Supporting Student Success: Building Well-Being into Medical Education

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Medical school has always been demanding, but today's learners face new pressures—from increasing uncertainty and academic intensity to stigma around asking for help. In this episode, Elizabeth Harry, M.D., welcomes Seetha Monrad, M.D., Associate Dean for Medical Student Education, and Erin McKean, M.D., Assistant Dean for Student Affairs, to discuss how Michigan Medicine is embedding well-being into medical education through thoughtful assessment, expanded mental health resources and a culture that helps students succeed without lowering expectations.

Transcript

Dr. Elizabeth Harry:

Welcome to the Well-Being of Michigan Medicine Podcast. I'm Dr. Liz Harry, and today we're talking about student well-being, but not in slogans in systems. 

I'm joined by two leaders shaping how we support medical students day-to-day. We have Dr. Seetha Monrad, Associate Dean for Medical Student Education and Dr. Erin McKean, Assistant Dean for Student Affairs, with oversight of medical student physical and mental health.

Today, we're going to dig into what students are up against, what actually reduces barriers to care in a meaningful way, and how assessment culture can affect mental health and what it looks like when support is not extra, but actually built into the training environment. So, thank you both for joining. I really appreciate you being here today.

Dr. Erin McKean:

Thank you.

Dr. Seetha Monrad:

Thanks.

Dr. Elizabeth Harry:

So, when we think about our medical students, when a medical student is truly doing well, not just sort of performing, but really thriving, what do you notice first?

Dr. Erin McKean:

I actually thought about this. I think about this a lot. What does it look like to do well? Often I notice nothing. I notice smiles, I notice that they just seem to be going along with life and performing well. And I think that's because they're feeling well and doing what they need to do.

Dr. Elizabeth Harry:

It's such an interesting point. It really helps underscore this idea that well-being is sort of in the hierarchy of needs. It's kind of at the bottom and it's really noticeable when it's not there. And if everything's kind of going as it should, ideally it's not noticeable and we're focusing on the other things, our academic interests or our social interests or what helps us thrive, but we're able to focus in other areas and it really only becomes apparent perhaps when we're not focusing on it. That's really helpful. I really appreciate that framing. And so, as we think about this then, and we think about student well-being, particularly in medical education, what do you guys think of as maybe a myth or a misconception that we as sort of folks in medicine have held for a long time, that you wish we could unlearn?

Dr. Seetha Monrad:

I think some myths are related to memories of one's own medical education training and rose-tinted memories of how we handled it at the time and then applying that experience to assumptions for what the Kerner learner experience is. And our learners have a very different entire framework than many of us who trained decades ago did. And I think it's important to recognize that when pondering decisions that are being made to support learner well-being that may not have been afforded to oneself when one was going through it themselves.

Dr. Elizabeth Harry:

Yeah, I love that. Part of it is this, in my day and we walked uphill both ways in the snow kind of thing. But one of the things that I notice sometimes people tend to forget about that is, yeah, but how much simpler were the patients and how much simpler was the medicine? And there's a lot of complexity and nuance and all of these things that our learners are dealing with now, that weren't present before. We didn't have the electronic health record, it didn't follow you home. There's all these different pieces of it that were fundamentally different when we're comparing.

And the other thing that I think is interesting when that comparison is brought up is that, we're in the business of relieving suffering. And so, if people are telling us they're suffering, is it our role to put a kind of value judgment on whether they ought to be suffering or not? Or are we just here to try to relieve suffering and they're telling us they're suffering and so we want to help. But yeah, I love that. That would be great to see that myth reverse. Any other myths that you guys want to-

Dr. Erin McKean:

I think related to that too, that might be in the students' heads frequently, is that, faculty didn't struggle or don't struggle, when in fact, a lot of people did or currently are. And I think, because everybody comes from such a high performing background, with high expectations for themselves, we often hide our struggles. And so, that can be a disadvantage sometimes to students who need to see that we all are humans and have struggled in the past or have things to work on.

Dr. Elizabeth Harry:

Yeah. And it seems like it also can go both ways. I think our students seem to really value when we're transparent with our struggles. I've also heard from them though, especially as a primary care doc, I've heard, "Well, you all seem really unhappy, so why would I pursue that path?" And so, I worry too about, I don't want them to not want to pursue some of our paths because of the struggles they see. And so, how do we have real honest conversations about what it looks like to be a physician right now and why it's still worth pursuing with the right resources and infrastructure and support. So, as we talk about our students, let's really dive into what's driving their distress. And if you were to have to narrow it down to the top three drivers of distress for our med students right now, what would they be?

Dr. Erin McKean:

I think when I see struggling students come in, obviously there is and always has been a volume issue. Volume of learning and knowledge and skills to acquire. That is how medicine is, it has to be done and it's a real pressure. I think there is also imposter syndrome because everybody comes in and like, "Oh my gosh, am I the only one struggling?" Which adds stress to that already high volume. And then, at a place like the University of Michigan, there's a pressure to commit to other things early. Research, service events, and I see students often feel pressured to jump right in before they even know what the academic volume's going to be. I think those are the three big things that I see.

Dr. Elizabeth Harry:

Part of it I'm hearing you say too is, early consolidation. Early really sort of clarifying, this is who I am, when they haven't had that early differentiation, haven't had that opportunity to really explore and say, these are all the possibilities, but this feeling that they have to consolidate quickly onto, this is who I am.

Dr. Erin McKean:

Holy moly. Yeah, that's a really good subpoint that I haven't thought about, but there is actually a pressure to commit also towards specialty earlier than ever, because of Match is harder than ever, which really artificially causes problems with our ability to have an open mind towards what do I want to do? Where do I want to go in medicine? I guess there's a sub point. Yeah, I should commit to activities and research, but also the feeling like, if I don't commit to something now, I'm behind.

Dr. Elizabeth Harry:

Yes. Yeah. So, which of these pieces are sort of, medicine is hard and it is, versus we designed it this way.

Dr. Seetha Monrad:

I think medicine is hard. I think there are some design aspects of the system of medical education that can and are being iteratively improved. I would say, medical education, the system is also happening in one of the more uncertain times there has been in terms of predictability and consistency. So, speaking even from a system standpoint, as opposed to individual student distress, students are entering a medical education space that's evolving in ways that the system and the shepherders or supporters in the system can't say with clarity, this is the next step, this is the path.

Things like the changing match environment, which is changing on a more than annual basis in terms of different requirements. Things like different requirements downstream, changing step, reporting structures, different grading systems in different schools, that are comparators for students entering the next phase. And so, from the perspective of what is different now and maybe contributing to some of the distress, there are things that are outside of predictability, experience of very seasoned educators and administrators, where understandably students will be uncertain of what the impact of this system's change or that external factor will be on their progression. And I see that more in the past, let's say half a decade or so.

Dr. Elizabeth Harry:

Yeah, Erin.

Dr. Erin McKean:

No, I was going to say, it's just a really good point, because some is how we design it and then medicine is just hard. But you're so right. The externalities that are changing our need for tolerance of ambiguity and comfort with uncertainty has gone up for sure, much more.

Dr. Elizabeth Harry:

And we know those are either protective, if you have comfort with uncertainty or predictive of burnout, this sort of lack of tolerance of ambiguity. And for all of us, I mean we're talking about for our leaders, how do we lead through uncertainty and helping people see that future vision of themselves and what could be. And I know you both think so much about professional identity formation and this idea of how do we help our learners think about who they are in this profession and who can they be, seeing what's possible.

And it strikes me that, as you were mentioning, sometimes when people are struggling, they feel like they're doing it alone. They feel like they're the only one that doesn't know how to handle the uncertainty or can't picture exactly where this is going to go or how it's all going to shake out and that maybe shame might come along with that, that there might be a deep feeling of shame. And so, I'm curious, do you see that? Do you see shame coming up when students are trying to balance these things, if they feel alone? And when you do, how do you see it show up?

Dr. Erin McKean:

That is a very common component to struggle, is shame, because again, we've all come from high performing backgrounds and have high expectations of ourselves. So yes, that is often related to, wow, I didn't get this academic success that I wanted or I failed this exam. I feel shame. I don't want to talk about it and then to withdraw and hide is common. Of course, everybody responds differently, but I do think that's a common thread. And also, personal life happens in med school. So, it's not just academic struggle, but personal struggle, family struggle, being able to support the people around. Maybe I feel like I've let my family or my friends down because I'm not there for them. Shame is a strong part of the experience, unfortunately.

Dr. Seetha Monrad:

And shame also has so many factors that feed into it, including cultural, familial, environmental. And so, there can be the shame that arises from not achieving something that is felt to be important or not passing an exam. There can be shame about not knowing what's going on and not wanting to seek for help. And in terms of us trying to support students, a lot of it will depend on people reaching out for help, but being very aware that there are students who that is not an easy space to enter for many reasons.

Dr. Elizabeth Harry:

I once was speaking with a learner who, the comment was made to them, "It sounds like you've been white-knuckling this for a while." And they were reflecting to me how proud they felt when they heard that, because there was this idea that, and this goes along with this idea of overachieving and hyperachievement and perfectionism, that white knuckling was somehow a badge of honor, that not reaching out, that not asking for help, somehow was reflective of this hard exterior being able to tolerate the discomfort.

Dr. Erin McKean:

We tried to approach that head-on, even in the first week of med school, in many ways. I have a PowerPoint and a talk that I give to the M1 students about all the services, all the holistic wraparounds, student affairs services we have. And getting at that, I'm picturing this emoji I have on one of the slides of a little face that's not smiling, kind of that straight line mouth across and the top of the head is blown off with a big mushroom cloud over the head. And that's the picture on the slide for our learning support team trying to take away, trying to announce right then and there, you've come in a high performer, it's not going to be that for many/most of you from here on out. And guess what? That's normal. Here's some services we preemptively have to offer you. One of the things that has developed over the past five years is, freely available, no cost to students, tutoring towards all of our core requirements, all of our core clerkships and scientific teaching.

So, tutoring, individual tutoring, group tutoring, is available. Consultation with a learning specialist, and we throw that out there the first week of med school and normalize it. So, to address shame and its partner stigma, tutoring, it's almost like an expectation for you all. This is hard and so because we expect it, everybody just do it. It's great, great reviews, let's go for it. So, addressing some of those things, those structural elements, that we can design away from, medicine is just hard, here's what we can do to support you. So, I think that's been one of the big things we've done to address that. Also, structured supports, meeting with your counselor or advisor. We have an opt-out now. We will pre-schedule a time to meet with your counselor early in med school. You don't have to come, but you don't have to take the mental energy to do that, it's just an expectation. So, there are things we can do to address the shame and stigma head-on.

Dr. Elizabeth Harry:

What I love about that though is, naming it, too and bringing forward the idea that this is predictable and that people are going to experience it. And also recognizing that our struggling folks, it is harder when you're having a hard time, whether it is because of mental health issues, depression, anxiety, whether it's because of negative self-talk, that our executive functioning gets harder. And it gets harder to make those appointments, it gets harder to find an organizing and just cross that finish line. And so, just taking that barrier away, is one less thing that people need to do in order to seek help, which I love. You both mentioned the relationship with assessment, whether it's performance, how people are doing and needing tutoring, being very used to being top of the class and doing really well. And Dr. Monrad, you've looked at the relationship between student well-being and high-stakes exam performance. What did you learn that surprised you?

Dr. Seetha Monrad:

This was a work we did a while ago trying to look at the association between student well-being and performance on licensure exam. And what we found was that, metrics of well-being in and of themselves were not predictors of performance, when you control for academic outcomes that are related to exam performance. And so what that meant for us practically was, we see a lot of students who have increasing distress around high stakes assessments or high stakes situations, and trying to balance the degree of distress or lack of well-being a student is experiencing, with their counseling, their risk of having a poor performance outcome. Having that baseline that the degree of distress is not in and of itself predictive of a poor outcome, unless there are some underpinning academic predictors that are also there. It's sort of like the analogy I use as a physician is, pain can be very severe and depending on the type of pain, not necessarily predictive of the degree of tissue damage or what have you, the severity of the thing causing it.

So, this helps guide students in terms of managing. Everybody is going to be terrified of their licensure exam. I think nobody is going to walk in there being 100% confident. And how to manage one's own emotional reactions with data, using data to inform decisions, as opposed to the gut feeling and the behaviors that can happen when poor well-being is there. And so, it's also informed how we think about designing our whole program of assessment across the medical school, giving formative and practice opportunities, and then gradually increasing the intensity and the stakes and the summativeness of them, to also allow people the ability to practice, gauging their own personal experience with their data metrics in safer ways and then moving forward and moving forward, until you get to the higher stakes licensure exams and clinical skills exams.

Dr. Elizabeth Harry:

I love that for so many reasons. One, that it helps people not spiral, because I could see, if the data were the opposite and your angst sort of predicted that you weren't going to do well, then you're going to have angst over your angst, because worrying about that. But the other thing you're sort of doing is, and I don't know if this was intentional, but sort of exposure therapy for the angst, saying we're going to do little bits and that way we can show that anxious part of you that you're going to be just fine and that we can move forward, which is great.

Dr. Erin McKean:

And so, can I jump in there too? I mean, now there will be folks who do experience higher levels of anxiety and that's okay and do experience it. I just wanted to note there is an ongoing grant that just got funded, that's a partnership between our learning and accessibility team, in student affairs, in the Office of Medical Student Education, as well as with psychiatry, that's going to be, really excited talking about it. A team-based approach to the educational foundations related to anxiety and test taking, as well as then the psychological and psychiatric underpinnings. And can we work together as a team? For some students where that isn't reassuring. We all have a level of stress and uncertainty about how that big exam's going to go, but some people do have a higher level. Can we intervene on both fronts as a team to have better outcomes? And so, there's a grant that just got funding with Dr. Schroder and J.T. Sangsland that are studying that.

Dr. Elizabeth Harry:

That's so cool too, because part of what that gets at is, are we really testing for the behavior that we're ultimately wanting out of people? And a lot of our licensure exams, you might argue, aren't exactly testing for what it means to be an excellent physician. They're testing for excellent memorizers and that's important too, although maybe in our current shift in knowledge era, maybe less important than the ability to apply things. So, I'm curious how then assessment, we've talked about the impact of assessment on potentially creating some anxiety, how we're dropping in a higher stakes assessment to try to manage that. How do we manage this tension between creating a supportive environment without lowering our standards in any way, which obviously is so important when lives are at stake and patient safety is at stake. How do you think about that tension?

Dr. Seetha Monrad:

Our program of education and assessment is developmental, with the expectations and the supports when you are a very early learner transitioning from not a medical professional to the profession of medicine being different when you're ending your time in medical school and transitioning now to a more independent physician. So, part of it is that the guidelines and processes are sequentially increased with time, related to the developmental trajectory of the learner. We also have robust processes to identify what are the standards of achievement of different assessments at different points, and constantly looking at, are students achieving them in the way that we think they should be.

Dr. Erin McKean:

Honestly, I think learners, faculty, staff, are actually all on the same page. Nobody actually wants to lower the standards. They want to have both well-being and high standards and they do go hand in hand. So, I am a strong believer that wellness or well-being is being able to do what we came here to do.

And if we think of it that way, then we start layering the supports to meet that. Everybody wants to meet those high standards. Okay, then how do we help you recognize when you're not? How do we build supports to get you to where you need to be? And I think honestly, if we all think about it that same way, we're all on the same page, we're all in this together, do not lower the standards. Let's just figure out ways to help people get there, whether it's somebody who's struggling because of academic and we give educational supports, physical or mental health, let's connect into those supports. Financial wellness, let's figure that out. You have a disability, we are absolutely wanting to provide accommodations and give you that support. If we think of it that way, there's no reason to even think about lowering standards. We don't even have to.

Dr. Elizabeth Harry:

Yeah. No, I love that. And it's just an argument that comes up sometimes as we think about some of these myths and the way that it feels like a false dichotomy, if you will, that it's either or and it's not. And I love that, that idea. It's really a growth mindset way of thinking of it, that we can get everybody to that place. We just need to understand what are the deficits and it's really sort of customized learning then. What exactly do we need to focus on for each learner? So, then as they progress along their learning environment, they end up in this environment where they're getting feedback then from team members. They're getting feedback from our faculty, they're getting feedback maybe from residents and interns. What is that culture like? How does it work? What are maybe some pain points? And if you could change one thing about feedback culture at a friction point where students struggle, what would it be?

Dr. Seetha Monrad:

One of the challenges is the fragmentation of clinical care, which means that, because our model of medical education still very much is, in some ways, apprenticeship, people are working with clinicians who are simultaneously providing patient care, running teams, et cetera. And so, in those environments, those are the naturalistic real world environments that are so important. But because of the clinical systems, there is no continuity in a lot of the learning environments that there used to be, when people would rotate, in the simpler time with simpler patients, for four weeks at a time. You got to know learners and your team. And so, the trust and the believability of feedback given, was intrinsically built in the system. Now the system is a challenge to that, because there's much more transactional short-term interactions, where the trust really has to be developed very rapidly and the type of feedback interaction has to be very targeted to what was observed, with a mindset for growth.

And as physicians, we all have that experience and those abilities to engage and connect with a patient and figure out rapidly in different settings, how do I assure this person, gain trust and have a therapeutic relationship? The idea of how do we translate that also to learners where yes, you may only have that same learner in your clinic once or twice, or you may rotate on for a week when the student is leaving because the schedules are different. I think thinking how to create the feedback culture with the acknowledgement that longitudinality is not always going to be there between you and the learner.

And same for the learner, vice versa, that just because this isn't your longitudinal doctoring faculty who has known you for years, there still can be truth and authenticity in the feedback you get for somebody who has just met you. Even if you're having a bad day or you heard differently from another person, how do we create that trust in a fragmented system? And it's completely, I'm convinced it's doable, because we have to do the same thing for patients. So, we should be able to do it for our learners.

Dr. Elizabeth Harry:

I think that's really insightful though, drawing that parallel to the skillset, that we have to develop these rapid relationships of assessment and trust with our patients. And so, it's a translatable skill in theory that our faculty have. And then also, how do we teach our learners that skill and at what point can they adapt it? Because they need to have that skill too then. How do they rapidly build that relationship with the people evaluating them? That's so interesting. I haven't thought about that before. And so, Dr. McKean, you've talked a lot about how we really try to wrap care around these students from the very moment that they get here to say, we have a lot of resources available, so that if these moments feel tough, if the assessment feels hard, or if the feedback feels hard or other things, to your point, life happens and you've led major changes to mental health support, including expanding access and funding, what was the first most important barrier to remove in order to get that done?

Dr. Erin McKean:

Actually, we are so lucky that we've had student leaders and administrators, faculty, staff leaders over the years, but Claire Collins, Caleb Kahn, former alums who are now physicians in the community and other student leaders that studied. Do students get mental health care? What are the barriers to getting that care? And found just a huge number having stigma and very close behind or showing stigma. I don't want to reach out because I shouldn't. Doctors don't have mental health issues. Whatever reason I'm not reaching out that way. Also, access, I'm too busy in my clinical space. I can't reach anybody on evenings and weekends, was another big barrier. And then cost. So, we know that insurance doesn't always adequately cover mental healthcare. And of course, students are not employees. So, that was a big difference between say resident learners, GME learners, and undergraduate medical education. They're coming in with different insurances and different payment options.

So, how do I know I'm going to find somebody for me? So we looked at all these barriers and then had this big rapid work group in 2020 with student leaders, faculty leaders, staff, and looked at, okay, what are all these barriers? What are possible solutions? And came up with, if we had a dedicated team of psychologists and psychiatrists who understand medical education in the unique time of life and experiences related to life, who are accessible at the times that medical students need them to be accessible, who the cost is covered, so it's not a barrier, and also just that barrier of reaching out and finding your insurance card and figuring this out. If we could attack those top three barriers by developing a comprehensive plan at no cost to students, we could overcome the resistance to seeking care. We kind of looked at those barriers and said, what can we do to address those?

Dr. Elizabeth Harry:

Yeah. And have you seen that that has effectively removed the barriers?

Dr. Erin McKean:

So, then a follow-up, Robyn Bernstein just graduated last year. Another student leader who is great and team studied the same survey from before we implemented this med student mental health to one year in. So, only one year in and things continue to evolve, because we have to sustain and build our program and found that stigma had gone down. The access issue was far improved. And of course cost, because this is no cost to students. Thank you to a dean's commitment to pay for it, of course, has a cost. Again, the system is bearing that cost because it is important, but no cost to students. Those things really helped to increase access.

Dr. Elizabeth Harry:

And we talked about opt-out earlier and that it helps lower the barrier to entry just from the executive functioning standpoint, but what about stigma and uptake did you notice around opt-out? Did it have any impact on those?

Dr. Erin McKean:

So, interesting, as we built in our therapy access arm, if you build it, they will come, just from students calling and accessing. We were not able to even implement the opt-out system with our therapists, meaning the psychologists in the official med student mental health program, because they were overwhelmed and already having a full caseload. And so, coming from there, we do have academic counseling and advising already available in student affairs, separate from the therapy arm of things. So, without even implementing opt-out checks, we were able to address stigma and access to some degree. We then said, okay, we can't get there with our therapist, we're going to do it with our academic counselors and advisors. And so, we need to assess that separately, but I will say, we're working with one of our student leaders right now to understand that. And we found 100% uptake.

Nobody opted out in our M1 class. Of our M3s, we offered check-ins with their counselors and advisors as an expectation, but it was opt-in, that was 70% uptake. So again, we've got studies to do. This is all just data analyzed. I do think opt-out has a higher uptake. Most people are like, "It's scheduled, I'll go and I could find things out." And there's no stigma. It's better uptake than opt-in. I have to call and set it up. But we're working on that to figure out what's the difference. So, data still to come.

Dr. Elizabeth Harry:

Yeah, TBA, maybe we have to have another podcast. Well, it seems like though there's early signals that it's working. What are you still trying to improve?

Dr. Erin McKean:

Our wait list time is good. We had to go from unlimited therapy to a soft cap of 12 sessions with therapists per year, just in terms of volume. So, we're trying to figure out how do we get students access in a timely way and make sure they're all supported? And our team is amazing, the therapists are great at doing warm handovers to community, if somebody needs escalated levels of support, higher than the soft cap of 12 per year. So, how do we implement flexible access, available access within the budget that we have and the constraints we have? How do we provide other options? Not just individual therapy, but what about group therapy for common things? Things like imposter syndrome, things like anxiety, ADHD is commonly. That might not be a great example, but are there places where we can provide group therapy and input?

So, that's probably another iteration. And I have to say, that is managed. I don't get into people's private medical therapy, that's in coordination with our mental health team. But I think these are the things we're working on is, can we see what gaps exist now, and building that even further? So, those are the things that are on the next to-do list.

Dr. Seetha Monrad:

I think not in necessarily our shop per se, but just thinking broader term and systematically, the resources and the programming we're able to offer our students is incredible. And our students then leave our system or go to a different part of the system and it's a transition. And so, I think, thinking how to support students then transitioning to other spaces where there may be different or fewer resources than has been provided here, is another thing that, just in the big picture, the learner is experiencing their life longitudinally. We chunk it up in undergrad, grad, et cetera, but how do we set people up for success? Such a great point.

Dr. Elizabeth Harry:

Yeah.

Dr. Seetha Monrad:

Yeah.

Dr. Elizabeth Harry:

Especially if they're used to having so much support around them and then say they move and need to establish new contacts and new relationships and what does that look like? Recognizing also, moving locally, has different resources.

Dr. Erin McKean:

It's a really great point. So, I started this job in 2020 when we started looking at overhauling med student mental health. And part of my impetus was, because I had been so grateful to the House Officer Mental Health Program at the University of Michigan. So, at that point, the House Officer Mental Health program was the gold standard. We were looking at that like, how do we deliver that kind of thing to students? Then we built this thing for students and made it kind of the gold standard. I went to talk to some resident groups after we built Med Student Mental Health and then they started saying, "Oh my gosh, how come we don't have what the students have?" And it's like this cycle. So, it's such a great point. It was kind of ironic to hear that, when really the impetus for building this came out of the residency program.

Dr. Elizabeth Harry:

It's a real virtuous cycle though, it keeps leveling up. And what I love about it too is the innovation. There's continued innovation. So, there's a ton available with all this innovation. And we talked about sort of overwhelm and we talked about as people are struggling, sometimes it feels hard to know exactly where to go next. And so, what is one small move a student could make in the next 24 hours that you think could really reliably improve how they feel, that isn't going to maybe feel time prohibitive?

Dr. Erin McKean:

Yeah, this is great. I have to quote our former learning and accessibility manager who's now the director of student affairs, J.T. Sangsland. I quote her all the time, "What is the right intervention for this student at this time, with this set of circumstances?" So, the answer going back to, what is that thing? Well, it depends on the student. But for some students, that's going to be, calendaring time to study, calendaring time, dedicating that time to work out or making a list of nutritious things I'm going to add to my grocery list or building a budget. Depends on where they're struggling or what would bring them peace. So, it depends. For some students, they're going to be good with all those things and they need to just sit and do some box breathing or therapy tools or just commit the time to make that appointment with their academic counselor advisor or make an appointment with med student mental health.

So, I think it depends on where they are. If a student is listening, and they just like, I have no idea, make an appointment with your counselor, advisor and student affairs, because they're great people to talk to, have a ton of resources. And if you haven't done it in recent time, do it. It'll be worth your time.

Dr. Elizabeth Harry:

I love it. And so, what if you had a student in front of you, who was saying they felt overwhelmed, but they really felt like, if I slow down, I'll fall behind. What would you say to them?

Dr. Erin McKean:

This is a tricky conversation that happens frequently. Because the reality is, they're often not wrong. Our curriculum is very intense and it's time locked. I have this amount of stuff to do in this block now or in this rotation now, and then I have an exam and it comes and I have to do it. They're not wrong.

There often isn't a whole lot of time. And so, sometimes, again, it depends on where the student is. We talk about different strategies like calendaring and working with supports to block time, different executive functioning coaching strategies. Sometimes we really don't have a great solution. You have to rest at some point. You will perform better if you have some rest, but there is limited time. Some students will need to step away. We can do that through leaves, but we can also do that with deferrals and different strategies. So, if a student is struggling, it's, talk with me, talk with your counselor or advisor. We'll help you figure that out. But they're not wrong.

Dr. Elizabeth Harry:

Yeah. Yeah, no, and I love that validating their experience. And also one of the things that I think about is, sometimes the advice we give people, in [inaudible 00:36:54] even, that nothing is so urgent that there isn't a moment to think.

Dr. Erin McKean:

Yes.

Dr. Elizabeth Harry:

You always have space to pause and think, and sometimes that space will make the urgent thing go that much better.

Dr. Erin McKean:

Right.

Dr. Elizabeth Harry:

Yeah.

Dr. Erin McKean:

Yes. We have to do that. Five seconds, step away, deep breath, pause and think through it. Same. You do have to sleep at some point because if you don't, you're still not going to remember. You're not going to be able to retain knowledge that way. There's a balance there for sure.

Dr. Elizabeth Harry:

Yeah. And what if they're coming to you earlier? So, before they're in crisis, what would be the advice that you would give them?

Dr. Erin McKean:

Oh, gosh. I mean, hopefully I get to know them, what their goals are, what their priorities are, what their strengths are. And if they're really feeling like, I have this pressure to go, go, go, understand what's driving that.

Dr. Elizabeth Harry:

Yeah.

Dr. Erin McKean:

And then share with them, here's some alternatives, here's some strategies. So, just help them work through, I don't know, where are you right now? It's always hard to say because, when I took this job, Tamara Gay was the student affairs dean before me. And when I was onboarding, she said, "Erin, it's just amazing the many, many unlimited ways people struggle." And I heard her and I'm like, Okay, I get that because I'm a physician, I get that. And I totally didn't get it, to be perfectly honest. Now five years in, I'm like, oh, I get it. Everybody's so different. So, I guess, try to meet them where they're at, understand their motivations, and try to give alternatives.

Dr. Elizabeth Harry:

And the other piece that is great about how you're describing it is, without judgment. It's just sort of understanding what's happening. Here are our options, what's the next right choice? What's the next best thing that we can do, given where we are? And so, we've talked a lot about what the learner can do and resources for the learner. And that's really important, because ultimately all we each have is ourselves and that's control the controllables and that's what's within our sphere of control. But you and I, we think about the institution and we think about our faculty and we think about designing systems, so that people can come in and thrive. And so, that brings us to thinking about our faculty and our institution and accountability there. If you could give every faculty member one job description line for student well-being, what would it be?

Dr. Erin McKean:

Oh gosh, I'd probably go back to my philosophy that everyone here, all students are here to be exceptional. They all want to succeed. Don't forget that. Help them do that. Give them clear, kind guidance. Have a baseline understanding without judgment. If you hold in your heart that we're all here to do well and truly believe that, I think you'll do a better job helping them with their education and understanding, knowing that faculty are busy and have their down times too. But I think that's the biggest thing, is just, know they're all here to be exceptional. Help them do that.

Dr. Elizabeth Harry:

And assume not only positive intent, but positive capability.

Dr. Erin McKean:

Correct.

Dr. Elizabeth Harry:

Yeah.

Dr. Erin McKean:

Yeah.

Dr. Elizabeth Harry:

And so, is there a policy or a norm that you can think of that has been changed or that you're working to change, that's had sort of an outsized impact on well-being?

Dr. Seetha Monrad:

There are many. I already talked a little bit about a norm of tutoring, this norm of having help, this norm of M checks, checking in with your counselor advisor. We're rolling that out. We're expanding that by the way, so that all your students get some checkpoints. So, this normalcy of checking in and taking advantage of the supports that exist for you, I think that's been a big change that's less focused on, right, we're not here to judge, we're just here to support. If things are going wrong, it's not because fundamentally something's wrong with you. Fundamentally, we just need to do a root cause analysis and start addressing those things.

Dr. Elizabeth Harry:

Yeah. I love that mindset. So, if every student listening just took away one line, especially maybe one that looks fine on the outside but maybe isn't feeling fine on the inside, what's one thing you'd want them to hear?

Dr. Erin McKean:

Life happens. It's okay to reach out for help. In fact, it's good to reach out to help. We have a whole team of people here whose whole job is to support you. That's what we want to do. We want to be exceptional teachers, supporters. So, reach out, it's good for all of us.

Dr. Elizabeth Harry:

Well, thank you so much to both of you, Dr. Monrad, Dr. McKean, thank you for joining us for a real world conversation about student well-being, how it's shaped by culture, assessment, access to care. I really am just amazed by all the work you're doing to support not extra, but really embedded help in the learning environment. And to our listeners, if you're struggling, you are not alone. And as you've heard, support is available. Please check your Michigan Medicine Student Well-being Resources and Mental Health Services. We've talked about many in today's podcast and we'll put links in the show note. Reach out early, reach out often, and please subscribe for more episodes. And as always, take care of yourself and take care of each other. Thank you.