Student Wellness is Critical to Creating a Safe Learning Environment

Podcast Transcript

Dr. James K. Stoller:

Hello and welcome to MedEd Thread, a Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano:

Hi. Welcome to today's episode of MedEd Thread. I am your host, Dr. Tony Tizzano, Director of student and learner health and assistant clinical professor of surgery here at Cleveland Clinic in Cleveland, Ohio. Today I am very pleased to have Dr. Christine Warren, associate dean for admissions and student affairs at the Cleveland Learner College of Medicine of Case Western Reserve University and associate professor of dermatology and Dr. Cory Chevalier, palliative medicine physician, assistant professor of medicine and director of wellness for Cleveland Clinic Learner College of Medicine here to join us. Dr. Warren and Dr. Chevalier, welcome to the podcast.

Dr. Cory Chevalier:

Thank you so much.

Dr. Christine Warren:

Thank you.

Dr. Tony Tizzano:

If we might get started by just telling us a little bit about yourselves, your backgrounds and your roles here at the clinic.

Dr. Cory Chevalier:

Sure. So, I've actually been at the Cleveland Clinic, I think this is my twelfth year now. I did my training here, my internal medicine residency training, my palliative medicine fellowship. Been involved in education ever since I started working with the internal medicine residency program and, you know, wellness and just focusing on how can we do things better? How can we have a better experience for learning and education has always been a passion of mine.

When I first started working with the residency program, that was one of the first things that I actually ended up doing was focusing on their wellness and their quality of life and how can we do things better? I started doing more with that with graduate medical education and GME. And at that time, I actually started doing some work with the medical school and got on a taskforce about, you know, with the transition of the new school, you know, what should we be doing? What changes should we be making? What should we be keeping the same? So, I got really invested and interested in, you know, how do we make our learning environment the best that it can be? So that's a little bit about where I came from with wellness and education.

Palliative medicine I've been working for the last eight years or so helping to run our in-patient collaborative palliative medicine and oncology in patient collaborative service. So, primarily I just work in patient. For the last eight years, I actually haven't a patient in clinic for about that entire length of time.

Dr. Tony Tizzano:

Excellent. And I imagine that having trained here really helps gain perspective in some of the roles that you serve now. Christine, how about you?

Dr. Christine Warren:

So, as you mentioned before, I am the associate dean for admissions and student affairs for the Cleveland Clinic Learner College of Medicine. I am also a graduate of the program. I was in the inaugural class at CCLCM and we really pride ourselves on family culture and we tell the students we are your professional family. So, as we talk about wellness and I think about each student, I really do care about them as a family member. And this is why this work is so important to me.

I did have the opportunity after attending CCLCM to go away and be at other institutions and train at other institutions but ultimately, I came back to the Cleveland Clinic and to work with CCLCM students because of what I think is a tremendous wellness culture and attention to wellness.

Dr. Tony Tizzano:

And I would agree. I think we're all glad that you're here and just from the comments I've gotten from students. So, welcome both. So, Cory if you can help frame the concept around the concerns related to wellness for students? How is it different now than it used to be and what are your major objectives?

Dr. Cory Chevalier:

Sure. So let me just say, you know, medicine can be stressful. I think we all know that. Focusing on our student's wellness and supporting them is absolutely critical to creating a safe learning culture in which they're comfortable learning. It's not only important because we know how big of an impact burnout has on the field but also creating a safe culture will help support the student's mental health, amongst many other parts of wellbeing. You know, we want our students to be well rounded in their care for others. So, we definitely want to make sure that those important things, people, activities that they're doing in and outside of medicine stay paramount as they go through their training.

And honestly, we want our students to be happy. We want them to be as Dr. Warren was saying. I mean we see them as family. I'm a physician advisor as well, you know, the students that I work with, I reach out to them pretty much every week. We want them to be fulfilled in their careers, fulfilled in their lives and that focus really needs to start now.

Dr. Tony Tizzano:

Excellent. And so, Christine, when we look at students that come on board, and particularly when they begin their clerkships, all of a sudden, they're the doctor. And, you know, there's not an easy way to sort out who's who when you walk into a room. So, they begin to develop this professional identity. And I wonder how steps can be taken so that they remain the person that they are, which is what got them here to begin with, and develop that professional identity at the same time. What are ways that we do that or help them do that?

Dr. Christine Warren:

Well, this is a marathon, not a sprint and we remind them of that. And as they move forward, they are going to need to stay in touch with who they were. I will say, as they develop their professional identity, there are some challenges to that. There are challenges for all of us sitting at the table. I think deciding who are we and can we ever fully remove ourselves from the physician identity that we have created? But it's looking at wellness and recognizing that wellness is different for each individual.

So, wellness is not just meditation and mindfulness. Wellness is physical wellness, financial wellness, spiritual wellness and many other areas. And so, the sooner we can draw the attention to students that self-care is important, wellness is important and give them the resources and tools while they're here in medical school, the better we'll be in supporting them as they develop that I would say healthy professional identity.

Dr. Tony Tizzano:

Sure. Well said. You know, I don't really interface much with students until the APM3, the art and practice of medicine course in their third year, beginning their clerkships. Definitely a stressful time but it's not lost on me that when they come here and matriculate, they're broken down into these four groups of eight. They spend a lot of time together and there's a solidarity. There's no question. Do you think that has a significant and positive impact that for me certainly was lost in a class of 220?

Dr. Christine Warren:

Yes. That sense of connectedness to be surrounded by your peers and a lot of the peer teaching that we have in the small groups we have to allow the students to feel that sense of belonging and that team support that other students might not get if they're in a very large class. So, I definitely think that contributes and that was something that was in jeopardy during COVID. That inability to connect with others, at least in a physical space. They were still connecting over Zoom but that is one aspect of wellness that is extremely important. Everyone wants to belong.

Dr. Tony Tizzano:

Yeah, absolutely. My son was in engineering at Miami University before COVID hit. But as he watched it unfold, he said, you know, beginning my third year, had COVID been there, I would have stopped going to school and had to wait until it was over. I could not have functioned in that because of the interaction and labs and what have you. And medicines in many ways the same. So, Cory, when we look at mental health, you know, what steps are taken to allow students to embrace it and not look at it as a potential sign of weakness so to speak?

Dr. Cory Chevalier:

Yeah. That's a great question. So, I think one of the first things that we talk about when students are first brought into the school is their wellness. You know, we, we normally have at least three sessions at the very beginning for the first years just within the first couple months focusing on their wellness, including their mental health. And actually, as a part of this, we proactively schedule them for a check in with our behavioral health therapist, Angelee Calla. So right from the very beginning, we're saying that this is something that's very important. This is something that we want to support you with and we make sure that they get connected as soon as possible.

We also make sure that we're working with our physician advisors to make sure that they're not there just academically but also to make them feel like they're at home. And we're always doing little things to help them feel supported and connected as well beyond that. You know, we always do support boxes for their step exams, you know, putting together large boxes of different things that make them know that we're thinking of them, we want them to succeed, we want them to feel supported. Winter holiday treats, Halloween gifts.

We do lunches in the middle of the day where we're bringing multiple classes together trying to make sure that different classes know each other. And at the same time, just building time for connectiveness. Right now, we're actually planning a hot chocolate bar for when they get back from winter break. Just something that our students are actually helping to spear head. Just another way to say, hey, welcome back. Know that you're supported. Know that we're here. Know that we're family.

Dr. Tony Tizzano:

That's fabulous. I'm really glad to hear that automatically you have everyone check in with someone with expertise in mental health because it sort of in a way could popularize the idea that this is the norm. I don't have to have a problem. We're gonna talk to everybody. There's a company that I am familiar with that has a not a large group of individuals, about 150 to 200, and they decided that mental health was a significant enough issue that they would have a psychologist, two of them, twice a week, wander through the open office environment at lunch. So, Tony, anything you'd like to discuss? How about you, Christine? And if you said yes, they had five or so minutes to kind of pin it down, and then if it was significant, they had latitude to take an hour.

If they defined something common among these individuals, they then would have a breakfast once a month that would entertain that topic. And over the course now of two years, they have 98 percent participation. And they've just made it okay to say, yeah, you know, this is mental health and it's just as important as my sore throat. So, Cory, when we look at students and how busy they are, you know, how do we keep them focused on their supporting themselves because you can get overrun. It's a freight train.

Dr. Cory Chevalier:

Yeah. No, that's a wonderful question. I think it's so easy in medical school and just in medicine in general to get focused on others. It's kind of, you know, people come into this field, they have a very giving heart. They want to help everyone around them. I think our hope and what we've seen is by being aggressive and being intentional on sharing all these different things, building all these different services, providing these times for giving back to them and just reminding them on, you know, ongoing basis of everything that exists. Building different times for them to come together with the academic teaching faculty, with themselves, that helps build a culture where they realize that no, no, this is something that we all need. Yes, I'm giving to my patients, yes, I'm giving to my colleagues, but this is something that is also important for me.

One of the things that we've done in, you mentioned APM3 and some other things, is actually take some time and last year we did a session where we built masks and we sort of explored their inner versus outer selves and I think that was one example of using creativity and art to sort of explore that, you know, that outward facing mask of who they are in the hospital. Who people see them. But then also those inside things, those things that maybe they're not sharing with everybody and, you know, the things that they need. The things that they are. The things that they may not be putting out there. Giving them time to reflect on that I think is critical because that helps them understand, well, what is it that I need? What are those things that may be missing or what are those things that really do help me?

Dr. Tony Tizzano:

That's interesting. I was at that session and actually, you know, I didn't get the deeper meaning that you just projected but I will tell you that subsequently when we broke out into small groups the conversation around what they had just done was nothing short of fabulous. So, you know, there are so many different ways.

So, Christine, when we look at emotional ability and so forth and we're building self-awareness, you know, burnout, everyone talks about it. How do we recognize it in these students on an individual basis?

Dr. Christine Warren:

I will say that being actually to physically see them, it helps with us identifying students that may be burning out. I think during COVID where students weren't coming into the classroom it might have been harder for faculty or peers to recognize burn out in their colleagues. But one thing is also in clinical settings a lack of empathy that may be developing or if a student perhaps always used to be meeting deadlines and then we notice that they're arriving late or not turning in work at expected times. These are all subtle signs, at least to us, that something might be going on. Or if they're calling out a lot sick at various time points, we need to check in with those students and, and simply reach out and say we've noticed a difference here and, and we want to make sure everything's okay.

Dr. Tony Tizzano:

Great. And so, one of the things that along those same lines in seeing how students feel, since day one, becoming familiar with the college, I heard the word reflection. And I think you guys have honed in on it and refined it to an art form. So, tell me about reflection around this as well, the opportunities that the students have and the importance of that.

Dr. Christine Warren:

So, reflection is part of our assessment system, our portfolio system. It's even a competency on their ability to move forward to the next year. And, and part of what they have to reflect on is their self-care. If they do notice that perhaps they're falling behind on making time for themselves or making time for themselves to connect with family and friends that they should develop a learning plan. Develop a way that they can reach their goals of regaining some of that self-care.

Dr. Tony Tizzano:

So, it really helps them to organize their thoughts around an issue they might be having that, you know, until they focus on it, they don't get. Cory?

Dr. Cory Chevalier:

Yeah. Just to add on to that. I'm actually a new physician advisor this year is one of my other roles in this school. And it's been incredibly impressive, the amount of reflection, especially of the portfolios that they go through. I think a really important part of that is to make sure that they're reflecting on, yes, these are things that can be improved but all the things that they're doing well. All the things that they're doing in awesome ways because they're such wonderful students that bring so much to each other, themselves, the patients. So, the reflection on all the amazing things that they're doing is incredibly important. And that's something that I know the team, especially the physician advisor team and student affairs team, works really hard to make sure that they're focusing on everything that they're doing well so that they know that they're helping people.

Dr. Tony Tizzano:

Excellent. So, you know, I think as I look at my own time as a student, I think all of us from time to time are subject to some sort of perhaps bias and I know that the college has spent a lot of time looking at implicit bias and microaggression. How does that impact wellness?

Dr. Cory Chevalier:

I think it can drastically impact wellness. I think it's something that I mean people deal with every day, people deal with every week. I mean many of our students are going to face biases in class and in the hospital with patients. I think everybody has bias. Part of that is, one, how can we help with the students and give them the tools that they need to deal with this bias in the moment? How do they interact when that happens? Two, making sure that those relationships with faculty, with, you know, the physicians in the hospital, with student affairs, with myself, with their PAs. Making sure those are strong relationships, people that they trust. We're not gonna know if those things are happening if they don't bring them to our attention.

So having those relationships be incredibly strong is 100% needed to make sure that we're able to address those issues when they do come up. And sometimes, as I said, everybody has biases but there are times where things go to the point where it has to be addressed. I mean things can't just be let go if somebody says something in the hospital. We need to make sure that that's being addressed. We must make these changes over time, no matter who's making these statements. So, having a culture that allows us to hear those things and then address those things and also having that trusting relationship with those people working the hospital or the people working with those patients so we can tell them this is what's happening. That's the way we are able to fix these biases and microaggressions.

Dr. Tony Tizzano:

Boy, an organization our size, that's a tall order. And I will tell you again just my window into this world is APM3 but there is no question that the students see a very strong I've got your back among the faculty and learner. No two ways about it. Extending that out into the larger population is a big, big job. Christine, what do we do to, to try to make that happen?

Dr. Christine Warren:

Well, it's education and training. And we all need this education. So, it extends beyond those individual interactions where microaggressions are occurring but more to the community at large and what can we do as an organization to educate ourselves. And so, we do have, stimulated through the education institute and many groups within the organization have partaken in microaggression training sessions, two-hour session, to come together and talk about microaggressions. Not only how to react in the moment but also what if you are the individual who commits the microaggression? How do you receive that feedback and then what can you do to try to repair and do better in the future.

Dr. Tony Tizzano:

Yeah, excellent. I think it is important just as much for the person who commits it to realize this doesn't necessarily mean I'm a bad person. I just hadn't thought about the way this came across and I think you can learn. It's that bi-directionality of learning.

So, jumping to something a little bit different. Students fail from time to time. Things don't go the way they; they want them to and I think it really can impact someone who's in medicine because they have this notion that I have to be next to perfect. How do we help them bounce back from that?

Dr. Christine Warren:

Well, first we have to tell them it's okay to fail and everyone is going to have a misstep. But again, supporting them first. Telling them we're there to support them. That we are going to help provide the resources to allow them to move forward, to improve, really focusing on a growth mindset. And that's why in our portfolios they reflect on strengths, as well as targeted areas for improvement. We all have moments when we have failed and it's how we can all move together and being able to overcome those.

Dr. Tony Tizzano:

Excellent. Well, along those lines, Cory, please, you had a comment?

Dr. Cory Chevalier:

Yeah. I just want to share one of the first things that we actually focus on with the students for the first years when they're coming in is imposter syndrome as well, which is tied up very tightly with, you know, that feeling of failure. One of the things that we talk about is looking at that feedback almost the way that an airline pilot looks at their instruments. You know, it's not necessarily failure. They're, they're looking, they're re-acclimating the plane as they're flying. Failure can be seen in terms of feedback and be seen in terms of growth.

One of the things that we've built and that we're going to be sharing with the students, in addition to that imposter syndrome session, is also an anti-resume survey that we've been collecting from students, to residents, to staff, to enterprise leaders, just people sharing that everybody fails. The most successful people in the room fail. So being able to have that, share that with the students and be like, no, no, even this person, even they've had multiple, multiple failures along the way. I think it's important to drive in the point that everybody fails. It's okay to fail.

Dr. Tony Tizzano:

And I think oftentimes what we take away from those failures is sometimes the most profound. We're able to impact change in ways that we might not otherwise have. So, I know there are wellness programs here, Cory, and, you know, what are some of the specific steps, outreach programs, that you have here at Learner?

Dr. Cory Chevalier:

Yeah, definitely. So, we started the conversation I think talking about mental health, and as I said, the first thing that we do is proactively meeting with the students with our behavioral health therapist. And a lot of people end up having ongoing discussions and ongoing conversations with her. We have our university health and counseling accessing. We have CWRU care, telehealth service. And there's ways to share concerns, not just one on one, but also anonymously. So, if somebody doesn't want to share their identity but they want to share a concern, there's multiple ways to share anonymously as well.

We mentioned physical health. We have our Cleveland Clinic fitness center that's pretty much right across the street from the medical school. Multiple Case Western fitness centers as well. Digital wellness support. Everybody who wants it, gets access to a free meditation approximately. I think there's probably 40 or 50 students who are using that right now. Go To Sleep Program, sponsored through Cleveland Clinic. We're going to be providing them some education on actually financial wellness as well because that's I think the number one top ask that they've had is more information on financial wellness.

This isn't specific to wellness, but, you know, the buddy system can be really helpful. Having our first years paired with upperclassman to make sure that they're learning the ropes and hearing about some of those things that may not be in the handbook. And just ample, ample opportunities for bringing classes together, for bringing faculty and students together. Different social times to get together, get to know each other more in that family type of way. It's built in a lot to the curriculum as well. You know, we, we'll formally teach on mindfulness, mentorship, imposter syndrome.

We're always reminding on resources. And you mentioned a professional identity as well and prioritizing kind of their self-formed goals through different exercises. These are all things that are done throughout those five years of their education.

Dr. Tony Tizzano:

You mentioned the dovetailing with upperclassman. I think that's really a key step and I'm involved with the Cleveland Medical Library Association and we interface with students from a medical student fraternity at Case. And we have speakers come every month and we do this kind of journal club. But the thing they will always want the most is to be able to talk to a medical student. You know, they want that next step. They want to see, you know, it's one thing to be the attending physician. Yeah, we've done this, don't worry about that. They want that new and fresh perspective that really only someone just a year or two ahead of them can provide.

So, Christine, you know, COVID was thrown upon us and I have to image with respect to wellness that you guys huddled and came out with some great steps to try to take back what you had before. How did you do that?

Dr. Christine Warren:

Lots of events. We, we're trying to plan with, within financial constraints. That's the hard balance but I think just physically being able to bring students and faculty together to build those relationships again. I think that's been of tremendous importance. Things students even do on their own. There is a what's called a social wellness committee that Dr. Chevalier oversees but students actually plan evens to go bird watching together or to cook together or to go on hikes together. And one thing the students did even during the pandemic is they created a virtual student lounge so that they could talk to other CCLCM students, which has continued because first and second years can't always touch base with folks that are clinical clerkships. So, this has really been nice for them to continue the communication. And then culinary medicine is something that developed actually during the pandemic and Dr. Chevalier helped organize that over Zoom which then moved into a teaching kitchen. I don't know if you want to mention something about that.

Dr. Tony Tizzano:

Yeah, please.

Dr. Cory Chevalier:

No, I can definitely speak to that. So, culinary medicine actually began during the pandemic. We were looking for ways to bring people together and also what an opportunity to provide some extra education on nutrition, in addition to just providing a place for the students to have fun. So culinary medicine was out of the Linters campus. There's a large teaching kitchen there and this was at a time where we couldn't actually have people in person together. So, I learned how to use 4k cameras. I learned how to use Lav mics and all sorts of things. And myself and Chef Jim over there and Dr. Mike Roizen did at least monthly sessions with the students in a virtual way. So, we'd send out the recipe and we'd send out the ingredients. They'd get everything ahead of time and we'd actually all cook together.

So, we'd demonstrate with our executive chef exactly and go through step by step as we're, we're talking, we're educating, we're having fun and the students were cooking along with us. And they would always show us things as we're going and we'd kind of eat together a little bit at the very end in a virtual way. It was a really wonderful way in a very difficult time to get together in a meaningful way. It wasn't just us sitting around. It was us doing something, us learning, us being together with Chef Jim, with Dr. Roizen.

It was a lot of fun and that's something that actually we're still continuing and still building on. This year we're just starting to actually bring that more formally into the curriculum and that's something that I think everyone's, I mean I'm really excited about that.

Dr. Tony Tizzano:

Yeah. I think food is a commonality among all of us. And it's entirely non-threatening. No one has the expectation that I should be good at baking or this or my souffle won't be quite as it should be. You know, they're there to learn and having some expertise there. I mean I would welcome an opportunity to see that. At one of the APM3 classes, I actually brought the ingredients for my grandmother's Christmas bread. I had it all premeasured and they knead a dough. You know, they said it at a previous time. They said, we talk about work-life balance, but that's all we do. We talk about it. We don't do anything for it. And I think cooking is just a fabulous segue into that.

Well, those are the questions I have and I'm curious if there's anything I've missed or something either one of you would like to comment on.

Dr. Christine Warren:

I just wanted to mention how critical it is that we do have a focus on wellness, wellbeing, mental healthcare among our trainees and among physicians. We know burnout, depression, anxiety and unfortunately suicide is higher in medical professionals and that's been seen in medical students as well. So, decreasing the stigma surrounding seeking care and providing them confidential resources, and that's what we do with having the students meet with a wellness check in. Someone they can meet with outside of the school. And we don't know if they continue to meet with her or not but it's providing those resources and letting them know that this is encouraged so that they will seek that care.

Dr. Tony Tizzano:

Yeah. That feels like to me like a key takeaway. This anonymous we meet, we all do it, and what we do with it from that point forward nobody knows. I mean I just think that's excellent.

Dr. Cory Chevalier:

I just want to share the importance of mentorship as well. When it comes to wellness, my mentors over the years, and they've been here in multiple different roles, have been some of the most important people in my wellbeing and just my professional growth. So that's something that we always want to make sure our students know the importance of is giving them education on mentorship and helping them find good mentors. And the last thing I just wanted to share is just the importance of being kind. I think that we all want to be that person that students feel comfortable talking with. When they're having a very difficult situation, being open to them and truly wanting to help them is probably more important than anything else that we can do in that situation. So just to end on the importance of kindness.

Dr. Tony Tizzano:

Well, kudos to both of you. I think it's fabulous the work you're doing. I think it shows and I wish it was something that was focused on when I was in medical school.

Well, thank you so much Dr. Warren and Dr. Chevalier.

Dr. Christine Warren:

Thank you.

Dr. Cory Chevalier:

Thank you.

Dr. Tony Tizzano:

This has been a great podcast. To our listeners, thank you very much for listening and we'll see you on our next podcast and have a wonderful day.

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, Sound Cloud, Stitcher, Spotify or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread and please join us again soon.