency and clear messaging around what is available, who provides the services, and how to access these services can be a major barrier,” says Erene Stergiopoulos, MD, a second-year psychiatry resident at the University of Toronto. In addition, there can be considerable lag between when a resident realizes they need help and when they manage to find a provider and schedule an appointment, says Dr. Meeks.
Even when these logistical barriers are overcome, trainees and physicians have to contend with the persistent stigma associated with mental health treatment in the culture of medicine, says Dr. Gold. A recent survey by the American College of Emergency Physicians found that 73% of surveyed physicians feel there is stigma in their workplace about seeking mental health treatment. Many state medical licensing boards still require physicians to disclose mental health treatment, which discourages many trainees and providers from seeking proactive care, says Mary Moffit, PhD, associate professor of psychiatry and director of the resident and faculty wellness program at Oregon Health & Science University, Portland.