Welcome to this session, The End to Stigma Begins With Us, How Physicians Can Address Stigma in the Medical Profession and Beyond. My name is Dr. Diane Hart. I'm the moderator for today's session. I am a consultant member of the Scientific and Planning Committee for this year's annual meeting. This session is critical to the APA's mission to support psychiatric physicians. According to the American Psychiatric Association, more than half of people with mental illness don't receive help for their disorders. Often people avoid or delay seeking treatment due to concerns about being treated differently or fears of losing their social status, professional goals and identities, and even their own perception of who they are and what they are capable of. Physicians do this too. Psychiatric physicians and other mental health care workers are on the front lines of healthcare, and it is critical that we support the mental health of these frontline heroes. Today, healthcare heroes have high rates of anxiety, mental health disorders including depression, anxiety, post-traumatic stress disorder. Sadly, each year, 400 physicians die by suicide. Today's objectives are to understand your own state's approaches to medical licensure, credentialing, and physician mental health, understand best practices and models, and how to advocate for institutional statewide change, to articulate and be able to engage in specific physician mental health advocacy tools at the institutional level, and be motivated to optimize your own and your colleagues' health and well-being. This session is meant to spark conversation that we hope will continue long after today. Post your reactions and ideas on social media at APA Psychiatric, tag our panelists, and the Lorna Greene Foundation. The meeting's hashtag is APAAM23, and this session's hashtags are nstigma, the N to stigma begins with S, and you are not alone. I've felt strong internalized shame around my diagnosis, and the mood-stabilizing medications I had started taking. That stigma was ever-present around me, too. On other rotations, I heard colleagues refer with unfounded prejudice to patients with bipolar disorder. You can't trust anything she says. She's probably lying, she's bipolar. These are words written in an op-ed in the LA Times by one of our panelists, our chairperson, Dr. Devika Bhushan, a physician and public health leader living with bipolar disorder. She experienced the impacts of stigma at all levels firsthand. We thank her for her bravery and her advocacy. Dr. Bhushan is a Harvard and John Hopkins trained pediatrician and public health leader. She has served on Stanford's faculty as California's acting Surgeon General in 2022. She was a leading key public health spokesperson and advisor to the governor. Her work can be found in multiple leading mainstream and scientific publications. Next, we have Dr. Michael Myers, a professor of clinical psychiatry at Sunny Downstate Health Sciences University. He is a specialist in physician health. As a clinician, researcher, teacher, writer, mentor, and consultant, he's authored or co-authored nine books, including nine books. And finally, Dr. Linda Worley. She is at the University of Arkansas for Medical Sciences College of Medicine, chief wellness officer. She founded the UAM's College of Medical Student and Faculty Wellness Programs and co-led the Vanderbilt Distressed Physicians course for over a decade. She has been a leader in organized medicine and has multiple publications focused upon well-being and preventing burnout. Our panelists' full bios and my own bio are available on the APA website and the meeting app, which I'm sure you've all downloaded. Each of our panelists will share their own stories and what led them to become effective physicians and mental health advocates. Please join me in welcoming our first panelist, Dr. Michael Myers. I got it. Okay. No financial relationships. So, Carol Hanisch, American feminist, forerunner to Gloria Steinem and others, the personal is political. So let me tell you just a little bit about the personal part of my presentation. My so-called lived experiences, which are both my own as well as my family's. So I grew up in this family in the 50s, very typical middle-class family. My father was an attorney. My mother was home full-time raising five kids, drinking a lot, depressed. It was undiagnosed. It was untreated. It was just kind of a mystery to us. And this was followed by my two older brothers, both of whom developed substance use disorders. And no surprise, these went undiagnosed and untreated as well until later in life for one of my brothers. So let me tell you a little bit more about myself. I first came in touch with what I call institutional internalized stigma in 1962. I was a first-year medical student, and one of my roommates, a fellow first-year medical student named Bill, a pseudonym, killed himself over the Thanksgiving weekend. And why I call this institutional internalized stigma is because we heard nothing from anyone in our institution about this. I was the one that stood in front of my class after the holiday weekend and told them that Bill had killed himself over the weekend. I can still remember that so vividly after all these years. When I sat down, as you know, you could hear a pin drop, and also I can still see the ashen faces of my classmates. And the professor of biochemistry then said, let's return to the Krebs cycle. Now, in his defense, I hadn't given him a heads up about the announcement I was about to make. And so I forgive him for that, but it really was a metaphor because nothing else was said. And over the years, this really galvanized me into this whole subject of physician health and well-being because of the way we were shut down. So fast forward then now to the summer of 1968. I had been a sort of previously heterosexually functioning man, lots of girlfriends, and I, as rather late, began to develop some same-sex feelings. I was a resident in internal medicine at LA County Hospital. I felt very alone with these feelings. I acted on them a bit in Los Angeles, which was all pretty negative in a respect. And here's why it was negative as I went to the library of LA County Hospital to look this up and found that I had a sociopathic personality disorder. This was in DSM-II. And if it wasn't that, it was a sexual perversion or a sexual deviation, which was meant to be like a little bit lighter. Nothing was very pretty about that. Also, I had never, ever heard of a gay doctor. Homosexuality was illegal. And it certainly was, you know, as I said, a diagnosis in DSM. So I was bisexual enough to really kind of go back into the closet that I never really left. And then later that year, I met the woman who became my wife, etc., etc. And I won't go into those details over the years, but basically that was an incorporated internal personalized stigma that I felt about this pretty awful thing inside me. So let me tell you then what came after. And I apologize. This slide, unfortunately, didn't make it to the app slides. But after a rotating internship I did a year of emergency medicine and internal medicine. Then I did my four-year residency. But it was the stigma of psychiatric illness and suicide that beckoned me. I had looked after so many individuals who died under my watch in the emergency room or in medical intensive care units. Back in those days, people were overdosing on a drug called Dordan, which is very dangerous. And despite peritoneal dialysis, many of our patients died of their overdoses. So then when I finished my training, I embarked on this 35-year career, half-time academia, half-time private practice. But I became very conscious of what I would call then pernicious stigma in doctors. It was the morbidity that we delay getting help and then the mortality that we're at risk of killing ourselves. So I'd only been in private practice about eight or nine years when another tragedy occurred. A friend of mine who was a psychiatrist who I trained with killed herself. And she killed herself without treatment. And she was having wild mood swings. But again, because of stigma, she did not receive any help. And that was it for me. The next morning, I converted my private practice to solely looking after only medical students and physicians and their family members. And that's what I did for the rest of my 35 years of private practice. So that's how I became the specialist in physician health. And I'll talk a little bit more about that. So let's get into the 80s and 90s. I began to do a lot of teaching, writing my first book on doctor's marriage. It was in the 80s and then through the 90s, other books on handbooks of physician health. I produced videotapes. One was on physicians living with depression. Another one was on physicians living with AIDS. Because remember, it was during the epidemic at that time. And also did a videotape on boundary crossing when doctors become sexual with their patients. I was volunteering. I was in Canada then, both the Canadian psychiatric and the American psychiatric and doing a lot. So I began to work my way up the ranks. And this was very deliberate and strategic because I really wanted, I wanted to have a voice. There was so much that I really wanted to convey. I've always seen myself as a mouthpiece for my patients who, because of stigma, cannot speak for themselves, except the ones of course who do speak openly. So in the Canadian Psychiatric Association, I got onto a lot of provincial national task force working groups. I got on the board of directors. Then became the president of the Canadian Psychiatric Association just after the turn of the millennium. That was my theme, new century overcoming stigma, respecting differences. Because again, I really wanted to highlight how much stigma was affecting us all. Then in the APA, I got on national components on physician health. Back in those days, it was called the Committee on Physician Health, Illness and Impairment, which was an improvement from the Committee on Impaired Physicians. I taught courses at the annual meetings. I've been presenting something on physician health at the annual meeting of the APA since 1988, with one exception. And then I got on in the assembly, became area seven trustee, and then serving on the board of trustees. Okay. Continuing the journey. Then I became training and vice chair at SUNY Downstate in Brooklyn. And this gave me an opportunity to really get in early with the medical students and residents and make sure that we had good resources set up fighting stigma. And I began then to look at internalized stigma in psychiatrists themselves, because this is a problem that we've been struggling with for a long time. Serving on the APA Scientific Program Committee. And then international conferences on physician health. For those of you who are familiar with those, they're every two years. They're triple sponsored by the Canadian, American, British Medical Associations. And so that also gave me a vehicle and an opportunity to talk about my work and spread it around the globe. And then that led me to doing podcasts and things here in Canada and the UK and Australia. The American Foundation for Suicide Prevention. I jumped at the opportunity to serve as a volunteer there and became the New York City chapter of AFSP. But what I was able to do there was initiate an annual walk where our residents and medical students could actually fundraise, but get to get a sense of what it's like for families to lose someone to suicide. Like it helps to destigmatize suicide, especially in the medical field. I've given a lot of memorial lectures when I'm called into a community where they've lost a physician to suicide and they really want somebody to come and kind of talk about this and explain it. And just again, just kind of make it legitimate to talk about. And a respectful death. We're still working on that. And then of course, National Physician Suicide Awareness Day, which has been with us now for about five years. That's the logo. It's every September. And it's a day of mourning. It's a day of reflection. It's a day of study. It's a day of hope and inspiration as we move forward. And let me conclude now with what I'm currently doing. I do an enormous amount of mentoring. That's one of the advantages of getting old. You can really do a lot of mentoring. I no longer do direct clinical work. I'm the ombudsperson for our medical students. So I deal with all of the medical student complaints of mistreatment. At our medical school, I'm a learning environment committee. So I deal with all the complaints of unprofessionalism in residence and in faculty and in staff. I'm continuing my ongoing postvention research, interviewing families of doctors and medical students who have died by suicide. That's in progress. I've been doing that since 2015. I write a blog. I write a lot of letters to the editor. Occasionally, one gets accepted for publication. And I'm working on my next book, which is the working title is Physicians with Lived Experience. How Their Stories Offer Clinical Guidance. And then finally, please remember this because it really resonates. Some of the most comforting words in the universe are, me too. That moment when you find out that your struggle is also someone else's struggle, that you're not alone and that others have been down the same road. Thank you very much. So it's a real honor to be here with all of my fine colleagues. And more importantly, I want to thank each of you for being here. I'm a firm believer that each of us is built for a reason and a purpose. And the tough things we go through, like Dr. Myers and I'm sure each of you, that's part of your training ground for what your calling is, for how you're going to make a difference in this world. Today, I'm just going to share a little bit about some of the pivotal points in my life that have led me to be so passionate about this and to end up now as a chief wellness officer. So if I could rewind time, I would go back to my internship when I saw one of my medical school classmates walking down the hall and she had tears going down her cheek. She went into the residence room. And I didn't reach out to her. I really didn't know her well. We all thought she was really, really smart. And she had the toughest patient board. She was caring for the hardest patients. The next morning, Saturday morning, she didn't show up for rounds. And what we learned was that she had gone out into a meadow and she had killed herself. She had ended her life by suicide. And to me, that was such a tragedy. All those years of education, what she could have done in her lifetime. And that just made a huge mark on my passion, my why of what I do. About a year later, when at the med school, the accreditation requirements were saying that we had to have medical student mental health programs. And so when a position came open for me to start that program and really build it, man, I jumped at that. I went through that door. And in 1993, I'm dating myself, but 1993 started running the medical student mental health program. Initially, when med students would come for care, they kind of tiptoe in like they were in the red light district. You know, they were this stigma. They didn't want anyone to know. And over time, my last name is Worley, but over time it became the cool thing to go and come in and they would ask one another, did you go see Worley Bird today? You know, so we worked on stigma really hard in the medical student realm. And by the time they would graduate, we had probably about 40% of the graduating class at one point or another had come to the medical student mental health program. So I felt like that was really successful. But in the early 2000s, we had four deaths ranging from an internationally known pediatric cardiothoracic surgeon to two residents and a medical student. And that shook up my world again. Here we had all these, we had these resources at least for med students. But when I dug into each of those losses, each one had been preceded by binge alcohol drinking. You guys are experts. You know that alcohol soaks the GABA neurotransmitters, really makes you chill quickly. We didn't have a lot of time to relax and do de-stressing. And so there's a whole culture in medicine. What was it called? Party hardy? After the big exams and all of that, I'm seeing smiles out there. It was really hard to change that culture, to teach other ways of de-stressing. So we did a couple things. We felt like this was a mandate for change both culturally and in our medical licensure questions. It was hard to convince the state medical board to change our licensure questions. It took us over a year and it took data. We did a qualitative study of how did these questions influence your decision to seek care or not. And these were the questions at the time. Have you been or are you presently being treated for a mental health condition? And if yes, was this voluntary or the results of medical board action? They could have gone for marital therapy. They could have gone for anything. But in our state, it was a public forum. So they would have to be answering these questions in front of a public. And so no doubt, people did not seek help. The other thing we did was a cultural shift. We started instituting healthy ways of de-stressing. My passion of course is ballroom Latin dancing. And so we started a ballroom dancing interest group. We had all levels come and we had the classes at the Children's Fitness Center. What a way to de-stress. You're in the moment, you're not intoxicated, and you're making friends. We also pulled in other physicians with really healthy ways of de-stressing to lead different groups. So we worked really hard to do a cultural change. Fast forward, the Joint Commission started recognizing and made a declaration that we cannot have disruptive physicians. And so we had to write a faculty code of conduct. And if physicians fell outside the guardrails of appropriate behavior, if they were swearing, throwing things, etc., we had to fix them. You guys can see me here. I'm pretty small. You can hardly see me on the other side of this podium. They expected me to fix those big scary docs who were like chairmen of departments and yeah. So for me, I had to figure out how do you do that? And so at that point, I reached out around the nation to find out who's really helping these doctors who are disruptive. And what I learned, they were not what I thought they were. I thought they were bad apples and you should just fire them. But what I learned is they were really the top of the food chain, the neurosurgeons, the cardiovascular surgeons, who never really were selected or trained in emotional intelligence. And I ended up going to the Vanderbilt Distress Physicians course as a faculty visitor and got so hooked I became one of their faculty. I would fly to Nashville or drive to Nashville and teach for over 12 years in the course. The other thing around that time is I got recruited out of full-time academic position to be a professional educator with State Volunteer Mutual Insurance Company. It was a physician's own medical malpractice company and I learned how to make films, videos, and taught, one year I taught a curriculum on dealing with difficult patients that trigger us, and the next year I taught the curriculum on dealing with difficult colleagues with a different hidden message of don't be one, and so that was really cool. From there I ended up getting to be a chief physician consultant in the VA for the chief medical officer in Vision 16. Vision 16 covers all these states, eight VA hospitals in the South Central United States, and there we initiated a Be a Hero, Save a Hero initiative, and I got to bring my skills of making film and taught how to recognize suffering and distress in our veteran population, and then how to reach out effectively for help and to connect with veterans. In the process I really came to see there's a big similarity between veterans and physicians. We're stoic, we're strong, we're self-reliant, and many are afraid of the stigma that would get in the way of your career. I also really came home to see how suicide is an action to stop suffering, to solve suffering, so we have to offer hope, we have to offer good alternatives to that suffering and make it safe, accessible, and affordable to get to so that people will reach out for that life ring when they are suffering. After that I ended up becoming a regional associate, oh, ooh, I have to hurry. I became a regional associate dean in Northwest Arkansas where we were expanding the medical education there to keep up with the population growth, and the blessing from those amazing years was I got to work with the best boss of my lifetime, Dr. Susan Smyth, the cardiologist, and she really was very worried about the physicians on the front lines, and we'd talk, and in my role as associate regional dean, she would bounce ideas off me, and she asked me one day to write up what my ideas would be if I could do anything I wanted to do, and I said, you know what I'd really love to do? I'd love to create a center for professional vitality, and I wrote it up, gave it to her, and she said, oh, we've gotta do this, I want you to do this, and I said to her, Susan, I've got a big job, but she ended up on Labor Day last year surprising me with a job offer to be the full-time inaugural chief wellness officer for the College of Medicine for the entire state of Arkansas, and I started the job in January, so I'm still learning. Most people don't understand what it is, but what it is, it's like helping to fix the coal mine where the physician canaries are being not well, right? It's a hard thing to change the system, so I'm a little overwhelmed, but I'm still learning, and I'm determined and optimistic, so that's what a chief wellness officer does, and right now, I guess I wanna give you an ask, is you're gonna hear more about the Lorna Breen Foundation. Lorna Breen, as we all know, is a hero on the front line of the pandemic, and her brother-in-law and sister have founded this foundation, and statewide, we're going out to change the medical licensure questions, so I encourage you to go to this website to remove the barriers for physicians to reach out safely for that life ring, and there's a map of states that are compliant, and here's just a quick example, and then I'm done, of to change, look at your own medical licensure laws in your state to see what they are, or your annual attestation, and just the good example that they have out there is ask just one question addressing all mental and physical health conditions. Here's a good example. Are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgment or that would otherwise adversely affect your ability to practice medicine in a competent, ethical, and professional manner? So please go do that if you haven't already gotten good questions where people can safely reach out for help, and in closing, this is my favorite saying that I said for years to med students. Life is far too short to suffer needlessly. Those who seek help are the courageous, healthy ones. Thank you. Lunch coma setting in just yet, or are we are we feeling okay? Anytime you want to get up and stretch do anything like that to keep yourselves engaged feel free We won't take it as you know not engaged in fact you are encouraged to do that So I wanted to ask a question of the audience Who here feels that they themselves carry a stigmatized identity of some kind? And how about walking alongside somebody else who is close to us with a stigmatized identity And how many in the room are practicing psychiatrists Non practice or non psychiatric clinicians of other kinds Great me too pediatrician And how about researchers? Same folks hands can go up because people wear many hats policymakers Great, thank you for participating in that and I wanted to ask a little bit more of a deep question So you heard from my esteemed colleagues dr.. Worley and dr.. Myers about losing close people classmates To suicide and I wanted wanted to ask if that has been the case for any of us in this room Great. All right. So my name is Devika Bhushan. I am a pediatrician turned policymaker. I spent about four years in California state government working at the Office of the California Surgeon General, really helping to launch the ACEs Aware Initiative, which transforms the way that we think about healing from childhood trauma. And last year, I spent some time as the acting Surgeon General for California. And during that time, it felt like it was an important time for me to actually shed light on my mental health journey with bipolar disorder. So I'll spend a little bit of time sharing that with you here today. These are my current disclosures. The two top categories are the places where I spend time, but I'm not representing any of these entities in my remarks today. I'm standing here as a mental health activist, primarily. And just to kind of take one giant step back, all of you will know very well what stigma looks like and where it derives from. But stigma is really, it comes to us from Greek. And in the Greek language, the word for a tattoo that specifically marked somebody as being less than has been turned into the modern word stigma. So these tattoos used to mark people who were slaves, were criminals, and didn't reside in sort of mainstream society. And the sociologist Irving Goffman has said that stigma serves to reduce us from a whole unusual person to a tainted and discounted one. As those of you who raised your hands when I asked if you have a stigmatized identity will readily know, it involves labels and stereotypes and assumptions, status loss that leads to marginalization and discrimination. Last year, there was a beautiful review published in The Lancet around mental illness stigma in which 80% of the folks with lived experience in mental health conditions agreed that stigma and discrimination related to that mental health condition was worse than the actual impact of that mental health condition itself. And in mental health, as you all will know, stigma will, specifically self-stigma, directly increases suicide rates, it reduces help-seeking and recovery success, it increases the number and the duration of episodes, as well as hospitalizations. And the several layers of stigma, which you all will be more familiar with than most audiences, are self-stigma, so the internalization of those stereotypes and assumptions, stigma by association. So this is actually the stigma that applies in the mental health field, right? So when folks are taking care of people who have stigmatized conditions, whether as family members, or they're doctors, or therapists, there's stigma by association that shows up, for instance, in the lack of mental health parity around insurance schemes. There's public stigma, so this is sort of the temperature of the water out there around knowledge, attitudes, and behaviors. And then there's structural discrimination, so the ways in which this gets embedded in our policies, and our laws, and our systems. For instance, we have only 2% of global health budgets being devoted to mental health across the world. And we know that there's a 10 to 20 year life expectancy difference for those who suffer from mental health conditions for all kinds of reasons, ranging from death by suicide to death by chronic condition, like cancer and heart disease that shows up more severely, and is diagnosed and treated differently. So stigma, in short, kills and it violates human rights. This is a photo graphic from the same Lancet Commission article that was published last October. And here's what it sounds like. So Dr. Hart quoted colleagues of mine in training who talked about patients. This first line is, you can't trust anything she says. She's bipolar. She's definitely lying, right? And this was an altercation between two patients for whom their admission actually had nothing to do with mental illness. But the stigma associated with that mental illness for one of the patients showed up in a very blatant way. I've been asked by a psychiatrist, actually, as I was trying to consider my family planning decisions about why on Earth I would consider having a biological child, because potentially giving somebody bipolar disorder is sort of the worst thing that you can think of. I've been told by a family member, unfortunately, that I would never be a good parent if I had a child with bipolar disorder, even though I've been in recovery for eight years, and it is very well controlled. And then after I shared my journey, a lot of the folks in my life who didn't know already approached me and said, hey, you know what? I would have never guessed that about you. And if you think about what that really means, it's that we have a set of very laden stereotypes and assumptions about who has bipolar disorder, and what they look like, and sound like, and what they can do in the world. And unfortunately, there isn't a lot of room in those two-dimensional stereotypes for three-dimensionality. And the same commission found, essentially, in reviewing 216 systematic reviews of stigma reduction campaigns, that the one baseline thing that had to be true for that to be successful was key contact between people who do and do not have lived experience. So you really help to make it a three-dimensional and nuanced understanding of what living with a mental illness is like, including stories of recovery and living well with the disorder. This was the piece that I published that was alluded to earlier by Dr. Hart. And I think one of the main places where people really resonated with some of what I had said, which was, essentially, that you can walk through this and live well with a mental illness, even one that is hugely stigmatized. You can go on to be professionally successful, personally successful. I have a two-year-old. I have a partner of 17 years and a number of really meaningful and fulfilling connections in this world. And I turned the wound around, in a way. And I talked about actually having superpowers that stemmed from having had bipolar disorder, including a really deep ability to be empathic and walk alongside other people who were experiencing really difficult things, whether those were patients, family members, colleagues, et cetera, and also the really deep self-insight that comes from an experience where you break and put yourself back together again, sometimes a few times over, where you learn what you're capable of, but also what you need your boundaries to be and what you need your self-care strategies to be to be the best version of yourself, and then how to sustain that across a variety of different kinds of settings and experiences. And this is a photo of the Japanese art of kintsugi, which is essentially when a ceramic object breaks, instead of throwing it away, what happens is it gets re-welded back together with gold paint included. And so not only does it become more unique and stable and strong, but it becomes a better version of itself in some ways than it was when it started. And I'll just close in about 30 seconds, but I wanted to share, as you can imagine, after I shared my story, the real gift of that disclosure was reaching millions of people who were also struggling or had a loved one who was struggling, and to help them know that they were not alone and that there was a path forward to recovery and to achieving their dreams. I heard from plenty of people who were in training who had never disclosed whatever it was that they were struggling with. This medical student, whose permission I have to share this here, basically said that she had always felt like she didn't belong in medicine because of her diagnosis of bipolar disorder, which is very common for many of us who suffer in silence with this condition. And she said, I do belong here, and my diagnosis will not prevent me from being successful as a doctor. So I just wanted to share one final slide, which is about half of my time is now spent in the mental health activism space, where I have built a couple of storytelling platforms, one of which is a weekly resilience and well-being action-packed newsletter that comes out every week, and another is a podcast and YouTube channel called Spread the Light, because stigma festers in the dark when we don't talk about our mental illnesses, and it really scatters in the light. I'm also privileged to be part of a team putting together a documentary film about bipolar disorder called Brainstorm. I'll pause there. Thank you to each of our panelists. When we were talking about how this session would go, each of our panelists said, we want this to be a conversation about ending stigma, and they wanted to have a fireside chat. And what we've learned is that this is being recorded for a future audience, so we want to make sure that future audiences can participate fully. So what we're going to do to have a fireside chat and to allow for the technology is we're going to ask, when you come up for a question, that you use the second microphone. Our panelists are going to come down, and they're going to use the first microphone to, as Dr. Meyer said, it's about Me Too, because this can happen to any of us. Any of us can face challenges with a mental health disorder, so they want this to be an inclusive chat. So while they're doing that, I'm going to remind you of why we're here and, again, go through some of the statistics and then show you a video from the Lorna Breen Foundation. So physicians have the highest suicide rates of any profession, 28 to 40 per 100,000. 400 physicians die by suicide each year. One in four physicians knows a doctor who completed suicide. More than half of physicians know a physician who has either considered, attempted, or died by suicide. An estimated 1 million Americans lose their physician to suicide each year. Physicians attempt suicide less often than women in the general population, but have a higher completion rate. Access to lethal means and stigma in credentialing and licensing applications are major contributors to physician suicide. Burnout has been shown to cause a 200% increased risk in medical errors. Highest risk specialties include anesthesiologists, psychiatrists, general practitioners, and general surgeons. Following Lorna Breen's suicide, her family turned their pain into purpose. They worked tirelessly until the Lorna Breen Health Care Provider Protection Act became federal law. If you have access to the slides, you can go to the video and you can share. You can see part of the video that I'm going to share. She called and went back to work because she was a dedicated physician just like so many health care workers And what she saw on April 1st, she reported back to us as Armageddon Patients dying in the waiting room where their portable oxygen would just expire and not enough beds not enough help She's working 15 hours and 18 hours only a handful of days later. She Was basically in a catatonic state she couldn't get out of her chair My name is Corey Feist I spent over 20 years as a health care leader and executive and during that time came firsthand with speaking with physicians about their burnout and their challenges as well as nurses and Really started a significant amount of work on it Lorna was the very driven physician always looking out for others always taking care of patients at that time There were so many of her colleagues who were calling out sick and contracting the virus because no one knew what kind of PPE to use She called us and said my colleagues are gonna be able to recognize that I can't keep up Unfortunately that fear of Basically her career being over was one of the things that we believe contributed to her decision to take her own life. I I Cannot change the culture in medicine I can point it out, but I can't change it myself And that's when Jennifer and I decided in a moment of calm That we needed to tell her story What COVID has now done is it is amplified beyond just burnout it goes to things like PTSD and depression this country now needs to lean into the conversation around removing barriers and improving their culture so that they have the ability to get the care without fear of repercussions Is there a way to get the care without fear of repercussions? I think there is a way to get the care without fear of repercussions Is the conversation changing or do we still Stopping the stigma is the first step of reaching out for even just saying I'm not doing well. I'm not okay We have to give our people the ability to report that problem to be honest So why aren't you getting help? The number one thing is I'm worried about reporting to some licensing board I'm worried it's gonna go on my insurance, which is also code for I'm gonna lose my job There are so many areas where because of their profession people are afraid to get the very help that they need. The fact that Dr. Breen was practicing in an emergency room in New York City which was literally ground zero. People almost never think about how stressful it can be. But it has become more and more and more part of their lives. You know this is the first ever piece of federal legislation that looks out for the health care workforce. So we're doing a very grassroots approach for encouraging all the hospitals in this country to just publish what the facts are currently. You have an expertise I mean you've been talking about the culture but in terms of what your own profession is you see this administrative burden thing and how it affects physicians so you would have some unique insights. We've talked a lot about how the culture in medicine was one of the contributors to Lorna's death. I've heard from many doctors, medical students, residents, nurses in training. Their expectations about how they're gonna be taken care of in the future are very different. We've really gone a long way towards not eliminating stigma about mental health coverage but at least expanding the conversation. So the lessons from the Breen bill are starting to kind of populate out into other professions where you know hey folks have seen a lot and they've gone through a lot and we need to be there for them. Absolutely. What are the big things that can be done? Some of them are really small and cost no money which is just having the conversation and checking in right? Exactly. Every single person in the healthcare workforce right now is sort of leaning into the culture piece. Take ownership of that, take responsibility. We all have a bigger voice than we think we do and a bigger impact than we think we do. Years ago you know we'd have a huddle it would never end with hey how are you doing now it's people like how you doing and they really really develop that culture. We know that Lorna cared as deeply about her colleagues as she did her patients. And so for me to be able to bring my professional background together with this very personal tragedy and to continue to shine her light of caring for others it's the most rewarding work I've ever done. So by attending this session you're already part of a culture of change. So we invite you to come up to ask your questions and we also have a handout that was prepared by one of the Lower Breen Foundation's partners. The AMA which is included in the session app. But if you are a paper person we have paper copies for you. So please use the microphone in the back to ask your questions. Thank you. Okay. Hi. Yeah I'm Raymond Reyes. I'm a local prison psychiatrist. Been a psychiatrist 31 years. Been in treatment for depression for 30 years. Mostly in remission. I wanted to say a couple of things real quickly. To me psychotherapy is the soul of psychiatry. But check this out. In the 31 years I've been a psychiatrist we've de-emphasized psychotherapy by medical professionals. And we've de-emphasized the role of psychotherapy in trainees. The most efficacious drug I've ever taken has been my psychotherapy. And in particular I'm gonna point out group psychotherapy. I was a an outpatient at the San Francisco VA Medical Center for 18 years. Every Monday for 18 years. And it really helped. The other thing I want to say is that there is trauma. Not just microaggressions but trauma. Psychic trauma from the way we physicians treat each other. Thank you for those comments. While we wait for the next question we ask any of our panelists. Why is self care essential physicians especially psychiatric physicians? That's a great question. I think if we're not doing well we can't give our very best to those we serve. I remember there is an unconscious. I was running a residential treatment program for adolescents who had had horrible trauma. And the date that was the anniversary of my own father's death November 2nd when I was just 17. I had no empathy for that young lady that day. And I was driving home and it was like oh my gosh there is an unconscious. I wasn't aware of how I was doing to be able to give my very best. And that's just a take-home example of myself. I think we've all had those days when we're tired. Or I shouldn't say how you are. But I know that if I'm spent I just don't have it to give. And I want to give my very best to my patients. I'll just add one thing to that. I've always felt as psychiatrists we don't have we don't have a lot of tools besides ourselves. You know we can prescribe medication and we can give ECT. Now we can give ketamine. Things like that. But mostly we're using ourselves. So it's really incumbent upon us to do our best in terms of self-care, self-compassion. But I realize though in some settings it's so hard for psychiatrists to do that. Especially in rural and underserved areas where they're the only one. And it's you're in well talk about moral injury. But that's often what they're feeling. The one thing I'd add there is sometimes there's this real burden to ask individuals to figure out how to how to create the space and the time for self-care. And it's increasingly difficult in practicing psychiatry and in other medical fields to really be able to to protect that time. And I think it has to you know Dr. Worley's work really emphasizes that there has to be a structural set of supports and systems in place to really allow physicians to thrive and to find that time for family leisure rest. Right. I mean I think all these things are very interlinked. Hi my name is Sheru Iyer. I work with the New York State Office of Mental Health. And I have something controversial to say so I want to couch it in a couple of other things first to make myself not seem so controversial. I like to say that I have 28 plus years of personal lived experience. I deal with my mental illness every day. I used to work at the same hospital and have worked in the emergency room not necessarily with Dr. Breen but I know that she was there. We just never had the shift together. And I also worked previously at Lincoln Hospital in New York City in the South Bronx which a few people might know is where three resident internal medicine residents died in the span of under two years all by suicide. I won't go into the details. My controversial question in context of all of that is that I worry that we spend a lot of time talking about wellness and burnout and self care and we don't talk about mental illness. I remember it really reflected for me when one of the Lincoln residents after the third suicide came to my office because we were requiring I won't even get started. We were requiring every internal medicine resident has to speak with a psychiatrist. And so she came to speak with me and she said well I'm not like them. I can't sleep. I can't eat. I don't enjoy anything anymore. I can't concentrate. I have no energy but I'm not like them. I don't need help. I go to the wellness room. I play table tennis. I do my yoga. I'm not like them. And so I worry that we create this kind of idea that OK well if we just do wellness we just do self care. Everything's going to be great. But if we can't stand up and say I'm a psychiatrist I am a medical professional I have a mental illness I get treatment for it. You can too. We continue to kind of couch that stigma in nicer words without necessarily making sure that we allow the next generation to be able to say I have a mental illness I need treatment and I'm going to go get it because it's no big deal. No bigger deal than getting my blood pressure taken care of. Thank you for sharing that. And I don't think it's controversial. I think it's brilliant. I think that when we did the medical student mental health program one of the things we taught was more about these are the signs of mental illness early on and it's safe to go get treatment. Go early before it gets bad. I think that we haven't made that step like you're talking about to be able to on a whole say listen I have a mental illness and be proud shoulders back chin up and I have hope and I'm giving you hope because it's treatable. Look I've got a great life you know. So thank you for sharing that. I really appreciate it. And that's why it helps when people who are practicing psychiatry especially because we're talking at the APA are open about their own either diagnosis or the treatment they've received because that's phenomenal role modeling especially for people in training because you know when you're young and you don't you don't have that many years behind you you really don't know you have a lot of usually catastrophic fears that if this if I get some help during residency I may not be allowed to finish or you know they hear a horror story of somebody who didn't their contract didn't get renewed but it's usually much more complicated than that. But when they can see people who they look up to and who are very high functioning doing well I think that really again helps a lot with the stigma. I just wanted to add one other thing is you know there's burnout doesn't seem to have the stigma associated with it as our diagnosis in DSM 5 have and somehow we've got to do something about that because as you know people will openly say I'm so burned out you know blah blah blah but very few will say I thought it was burnout but I went to a psychiatrist and I've been diagnosed with MDD I'm now on treatment and I can't tell you how much better I feel in fact I don't really feel burned out anymore I really love what I do I still get tired but at least I feel I've got a diagnosis and I'm getting I think appropriate treatment. How many of you know Jake Goodman or know of him? So he is a psychiatry resident who a few months ago made a viral social media campaign around the fact that he took medication for his depression. So he had a photo where he basically you know showed showed the the pill under the on the tongue as he was yeah it was it was really powerful and I mentioned that because you know there's a number of younger you know social media savvy psychiatrists who are doing similar great works or Jesse Gold is another one who has written about taking medication for depression and anxiety right and and there's others but I think it does so much to reduce stigma to know that the people who are giving you the you know the the pill that you're gonna be taking are actually already in in the world that you're in and they're patients themselves. Good afternoon everyone my name is Petra Karels I'm a fourth year resident from the Netherlands and I would like to share some experience about I have bipolar disorder since about six years my first episode was manic psychosis and in the years before I already had several treatments for personality disorder and because my youth was not that optimal and when I applied for the for the job interview to become a psychiatric resident and the main supervisor had quite a strong association between bipolar disorder and the risk of suicide because in the same area there has been a resident who committed suicide bipolar disorder so in that job interview asked me yeah but what if you commit suicide and I was quite shocked and stumbled some like now that I don't think the chances are that high and we had another appointment to complete my application and I made him I said in that next I said that I thought that was a bit of a strange question and he apologized and I accepted and that was the start of a working relationship with him and already in the year before I thought I need peers to talk with this about this special that you're a patient and you're a doctor at the same time and you you treat patients with bipolar disorder and your patient so I I started my own intervision group in the Netherlands and we have now I think five intervision groups especially for psychiatrists and psychiatric residents who are psychiatric patients themselves some online some life some combinations and it's been really really helpful so I recommend that to everyone thank you for your advocacy thank you so much for sharing that I also want to introduce you to a resource and I was thinking of this Raymond when you spoke about group therapy a colleague and friend of mine in New York City dr. John Budin Budin is very open about living with bipolar illness and he is on the board of the DBS it's the the Depression and Bipolar Support Association he's on the board of directors but he has started an international group for doctors living with mood disorders and he started this during the pandemic but he's continuing to meet virtually and so if anybody is interested in that or that resource just speak to me afterwards and I'll give you his email because I know that there are still openings it's been a fascinating journey for him doing this because some people have joined the group with a pseudonym because they weren't ready to disclose their identity and likewise those same individuals wouldn't turn their camera on at first and again I mean we're seeing how the layers of stigma diminish with safety because after a few groups when the individuals feel wow this is very very helpful to meet people from all over the world who are physicians and then you know the camera goes on that sort of thing so it's really nice to hear and I'm I'm so grateful that he's doing this because so many physicians with mood disorders do feel isolated and we all know this but you know peer work is really where the self stigma layers get get dissolved as exactly how you're talking I mean and that's what it took for me personally to to eradicate my own self stigma and shame around the diagnosis was meeting lots of successful professionals and in all walks but especially in medicine I want to know from our panelists what would you do because I'm an admissions committee that sounds like an illegal question like what would you what would you what kind of advice would you give to an applicant a medical student resident a practicing physician if they are asked a question that is inappropriate what steps should they take with so that they don't have the fear retaliation well I've got a lot to say about that is the question about whether whether or not to talk about it or disclose it or something like that yeah what do after it's okay one area that I've been working on most recently our personal statements of medical student applicants medical school applicants as well as applications to residency and this was I mean I've been interested in this for a long long time because I've been on our medical student admissions committee and what will happen then if somebody applies and they make a disclosure in their personal statement then they give many of them to me because I'm one of the psychiatrists on the committee I'm always excited to interview these people because these are individuals who have given an enormous amount of thought to that personal disclosure they've discussed it with their advisors their parents other loved ones their therapist etc etc and they're very clear by putting it there that they believe that they are showing their fitness for medicine because they know what it's like to be a patient they know what it's like to have something that's stigmatized they know what it's like also sometimes to receive good care and not so good care things like that and what more can you say I mean that adds empathy that they'll bring to medical studies and things like that however I have a whole other series of lectures that I give to individuals though who are sometimes the advisors of these applicants because far too often the advisors say take that out you'll never get into medical school or you'll never get a residency it's very competitive and some of them do take it out because they are afraid of that but others will are you know they'll hold on to it and leave it there and then they say and we have to respect them for this I don't want to study in a place then if if my applicant is going to be throwing the applications can be thrown in the wastebasket that's not where I want to study medicine or my residency I mean what they're talking about is the duplicity of medicine us and them and that sort of thing and so that's why individuals like that really need a lot of support then the final thing I want to say then is others I think you said it and somebody else said it too is the judgment that is is in our own ranks you know and you know in in in the field of psychiatry as well we still got a long ways to go in educating fellow psychiatrists about internalized stigma in themselves when I asked dr. John I'm on our grand rounds committee and when I asked dr. John Budin to come and give a grand rounds it was okay but I've been doing these things for years he got very few questions and suddenly it was over I don't know if what he had to say was just too provocative too scary to the psychiatrist at my medical school or what but it was rather lackluster I'd say in terms of the robust Q&A that I'm used to seeing when somebody comes and talks about neurotransmitters I'm glad every one of you spoke of self stigma and that occurs as dr. Myers just pointed out not just on an individual basis but also perhaps on an organizational level 2011 I was the president of the Northern California Psychiatric Society which happens to be the host district branch of this meeting as the president I was invited to the prof ed committee professional education committee of which I am NOT a member would you like to offer an idea of you know some kind of presentation that we can put together and I offered this panel this very kind of panel I even had a friend who was going to fly in from Baltimore and talk about when he lost his license for sleeping with a patient the experience of losing your license due to an ethical breach so we wanted to talk about vulnerability the response was can't do that, people aren't ready for that. That was 2011, so here we are today. Hello everyone, I'm Magdalena Flaga-Uczkiewicz, I'm from Warsaw, from Poland. I want to tell a story from my country. Last year we lost a psychiatrist, a very famous, prominent psychiatrist, by suicide. Everyone knows how he died, but nobody spoke about that. Everyone knew him, he was a brilliant doctor. Only one of his friends wrote something on social media, but it was like, he was a great doctor, a great friend, but we can't speak about the death, how he died. I think we have to start to change that, where all the professors, all the prominent people, they are silent. I guess where my head went to with that was, just thinking about the suffering he must have had, and to choose the action to end his life, to relieve that suffering, rather than to find hope and treatment. The loneliness, too, yeah. We've got to keep making it be safe. If somebody is suffering, we need to see it, we need to not judge it, we need to reach out with compassion, connection. That's a part of the healing tincture that physicians bring, is when you care, that connection, with good boundaries, though. But yeah, and then offer good treatment and hope, and then talk about it. Thank you for sharing that. I'll just add a little bit to that. I, for some years, have been trying to figure out how we can make deaths by suicide more dignified. As you know, as we lived through the AIDS epidemic, we didn't see obituaries until, I think it was Rock Hudson, that said that he died by AIDS. And then there was a spin-off from that, I think, around the world. Because prior to that, where I was living and working, I was losing patients to AIDS, and other doctors were as well, and it was said that he died of cancer, or they died of a sudden death, or something like this. I was just recently in a province in Canada, called there because they had lost two surgeons to suicide within about a 12-day period of each other. One of them, and I looked at the obituaries online, both beautiful testimonials of their lives. One of them, though, did mention that the death was by suicide. And what I liked about that, in honor of the man's widow, who's also a physician who wrote the obituary, was that it gave an opportunity for them to be authentic in how much he suffered. He had been diagnosed, by the way, with a motor neuron disease. And then depression, and then suicide followed on that. But for some reason or other, they thought, well, maybe that's a little more legitimate than the other one. Only because it was perhaps a reaction to something like that, when they, of course, both should be, as I say, understandable, dignified deaths. But the other thing, too, when the cause of death is listed, and this obituary did that, they were able to thank the treatment team. So they thanked all of the neurologists, and they thanked all of the mental health team, who were looking after the physician as well, which I thought was another lovely touch to this, all adding up to dying with dignity. So, you know, the grief process that the family and loved ones go through after somebody dies by suicide is, again, shrouded in so much shame and stigma. And for instance, I have a family friend who died by suicide, and I have other family friends who have died by other things, like pediatric cancers. And every year we'll commemorate birthdays, their parents will post things about them, et cetera. But the person who has died by suicide is never spoken of, and their family's grief is less, where it's more hidden. It's not given public view, and it's just not fair. Thank you. Yeah. That's a good question. Thank you. Jan Willem de Boer, also from the Netherlands. I would like to share a few examples of internalized stigma. I have been taking lithium for almost 10 years because of burnout. It's also not a medicine, it's a supplement. And my short manic state was also not really mania because it was induced by duloxetine. It's completely different. Sometimes I joke about this, or I choose which way to formulate, depending on who I'm talking to. Thank you. Thank you for sharing your story. Thank you. Good afternoon. I'm George Keepers. I'm from Portland, Oregon, in the Department of Psychiatry there. Thank you for this presentation and for sharing your personal stories. I have a couple of comments to make. The first one is that a number of years ago, I think it was right before the pandemic, I attended the ACGME Annual Education Conference. And Tom Naska had arranged a panel presentation in front of that conference that included Daryl Kirsch talking about this issue. I think maybe, Dr. Worley, you might have been there. I can't remember. And Daryl described his own history of depression and treatment of depression, which made a huge impact on the very large audience. It's over 1,000 people that attend that conference. And it made a major impact on me and motivated me to share personal stories from my own family about suicide and mental illness with others in a way that would destigmatize it and enable others to come forward with their own stories. We've done grand rounds in which I've done this now at OHSU, and they have been extremely meaningful, described by the participants as the most meaningful presentations that we've made in several years, with a very robust discussion during it. So I really value what you're doing with this. One issue I want to raise with you for the panel's discussion is this. We have a very robust resident and faculty wellness program at OHSU, and we take very good care of our doctors. Health care is a very stressful profession for everybody who is in it, and nurses have high suicide rates, and the employees of our medical center have been under stress during this time, and we don't have such good programs for them. And I think our focus on just physicians needs to shift to a focus on health care in general, and our colleagues in other areas of health care needs to be a focus of our attention in this matter as well. And I'd say one other thing is we tend to focus a little bit on the personal responsibility for care, and Dr. Worley has mentioned this to me previously. I think we also need to think very carefully about the systems of care that enable us to work in stressful environments that don't induce burnout and that enable us to get the care that we need when we need it. So I'm interested in your discussion on those topics. Thank you. I'll just salute your program in Oregon. It's one of the best in the country, and to you and Mary Moffitt and others who do such wonderful work there. I wanted to just also add something about physician health programs that are across the country, because depending on the state where you're in, there are still a lot of physicians who have fearful feelings or ambivalent feelings about physician health programs. I always urge people, depending on what state they're in, of course, to really check that out very carefully, because most programs have really come a long ways, especially through the annual meetings of the Federation of State Physician Health Programs and things like that, which brings me to when you were talking about the fine work that's come out from Corey Feist and the Lorna Breen National Health Practitioners Act. One of their wonderful, tangible products at the moment is our toolkits for the individual and for a group to lobby their particular state licensing medical board about the current questions, and you asked about that, that we should all be familiar with really how those questions are worded, and then, Linda, you put it in your presentation as well. Some of them have come around, but not all of them. Some of them are really dragging their heels, and we published an article which I think was now ten years ago in the Journal of the American Academy of Psychiatry and the Law to really point out the ones that were violating the Americans with Disabilities Act, and so hopefully some of those have changed, but I think you can get the closest update from the website of the Dr. Lorna Breen Practitioners Act because it is a work in progress, but it can't happen fast enough because it is such a deterrent for people who are terrified to really go for help, and some are losing their lives. Thank you. Please, your comment. Sorry to hog the mic. I had to say a couple of quick things. First of all, a thank you to Dr. Keepers. I'm an OHSU graduate, so I would say certainly he inspired me to be standing here today in part, and I'm curious, especially his statement about professionals in health care outside of just us MDs, and how many of you work in large health care organizations or larger group practices, things like that? So I work at the New York State Office of Mental Health, and the timing for this talk is really accurate because just last week we did a panel discussion across the entire New York State Office of Mental Health with participants across every sector of our organization. We had me, we had a psychologist, we had social workers, the director of diversity, people in the finance department, you name it, we had it all talking about their lived experience and how it affected their lives, and I think it was a really kind of eye-opening thing to say, look, it doesn't matter what level you are, where you are in the ladder, none of that matters. This crosses all sectors, and I think we don't say that enough. My question, though, on top of that, is about the things that you have up on your slide there, which is social media. And social media and the internet, I think, in some ways, has got ahead of us as far as the stigma piece goes, both in a good way and a bad way, and the bad way is something I was going to ask about in terms of what's my own personal experience, where prospective employers have found things on the internet and told me directly they would not hire me because of what they saw on the internet regarding my mental illness, or kind of quiet whisper campaigns that I've heard based on what people have found online about me. And so I worry and wonder about how we could try to get ahead of that in some ways in the stigma realm as well, like how can we make it so that what's actually out there isn't supposed to be stigmatizing but actually can be beneficial, especially to the next generations. We'll leave the microphone. We want to make sure that we heard something correctly. Did you say that you had disclosed something or whatever that then was used against you or something like that? I don't want to go into lots of details, but I can say there were materials on the internet that were posted not of my knowledge regarding my mental illness that were found by a prospective employer who Googled my name before I came for my interview, asked me point blank during the interview, can you please explain this posting on the internet? I was caught dumbfounded. I didn't really know how to answer the question, so I kind of laughed it off, and I was later denied the position. I asked, why did you guys, so that I understand what's going on, and said, well, it's because of what we found on the internet. For what it's worth, I'm glad they denied it, because I got a better job. LAUGHTER APPLAUSE This will be our final question during this session. Hi, everybody. My name is Koki Ta. I'm a local practicing psychiatrist. So, just for the panel, though I think it may be directed mostly at Dr Myers, with your clinical experience working specifically with residents, medical students, physicians, families of, what helps get our colleagues in the door to get treatment? What are the best ways to really encourage that seeking out of treatment? And, Dr Wuerl, I'll open the whole panel to you, by the way. So, I think it's really important, what I've found to get people to come in to see us, or me, was to do proactive presentations, so that they see you, they connect with you in person, feel like you're going to be safe. Number one, be accessible, be confidential, affordable. Do not do the medical record-keeping in Epic, because that makes them really skittish and scared, and have better medical licensure laws. Yeah, that's the old-fashioned record-keeping, because you have to keep a record, but it can be separate from the EMR. The other point I want to make, and I believe in this strongly, are personal testimonials. I think the more that we pass around articles that we've read, in JAMA, in the New England Journal of Medicine, or any other publication that are first-person accounts of a medical student or a resident, especially for that cohort, that is describing their journey, or whatever, being diagnosed and receiving some treatment, and how they feel about it, the more we keep a file of those, and even circulate them around through GME, or whatever the repository of those kinds of articles are, I've been looking at those now for 20 or 30 years, and they're more and more common. I am convinced that, in fact, I saw this in my practice, that I'd see a new patient, and I'd say, Dr. Meyers, I've been thinking about coming to see you for six months. However, I read an article last week in JAMA about another medical student, and thought, oh, my gosh. Then I thought, then I'm going to go get some help. And so, like my last slide there, you realize you're not alone. So it's kind of normalizing it. It's getting out that new message that it's the smart thing to do, the responsible thing to do, the healthy thing to do, as opposed to covering up when it's weak and shameful. We've got to continue to fight that and see this really as a proactive, positive step. Look what you did. So, I mean, I totally agree with everything you've both said. What made it easy for me as a medical student to seek treatment was the fact that it was at University Health Services, separate from the hospital record and set of systems, and it was free, confidential, exactly like Dr. Worley talked about. And I think when you start digging, you start realizing all of your friends and your colleagues are also seeking the exact same services, and so normalizing that, which I didn't back then, but I think the culture is very different now, you know, 14 years later, where people are normalizing it, and it's completely okay to go down the hallway to see somebody for your depression and or anxiety, and people are talking about it now, and I think the culture really is starting to shift among the younger folks. But I wanted to address the question around social media and stuff just showing up without your consent in the ether, right? Because I think it's a very similar set of issues that arise when you figure out whether it's reasonable or desirable or ideal for you to disclose that on a college essay or a medical school application or whatever it is, right? It's the same exact process. It's a gating mechanism, and you want to know how much of myself to show up with at the get-go. Like, eventually, you'll maybe disclose and get accommodations or anything else that you need, but do you want to show up as your full self at that moment? And, of course, you know, post a public disclosure like the one I made last year, cat's out of the bag, but I chose for that to happen, and I'm comfortable with all those ramifications from here on out. I think it becomes much more complicated when it's information that's put out without your consent, and it means your story to share and the value and the ways in which you would want to share that. And I think one, I mean, as a person with lived experience, one kind of benchmark that I had early on was never make a disclosure in a moment where you're not fully and completely well, right? And that I've stuck to from sort of the early days of my illness, and I've been happy that that's been the case because I sort of came of age as social media was coming into its own. But that's a really tough one. I'm really sorry that happened to you. In our last few moments, I'm going to give Dr. Worley, Dr. Myers, and Dr. Bichon an opportunity to give a call to action or a final take-home point. So my call to action would be at the first signs of difficulty, reach out with courage and shoulders back, chin up, because you'll be better with what you can give to the world if you do that and be a role model for others. I've got two quick calls for action. The second one I just added, and I thought about it when you asked your question about resources and things like that. The other thing you can do when you read these first-person accounts, if there's an email, send the person an email and thank them for doing that. You don't know them at all. I've been doing that for years, and I've made so many friends that way just by doing that because they feel good about it, too. They've made a big step by doing this. We're all in this together. They really are allies. The second one, which now I've lost a lot of time, of a call to action, I think I'll just leave that. Mine is in the rooms and with the people with whom you feel safe, share as much of your journey as you feel comfortable doing because that's really the thing that we know is going to drive the needle on stigma in the long run. I just remembered it, what it was. When you have a colleague who's out on medical leave, please don't forget about them. Send them a note. Send them a card. They may not feel like visitors. You don't know, but at least check it out with them because, again, it doesn't take very long at all for them to kind of feel alienated or kind of other or less than. They really appreciate that touch. Thank you. Thank you all for attending this session. Again, this session was meant to spark conversation that we hope will continue long after today. Please continue to share your reactions and ideas on social media, tag APA Psychiatric, our panelists, and the Lorna Breen Foundation. The American Medical Association is a partner with the Lorna Breen Foundation and they generously allowed us to share videos and also produce a handout for this session. You can find the handout in your app or paper copies are available today. In addition, in order to continue to give you an opportunity to consider how you can be involved in this work and some self-care ideas, we also created a handout for you that is in the app. So we, again, thank you for attending this session, sharing your stories and your experiences and your ideas. And I especially would like to thank each of our panelists who have, even way before today, been advocates for physicians, health care workers, and for an amazing session. And we really appreciate each one of you. Thank you. Thank you, Dionne, for... Thank you, Jinx.

mental health

stigma

healthcare providers

systemic change

peer support

bipolar disorder

personal stories

advocacy

cultural change

insurance barriers

inclusive environments

professional repercussions